Guidelines for the Early Management of Adults with Ischemic Stroke From the AHA/ASA Stroke Council

Harold P. Adams, Chair; Gregory del Zoppo, Vice-Chair, Mark J. Alberts, Deepak L Bhatt, Lawrence Brass, Anthony Furlan, Robert L. Grubb, Randy Higashida, Edward C. Jauch, Chelsea Kidwell, Patrick D. Lyden, Lewis B. Morgenstern, Adnan I. Qureshi, Robert H. Rosenwasser, Philip A. Scott, Eelco FM Wijdicks

Stroke 2007; 38(5): 1655-1711

Presentation Compiled by the AHA Stroke Council Professional Education Committee

Susan C. Fagan, Chair Deborah Bergman Dawn Bravata Seemant Chaturvedi Kari Dunning Kathryn Taubert, Staff Scientist Karen Modesitt, Staff

Introduction
This slide set was adapted from the AHA/ASA Guidelines for the Early Management of Adults with Ischemic Stroke From the American Heart Association/American Stroke Association Stroke Council, Clinical Cardiology Council, Cardiovascular Radiology and Intervention Council, and the Atherosclerotic Peripheral Vascular Disease and Quality of Care Outcomes in Research Interdisciplinary Working Groups

The American Academy of Neurology affirms the value of this guideline as an educational tool for neurologists.
The full-text guidelines are available on the Web site of the AHA (www.americanheart.org)

Introduction Contd
Since the 2003 AHA Stroke Council guidelines, evidence has been published to further refine the approach to the patient with acute ischemic stroke.
In some cases, where supportive evidence from clinical trials was not available, the panel made a specific recommendation on the basis pathophysiology and expert practice experience.

Changes from 2003 Guidelines

Entirely new section on prehospital care
Stroke Centers More detailed recommendations on general supportive care and hospitalization Multimodal Imaging Recommendation to RESTART antihypertensives at 24 hours after onset. New recommendations re: thrombolysis eligibility and delivery
Adams et al. Stroke 2003; 34:1056-1083

Changes from 2003 Guidelines Contd

Recommendations AGAINST clopidogrel acutely
Recommendations AGAINST using experimental strategies as part of routine care (hyperbaric O2, Merci device, glycoprotein IIbIIIa antagonists, druginduced hypertension, combination reperfusion strategies)

Adams et al. Stroke 2003; 34:1056-1083

AHA Classes and Levels of Evidence

Class I Agreement the treatment is useful and effective Class II Conflicting evidence and/or a divergence of opinion about the usefulness/efficacy of a treatment. Class IIa Weight of evidence is in favor of the treatment. Class IIb Usefulness/efficacy is less well established by evidence Class III Evidence and/or general agreement that the treatment is not useful/effective and in some cases may be harmful. Levels of Evidence A: Data derived from multiple randomized trials. B: Data derived from a single randomized trial or nonrandomized studies. C: Consensus opinion of experts.

Components of Acute Treatment

Prehospital Care Stroke Center Designation Emergency Evaluation and Diagnostics Supportive Care Thrombolysis (IV and IA) Antiplatelet agents / anticoagulants Volume Expansion / Induced Hypertension Surgical/ Endovascular Interventions Combination Reperfusion Therapy Neuroprotection Hospital Care Treatment of Acute Complications

Prehospital Management and Field Treatment

New: Activation of the 9-1-1 systems by patients or other members of the public is strongly supported because it speeds treatment of stroke (Class I, Level B) New: To increase the number of patients who can be seen and treated within the first few hours after stroke, educational programs to increase public awareness of stroke are recommended (Class I, Level B)

Prehospital Contd
New: To increase the number of patients who are treated, educational programs for physicians, hospital personnel, and EMS personnel also are recommended (Class I, Level B) New : Brief assessment by EMS personnel are recommended (Class I, Level B)
New :The use of a stroke algorithm is encouraged (Class I, Level B)

Prehospital Contd
New: The panel recommends that EMS personnel begin the initial management of stroke in the field (Class I, Level B) New : The development of stroke protocols to be used by EMS personnel is strongly encouraged. Patients should be transported rapidly for evaluation and treatment to the closest institution that provides emergency stroke care as described in the statement (Class I, Level B)
New: Telemedicine can be an effective method to extend acute stroke care to rural areas. (Class IIb, Level B)

Designation of Stroke Centers

The creation of PSCs is strongly recommended (Class I, Level B). The organization of such resources will depend on local variable.
The development of CSC is recommended (Class I, Level C) Certification of stroke centers by an external body, such as JCAHO, is encouraged (Class I, Level B) For patients with suspected stroke, EMS should bypass hospital that do not have resources to treat stroke and got the closest facility capable of treating acute stroke (Class I Level B)

Emergency Diagnosis and Management: Class I recommendations

The goal is to complete an evaluation and decide on treatment within 60 minutes of the patients arrival in the ED. Acute stroke teams are encouraged. (Class I, Level B)
The use of a stroke rating scale is recommended (e.g., NIH Stroke Scale) (Class I, Level B) Patients with clinical evidence of acute cardiac or pulmonary disease may warrant a CXR (Class I, Level B)

Emergency Diagnosis and Management Contd An ECG is recommended (Class I, Level B) Basic blood tests are recommended (Class I, Level B)

Emergency Diagnosis and Management: Class III Recommendations

New: Most patients with acute stroke do not require a CXR as part of their initial evaluation (Class III, Level B) Most patients with stroke do not need a CSF exam (consider if clinical picture suggestive of SAH and CT head normal) (Class III, Level B)

Brain and Vascular Imaging : Class I recommendations

Imaging of the brain is recommended before initiating specific therapy (Class I, Level A)
In most instances, CT will provide the information to make decisions about emergency management (Class I, Level A) New: The imaging study should be interpreted by a physician with expertise in reading brain CT and MRI (Class I, Level C)

Brain and Vascular Imaging: Class I recommendations

Some findings on CT, such as a dense artery sign, are associated with poor prognosis (Class I, Level A)

New: Multimodal CT and MRI may provide additional information that will improve diagnosis of ischemic stroke (Class I, Level A)

Brain and Vascular Imaging: Class II Recommendations

Other than hemorrhage, no specific CT finding should preclude use of IV rtPA within 3 hours of stroke onset (Class IIb, Level A)
Vascular imaging is required before intra-arterial or endovascular interventions (Class IIa, Level B)

Brain and Vascular Imaging: Class III Recommendations

New: Emergency treatment of stroke should not be delayed in order to obtain multimodal imaging studies (Class III, Level C)

New: Vascular imaging studies should not delay treatment of acute stroke patients whose symptoms started <3 hours ago (Class III, Level B)

General Supportive Care: Class I Recommendations

Airway support and ventilatory assistance are recommended for the treatment of acute stroke (Class I, Level C)
Hypoxic patients with stroke should receive supplemental oxygen (Class I, Level C) Fever should be treated and antipyretic medications should administered to lower temperature in febrile patients (Class I, Level C)

General Supportive Care Contd

Cardiac monitoring to screen for atrial fibrillation and other potentially serious cardiac arrhythmias should be performed during the first 24 hours after onset of ischemic stroke (Class I Level B) The management of arterial hypertension remains controversial. It is generally agreed that a cautious approach to the treatment of arterial hypertension should be recommended (Class I, Level C)

General Supportive Care Contd

Patients who have elevated blood pressure and are otherwise eligible for treatment of rtPA may have their blood pressure lowered so that their systolic is< 185 mm Hg and their diastolic blood pressure is < 110 mm Hg (Class I, Level B)
New: Until other data become available, consensus exists that the previously described blood pressure recommendations should be followed in patients undergoing other acute interventions to recanalize occluded vessels, including intra-arterial thrombolysis (Class I, Level C)

General Supportive Care Contd

New : Patients with markedly elevated blood pressure may have their blood pressure lowered. A reasonable goal is ~ 15% during the first 24 hours after onset of stroke. Medications should be withheld unless SPB > 220 or MAP >120 (Class I, Level C)
The cause of arterial hypotension in the setting of acute stroke should be sought (Class I, Level C)

New: Hypoglycemia should be treated in patients with acute ischemic stroke (Class I, Level C). Marked elevations in blood glucose should be avoided.

General Supportive Care: Class II Recommendations

New: There is no data to guide selection of medications for the lowering of blood pressure in the setting of acute ischemic stroke. The recommended medications and doses are based on general consensus (Class IIa, Level C) New: For patients with preexisting hypertension evidence indicates antihypertensive therapy medications should be restarted at ~ 24 hours (Class IIa, Level B) New: Persistent hyperglycemia (>140 mg/dL) during the first 24 hours after stroke is associated with poor outcomes (Class IIa, Level C)

General Supportive Care: Class III Recommendations

Non-hypoxic patients with acute ischemic stroke do not need supplemental oxygen therapy (Class III, Level B
New: Data on hyperbaric oxygen are inconclusive, and some data imply that the intervention may be harmful (Class III, Level B) Despite the efficacy of hypothermia for improving neurological outcomes after cardiac arrest, the utility of induced hypothermia for the treatment of patients with acute ischemic stroke is not established (Class III, Level B)

Intravenous Thrombolysis: Class I Recommendations

IV rtPA (0.9 mg.kg, maximum dose 90 mg) is recommended for selected patients who may be treated within 3 hours of onset of ischemic stroke (Class I, Level A) New: Besides bleeding complications, physicians should be aware of the potential side effect of angioedema that may cause partial airway obstruction (Class I, Level C)

Intravenous Thrombolysis: Class II Recommendations

A patient whose BP can be safely lowered with antihypertensive agents may be eligible for treatment. (Class IIa, Level B) New: A patient with a seizure at the time of onset may be eligible for treatment. (Class IIa, Level C)

Intravenous Thrombolysis: Class III Recommendations

IV streptokinase for treatment of stroke IS NOT recommended. (Class III, Level A)

New: Use of IV fibrinolytics other than tPA (reteplase, tenecteplase, etc) outside a clinical trial in NOT recommended. (Class III, Level C)

Intraarterial Thrombolysis: Class I Recommendations

Intraarterial thrombolysis is an option for major stroke if administered within 6 hours of onset. ( Class I, Level B) Intraarterial thrombolysis should only be attempted at experienced stroke centers (Class I, Level C)

Intra-Arterial Thrombolysis : Class II III recommendations

New: Intra-arterial thrombolysis is reasonable in patients who have contraindications to use of IV thrombolysis, such as recent surgery (Class II, Lvel C) The availability of intra-arterial thrombolysis should generally NOT preclude the use of IV rtPA in eligible patients (Class III, Level C)

Combination Reperfusion Therapies : Class III recommendation

New: Combinations of interventions to restore perfusion cannot be recommended outside the setting of clinical trials (Class III, Level B)

Anticoagulation: Class III Recommendations

Urgent anticoagulation for the prevention of early recurrence, halting worsening or improving outcomes, is NOT recommended. (Class III, Level A)

Urgent anticoagulation is NOT recommended for moderate to severe strokes because of an increased risk of serious intracranial hemorrhage. (Class III, Level A) Initiation of anticoagulant therapy within 24 h of IV rtPA is NOT recommended. (Class III, Level B)

Antiplatelet Therapy: Class I Recommendation

New Dose Added: Oral aspirin (initial dose of 325 mg) within 24 to 48 hours of stroke onset is recommended for most patients (Class I, Level A)

Antiplatelet Therapy: Class III Recommendations

Aspirin should NOT be considered a substitute for IV rtPA. (Class III, Level A)
Aspirin is NOT recommended within 24 h of IV rtPA. (Class III, Level A) New: Clopidogrel alone or in combination with aspirin is NOT recommended. (Class III, Level C) New: Use of IV GPIIbIIIa receptor antagonists outside of clinical trials NOT recommended. (Class III, Level B)

Hemodilution : Class III Recommendation

Hemodilution with or without volume expansion is NOT recommended for patients with acute ischemic stroke (Class III, Level A)

Vasodilators in Acute Ischemic Stroke

Methylxanthine derivatives (e.g., pentoxifylline) are vasodilators that also inhibit platelet aggregation Several studies have evaluated the use of pentoxifylline for the reduction of 30-day mortality Neither pentoxifylline nor pentofylline has been shown to improve outcomes after stroke

Vasodilators: Class III Recommendation

Medications such as pentoxifylline are NOT recommended for patients with acute ischemic stroke (Class III, Level A)

Induced Hypertension Recommendations

Class I: New: In exceptional cases, vasopressors may be used to improve cerebral blood flow, but this use requires close neurological and cardiac monitoring (Class I, Level C) Class III: New: Drug-induced hypertension is NOT recommended for most patients with acute ischemic stroke (Class III, Level B)

No Surgical Recommendations
Safety and effectiveness data about surgical interventions for patients with acute ischemic stroke are insufficient to make recommendations

Endovascular Intervention : Class II Recommendations

New: Although the MERCI device is a reasonable intervention for extraction of intra-arterial thrombi in carefully selected patients, the utility of the device in improving outcomes after stroke is unclear; additional clinical trials are needed to define its role in the emergency management of stroke (Class IIb, Level B) The usefulness of other endovascular treatments is not established (Class IIb, Level C)

Neuroprotection: Class III Recommendation

NO intervention with putative neuroprotective actions has been established as effective in improving outcomes after stroke, and therefore none currently can be recommended (Class III, Level A)

Hospitalization: Class I Recommendations

The use of stroke units incorporating rehabilitation is recommended (Class I, Level A)
SC anticoagulants for prevention of DVT in immobilized patients is recommended (Class I, Level A) New: The use of standardized stroke care order sets in recommended (Class I, Level B) Early mobilization to prevent subacute complications of stroke is recommended (Class I, Level C)

Hospitalization: Class I Recommendations

New: Assessment of swallowing before starting eating or drinking is recommended (Class I, Level B)
Patients with pneumonia or UTI should receive antibiotics (Class I, Level B). Treatment of concomitant medical diseases is recommended (Class I, Level C) Early institution of interventions to prevent recurrent stroke is recommended (Class I, Level C)

Hospitalization: Class II Recommendations

New: Patients who cannot take food and fluids orally should receive NG, ND or PEG feedings to maintain hydration and nutrition while undergoing efforts to restore swallowing (Class IIa, Level B) ASA can be used for DVT prophylaxis but is less effective than anticoagulation (Class IIa, Level A) Intermittent pneumatic compression devices are recommended for patients who cannot receive anticoagulation (Class IIa, Level B)

Hospitalization: Class III Recommendations

New: Nutritional supplements are NOT needed (Class III, Level B) New: Prophylactic antibiotics are NOT recommended (Class III, Level B) If possible, placement of an indwelling bladder catheter should be avoided because of risk of UTI (Class III, Level C)

Treatment of Neurologic Complications : Class I Recommendations

Patients with major infarctions affecting the cerebral hemisphere or cerebellum are at high risk of brain edema and increased ICP. Measures to lessen the risk of edema and close monitoring of the patient for worsening during the first days are recommended (Class I, Level B) New: Transfer of the patient to a center with neurosurgical expertise should be considered Patients with acute hydrocephalus secondary to ischemic stroke can be treated with a ventricular drain (Class I, Level B)

Treatment of Neurologic Complications : Class I Recommendations

Decompressive surgical evacuation of a spaceoccupying cerebellar infarction is a potentially lifesaving measure, and clinical recovery may be very good (Class I, Level B) Recurrent seizures after stroke should be treated as with other acute neurological conditions (Class I, Level B)

Treatment of Neurologic Complications : Class II Recommendations

Aggressive medical measures, including osmotherapy, are UNPROVEN for management of malignant ischemic cerebral edema (Class IIa, Level C). Hyperventilation is short-lived and medical measures could delay decompressive surgery. Decompressive surgery for malignant edema in the cerebral hemisphere may be lifesaving but impact on morbidity is unknown. For severely afflicted patients, advice about the possibility of life with severe disability should be given to the family (Class IIa, Level B)

Treatment of Neurologic Complications : Class II Recommendations

New: No specific recommendation is made for treatment of asymptomatic hemorrhagic transformation (Class IIb, Level C)

Treatment of Neurologic Complications: Class III Recommendations

Corticosteroids NOT recommended (Class III, Level A)

Prophylactic anticonvulsants are NOT recommended (Class III, Level C)

Summary
These guidelines provide comprehensive and timely evidence-based recommendations.
There is an intent to fully update the guidelines every three years, with updates encouraged when pivotal studies are published.