Acute Ischemic Stroke Guidelines Updated With Comprehensive Recommendations

William J. Powers, MD, H. Houston Merritt Distinguished Professor, Neurology, University of North Carolina

William J. Powers, MD

The American Heart Association (AHA)/American Stroke Association (ASA) has issued an update to the 2018 guidelines for the early management of acute ischemic stroke, clarifying prior recommendations and taking into consideration new clinical trial data. The guidelines offer a comprehensive breakdown from symptom onset through 2 weeks poststroke.¹

Ultimately, the guidelines include advice for prehospital care, urgent/emergency evaluation and treatment with intravenous and intra-arterial therapies, as well as management during a hospital stay, such as secondary prevention measures to institute within 2 weeks. Additionally, the guidelines state their support for the use of stroke systems of care in both the prehospital and hospital settings.

“This update has new material based on recent clinical trials as well as a section on instituting secondary stroke prevention in the hospital among the new recommendations are some dealing with people who wake up with stroke and people who have minor stroke,” lead author William J. Powers, MD, H. Houston Merritt Distinguished Professor, Neurology, University of North Carolina, said in a statement.² Powers and colleagues did note that despite this update, in many instances, limited data exist which demonstrate an urgent need for continued research on treatment of acute ischemic stroke.

Some of the notable updates to intervention for acute ischemic stroke include the following:

1. Dysphagia screening has been deemed effective in identifying patients who are possibly at high risk of aspiration.
2. Intravenous (IV) aspirin is not to be given within 90 minutes post-administration of IV alteplase.
3. Patients who experience a non-cardioembolic ischemic stroke should not be given triple antiplatelet therapy—such as aspirin, clopidogrel, and dipyridamole—for secondary prevention.
4. Standard IV alteplase dosing at 0.9mg/kg per hour with 10% bolus per 1 minute is considered beneficial for those who awaken (within 4.5 hours) with acute ischemic stroke symptoms, or those who have an unclear time of onset (>4.5 hours) and have a diffusion-weighted imaging (DWI) lesion smaller than one-third of the middle cerebral artery (MCA) territory without visible signal change on fluid-attenuated inversion recovery (FLAIR) imaging.
5. Tenecteplase is OK to administer in place of IV alteplase in those who are ineligible or who have contraindications to receive alteplase.

The group determined that prehospital procedures should be developed that can help with rapid identification and triage of patients who are fibrinolytic ineligible with a high likelihood of large vessel occlusion (LVO), who should possibly be transported to the nearest facility capable of thrombectomy. As well, these systems of care should be developed with the need for speedy treatment of those who are eligible for fibrinolytic therapy or thrombectomy in mind.

The group also newly recommended that “educational programs should be designed to specifically target the public, physicians, hospital personnel, and emergency medical services (EMS) personnel to increase use of the 9-1-1 EMS system, to decrease stroke onset to emergency department (ED) arrival times, and to increase timely use of thrombolysis and thrombectomy.”

Hospital stroke teams, which guidelines have recommended to include physicians, nurses, and laboratory and radiology personnel, are now also recommended to undergo “multicomponent quality improvement initiatives,” including education in the emergency department, and should allow for multidisciplinary teams to have easy access to neurological expertise.

Powers and colleagues also noted that telestroke and teleradiology evaluations of those with acute ischemic stroke can be effective for determining eligibility for IV alteplase, as well for the administration of the treatment. These services have been deemed reasonable for triaging those who may require interfacility transfer and to provide support for decision-making via phone consultation to community physicians when stroke teams and systems are not available.

New imaging recommendations included the establishment of systems to perform brain imaging studies as quickly as possible, as well as the use of computed tomography angiography (CTA) with CT perfusion or MR angiography with diffusion-weighted magnetic resonance imaging (DW-MRI) with or without MR perfusion for certain patients. For those who are eligible for IV alteplase, it is recommended to be initiated prior to MRI to exclude cerebral microbleeds, with multimodal neuroimaging also recommended to be done post-administration for eligible patients.

“The purpose of these guidelines is to provide an up-to-date comprehensive set of recommendations in a single document for clinicians caring for adult patients with acute arterial ischemic stroke,” Powers and colleagues wrote. “The intended audiences are prehospital care providers, physicians, allied health professionals, and hospital administrators.”

The full guideline can be viewed here.

REFERENCES

1. Powers WJ, Rabinstein AA, Ackerson T, et al. Guidelines for the Early Management of Patients With Acute Ischemic Stroke: 2019 Update to the 2018 Guidelines for the Early Management of Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke. Published online October 30, 2019. doi: 10.1161/STR.0000000000000211.

2. 2019 Update on 2018 Guidelines on the Early Management of Acute Ischemic Stroke. AHA Science News. Youtube. youtube.com/watch?v=jQyWVaR5Rx4. Published October 30, 2019. Accessed November 4, 2019.