Guidelines for the early management of adults with ischemic stroke. A guideline 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

Guidelines for the early management of adults with ischemic stroke. A guideline 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 Guidelines for the Early Management of Adults With Ischemic Stroke. A Guideline 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

1st April 2007
American Heart Association
American Stroke Association
Summary

Source: National Guidelines Clearinghouse

GUIDELINE OBJECTIVE(S)
  • To provide an overview of the current evidence about components of the evaluation and treatment of adults with acute ischemic stroke
  • To provide updated recommendations that may be used by physicians who provide acute stroke care within the first hours to time of initial diagnosis, treatment, and initial hospitalization
TARGET POPULATION

Adults with ischemic stroke

INTERVENTIONS AND PRACTICES CONSIDERED

Assessment

  1. Prehospital evaluation
    • Brief assessments by emergency medical services (EMS) personnel
    • Use of a stroke identification instrument, such as the Los Angeles or Cincinnati screens
    • Initial management of stroke in the field
    • Development of stroke protocols
  2. Emergency evaluation
    • Establishment of a protocol for the emergency evaluation of patients with suspected stroke
    • Designation of an acute stroke team
    • Use of a stroke rating scale (National Institutes of Health Stroke Scale)
    • Hematologic, coagulation, and biochemistry tests
    • Additional tests as indicated
  3. Brain and vascular imaging
    • Computed tomography (CT), multimodal CT, multimodal magnetic resonance imaging (MRI)
    • Vascular imaging

Management/Treatment

  1. Prehospital management and field treatment
    • Activation of the 9-1-1 system by patients or other members of the public
    • Educational programs to increase public awareness of stroke
    • Educational programs for physicians, hospital personnel, and EMS personnel
    • Rapid transport of patients to the closet facility capable of treating acute stroke for evaluation and treatment (including notification of the receiving Emergency Department)
    • Telemedicine
  2. Creation and certification of stroke centers
    • Primary stroke centers
    • Comprehensive stroke centers
  3. General supportive care and treatment of acute complications
    • Airway support and ventilatory assistance
    • Supplemental oxygen
    • Treatment of sources of fever with antipyretic medications
    • Cardiac monitoring to screen for atrial fibrillation and other potentially serious cardiac arrhythmias
    • Management of arterial hypertension
    • Correction of hypovolemia and optimization of cardiac output (normal saline)
    • Treatment of hypoglycemia and hyperglycemia
  4. Intravenous recombinant tissue plasminogen activator
  5. Intra-arterial thrombolysis
  6. Administration of anticoagulants/antiplatelet agents
  7. Volume expansion
  8. Vasodilators
  9. Vasopressors (in exceptional circumstances as indicated)
  10. Mechanical Embolus Removal in Cerebral Ischemia (MERCI) device for extraction of intra-arterial thrombi (in selected patients)
  11. Hospitalization
    • Comprehensive specialized stroke care following admission to stroke units, incorporating rehabilitation
    • Standardized stroke care order sets
    • Early mobilization of less severely affected patients
    • Measures to prevent subacute complications
    • Assessment of swallowing
    • Use of nasogastric, nasoduodenal, or percutaneous endoscopic gastrostomy (PEG) feedings to maintain hydration and nutrition
    • Antibiotic treatment of patients with suspected pneumonia or urinary tract infections
    • Prevention of deep vein thrombosis
      • Aspirin
      • Subcutaneous anticoagulants (in immobilized patients)
    • Treatment of concomitant medical diseases
    • Interventions to prevent recurrent stroke
    • Intermittent external compression devices
    • Indwelling bladder catheters
  1. Treatment of acute neurological complications
    • Measures to lessen the risk of edema and close monitoring of the patient for signs of neurological worsening
    • Ventricular drain placement for acute hydrocephalus
    • Decompressive surgical evacuation of a space-occupying cerebellar infarction
    • Treatment of recurrent seizures after stroke
    • Hyperventilation
  2. Palliative care
    • Honoring patient's advanced directives
    • Discussion of prognosis and treatment options with family
MAJOR OUTCOMES CONSIDERED
  • Stroke-related morbidity and mortality
  • Adverse events associated with treatment
  • Vascular events following stroke
  • Neurologic complications
  • Functionality