2026 Guideline for the Early Management of Patients With Acute Ischemic Stroke: A Guideline From the American Heart Association/American Stroke Association
1. In pediatric patients with suspected stroke transported by ambulance, the usefulness of common adult stroke screening tools is uncertain because they perform poorly for identification of stroke. Newer pediatric stroke screening tools demonstrate good interrater reliability; however, their sensitivity, specificity, and predictive value in the prehospital setting remain to be determined, and their usefulness is unknown.
2. Remote ischemic conditioning (RIC) in the prehospital setting is not associated with improved functional outcomes and is not recommended.
3. Prehospital use of glyceryl trinitrate (GTN) is not associated with improved functional outcomes and may pose harm, particularly in cases of intracerebral hemorrhage, and is not recommended.
4. Early prehospital BP reduction to 130–140 mm Hg is not beneficial and could be harmful in ischemic stroke and is not recommended.
1. Hospitals and EMS professionals should establish agreements and protocols to prioritize interhospital transfer of patients with acute stroke needing a higher level of care to reduce door-in-door-out (DIDO) times.
2. In areas with well-coordinated stroke systems of care and local hospital(s) proficient in thrombolysis delivery and secondary interhospital transfer, direct transport of patients with suspected LVO to a distant (eg, 45–60 min) TSC compared with transport to a local stroke center does not improve 3-month clinical outcomes.
1. In patients with suspected AIS, the use of MSUs over conventional EMS where available is recommended for the transport and management of thrombolytic-eligible patients to ensure the fastest achievable onset-to-treatment time and improve functional outcomes.
1. Hospitals caring for patients with acute stroke that provide EVT (ie, TSC, CSC hospitals) should develop a system to comprehensively track key time metrics and other care processes relevant to thrombectomy (eg, door-to-puncture time, successful reperfusion), as well as long-term patient outcomes.
2. Hospitals caring for patients with acute stroke that provide EVT (ie, TSC, CSC hospitals) should credential neurointerventionalists using established and agreed upon training and certification standards.
EMERGENCY EVALUATION AND TREATMENT
Initial, Vascular, and Multimodal Imaging Approaches
1. In pediatric patients with suspected AIS, emergent brain and vascular imaging with MRI/MRA of the cervical and intracranial vessels is reasonable to identify patients with large vessel occlusion and to differentiate arterial ischemic stroke from hemorrhagic stroke or stroke mimics.
2. In pediatric patients with suspected AIS, emergent brain and vascular imaging with CT/CTA of the cervical and intracranial vessels is reasonable if MRI/MRA imaging is not available immediately (within 25 minutes) to identify patients with large vessel occlusion.
1. In patients with mild to moderate severity AIS who have been treated with IVT, intensive SBP reduction (target of <140 mm Hg compared with <180 mm Hg) is not recommended because it is not associated with an improvement in functional outcome.
2. In patients with AIS with LVO of the anterior circulation who have been successfully recanalized by endovascular therapy (mTICI 2b, 2c, or 3) and without other indication for blood pressure management target, intensive SBP reduction target of <140 mm Hg for the first 72 hours is harmful and not recommended.
1. In hospitalized patients with AIS with hyperglycemia, treatment with IV insulin to achieve blood glucose levels in the range of 80 to 130 mg/dL is not recommended to improve 3-month functional outcomes.
1. In adult patients with AIS who are eligible for IVT within 4.5 hours of symptom onset, treatment should be initiated as quickly as possible, assuring safe administration and avoiding potential delays associated with additional multimodal neuroimaging, such as CTA/MRA, and CT/MR perfusion imaging.
2. In pediatric patients aged 28 days to 18 years with confirmed AIS presenting within 4.5 hours of symptom onset and disabling deficits, IVT with alteplase may be considered as it is safe, but efficacy is uncertain.
1. In adult patients with AIS presenting within 4.5 hours of symptom onset or last known well and eligible for IVT, tenecteplase at a dose of 0.25 mg/kg body weight (max 25 mg) or alteplase at a dose of 0.9 mg/kg body weight is recommended to improve functional outcomes.
2. Tenecteplase at a dose of 0.4 mg/kg body weight is not recommended for patients with AIS presenting within 4.5 hours of symptom onset because it has not shown additional benefit and has shown the potential for harm compared with the 0.25 mg/kg dose.
Extended Time Windows for Intravenous Thrombolysis
1. In patients with AIS who have salvageable ischemic penumbra detected on automated perfusion imaging and who (a) awake with stroke symptoms within 9 hours from the midpoint of sleep or (b) are 4.5–9 hours from last known well, IV thrombolysis may be reasonable to improve functional outcomes.
1. In patients with AIS from anterior circulation proximal LVO of the ICA or M1, presenting within 6 hours from onset of symptoms, with NIHSS score ≥6, prestroke mRS score of 0 to 1, and ASPECTS 3 to 10, EVT is recommended to improve functional clinical outcomes and reduce mortality.
2. In selected patients with AIS from anterior circulation proximal LVO of the ICA or M1, presenting between 6 and 24 hours from onset of symptoms, with age <80 years, NIHSS score ≥6, prestroke mRS score 0 to 1, ASPECTS 3 to 5, and without significant mass effect on imaging, EVT is recommended to improve functional clinical outcomes and reduce mortality.
3. In selected patients with AIS from anterior circulation proximal LVO of the ICA or M1 presenting within 6 hours from onset of symptoms, with age <80 years, NIHSS score ≥6, prestroke mRS 0 to 1, ASPECTS 0 to 2, and without significant mass effect on imaging, EVT is reasonable to improve functional clinical outcomes and reduce mortality.
4. In patients with AIS from anterior circulation proximal LVO of the ICA or M1 presenting within 6 hours from onset of symptoms, with NIHSS score ≥6, and ASPECTS ≥6, who have a prestroke mRS score of 2, EVT is reasonable to improve functional clinical outcomes and reduce accumulated disability.
1. In patients with AIS, with basilar artery occlusion, a baseline mRS score of 0 to 1, NIHSS score ≥10 at presentation, and PC-ASPECTS ≥6 (mild ischemic damage), EVT within 24 hours from onset of symptoms is recommended to achieve better functional outcome and reduce mortality.
1. In the management of patients with AIS in the setting of LVO, preoperative administration of tirofiban before EVT is not useful to improve 90-day functional outcome.
1. In pediatric patients ≥6 years with acute neurological symptoms and ischemic stroke due to LVO and within 6 hours from symptom onset, EVT can be effective if performed by experienced neurointerventionalists to improve functional outcomes.
2. In pediatric patients ≥6 years with acute neurological symptoms and ischemic stroke due to LVO, 6 to 24 hours from symptom onset, and with potentially salvageable brain tissue, EVT can be effective to improve functional outcomes.
3. In pediatric patients aged 28 days to 6 years with acute neurological symptoms, including first-time seizure and AIS due to LVO, within 24 hours from symptom onset, and with potentially salvageable brain tissue, EVT performed by neurointerventionalists with pediatric experience may be reasonable to improve functional outcomes.
1. In patients with minor (NIHSS score ≤5) noncardioembolic AIS or high-risk TIA (ABCD2 score ≥4), DAPT (aspirin plus clopidogrel) initiated early (ideally within 12–24 hours of symptom onset) and continued for 21 to 90 days, followed by SAPT, is reasonable to reduce the risk of recurrent ischemic stroke.
1. In carefully selected (eg, milder severity) patients with AIS with atrial fibrillation, a strategy of early oral anticoagulation poststroke is low risk and is reasonable compared with a strategy of delayed anticoagulation, although the efficacy of early anticoagulation for prevention of early recurrent stroke is not established.
1. In patients with stroke with dysphagia, treatment with pharyngeal electrical stimulation (PES) can be beneficial to reduce dysphagia severity and decrease the risk of aspiration.
1. In patients with large hemispheric infarction 18 to 70 years of age, the use of IV glibenclamide does not result in improved functional outcome and is not recommended.
2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack: A Guideline From the American Heart Association/American Stroke Association [2]
DIAGNOSTIC EVALUATION FOR SECONDARY STROKE PREVENTION
1. In patients suspected of having a stroke or TIA, an ECG is recommended to screen for atrial fibrillation (AF) and atrial flutter and to assess for other concomitant cardiac conditions. (Level of Evidence: B-R)
2. In patients with ischemic stroke or TIA, a diagnostic evaluation is recommended for gaining insights into the etiology of and planning optimal strategies for preventing recurrent stroke, with testing completed or underway within 48 hours of onset of stroke symptoms. (Level of Evidence: B-NR)
3. In patients with symptomatic anterior circulation cerebral infarction or TIA who are candidates for revascularization, noninvasive cervical carotid imaging with carotid ultrasonography, CT angiography (CTA), or magnetic resonance angiography (MRA) is recommended to screen for stenosis. (Level of Evidence: B-NR)
4. In patients suspected of having a stroke or TIA, CT or MRI of the brain is recommended to confirm the diagnosis of symptomatic ischemic cerebral vascular disease. (Level of Evidence: B-NR)
5. In patients with a confirmed diagnosis of symptomatic ischemic cerebrovascular disease, blood tests, including complete blood count, prothrombin time, partial thromboplastin time, glucose, HbA1c, creatinine, and fasting or non-fasting lipid profile, are recommended to gain insight into risk factors for stroke and to inform therapeutic goals. (Level of Evidence: B-NR)
6. In patients with cryptogenic stroke, echocardiography with or without contrast is reasonable to evaluate for possible cardiac sources of or transcardiac pathways for cerebral embolism. (Level of Evidence: B-R)
7. In patients with cryptogenic stroke who do not have a contraindication to anticoagulation, long-term rhythm monitoring with mobile cardiac outpatient telemetry, implantable loop recorder, or other approach is reasonable to detect intermittent AF. (Level of Evidence: B-R)
8. In patients suspected of having an ischemic stroke, if CT or MRI does not demonstrate symptomatic cerebral infarct, follow-up CT or MRI of the brain is reasonable to confirm a diagnosis. (Level of Evidence: B-NR)
9. In patients suspected of having had a TIA, if the initial head imaging (CT or MRI) does not demonstrate a symptomatic cerebral infarct, follow-up MRI is reasonable to predict the risk of early stroke and to support the diagnosis. (Level of Evidence: B-NR)
10. In patients with cryptogenic stroke, tests for inherited or acquired hypercoagulable state, bloodstream or cerebral spinal fluid infections, infections that can cause central nervous system (CNS) vasculitis (eg, HIV and syphilis), drug use (eg, cocaine and amphetamines), and markers of systemic inflammation and genetic tests for inherited diseases associated with stroke are reasonable to perform as clinically indicated to identify contributors to or relevant risk factors for stroke. (Level of Evidence: C-LD)
11. In patients with ischemic stroke or TIA, noninvasive imaging of the intracranial large arteries and imaging of the extracranial vertebrobasilar arterial system with MRA or CTA can be effective to identify atherosclerotic disease, dissection, moyamoya, or other etiologically relevant vasculopathies. (Level of Evidence: C-LD)
12. In patients with ischemic stroke and a treatment plan that includes anticoagulant therapy, CT or MRI of the brain before therapy is started may be considered to assess for hemorrhagic transformation and final size of infarction. (Level of Evidence: B-NR)
13. In patients with ESUS, transesophageal echocardiography (TEE), cardiac CT, or cardiac MRI might be reasonable to identify possible cardioaortic sources of or transcardiac pathways for cerebral embolism. (Level of Evidence: C-LD)
14. In patients with ischemic stroke or TIA in whom patent foramen ovale (PFO) closure would be contemplated, TCD (transcranial Doppler) with embolus detection might be reasonable to screen for right-to-left shunt. (Level of Evidence: C-LD)
1. In patients with stroke and TIA, it is reasonable to counsel individuals to follow a Mediterranean-type diet, typically with emphasis on monounsaturated fat, plant-based foods, and fish consumption, with either high extra virgin olive oil or nut supplementation, in preference to a low-fat diet, to reduce risk of recurrent stroke. (Level of Evidence: B-R)
2. In patients with stroke or TIA and hypertension who are not currently restricting their dietary sodium intake, it is reasonable to recommend that individuals reduce their sodium intake by at least 1 g/d sodium (2.5 g/d salt) to reduce the risk of cardiovascular disease (CVD) events (including stroke). (Level of Evidence: B-R)
1. In patients with stroke or TIA who are capable of physical activity, engaging in at least moderate-intensity aerobic activity for a minimum of 10 minutes 4 times a week or vigorous-intensity aerobic activity for a minimum of 20 minutes twice a week is indicated to lower the risk of recurrent stroke and the composite cardiovascular end point of recurrent stroke, MI, or vascular death. (Level of Evidence: C-LD)
2. In patients with stroke or TIA who are able and willing to increase physical activity, engaging in an exercise class that includes counseling to change physical activity behavior can be beneficial for reducing cardiometabolic risk factors and increasing leisure time physical activity participation. (Level of Evidence: B-R)
3. In patients with deficits after a stroke that impair their ability to exercise, supervision of an exercise program by a health care professional such as a physical therapist or cardiac rehabilitation professional, in addition to routine rehabilitation, can be beneficial for secondary stroke prevention. (Level of Evidence: C-EO)
4. In individuals with stroke or TIA who sit for long periods of uninterrupted time during the day, it may be reasonable to recommend breaking up sedentary time with intervals as short as 3 minutes of standing or light exercise every 30 minutes for their cardiovascular health. (Level of Evidence: B-NR)
1. In patients with stroke or TIA who smoke tobacco, counseling with or without drug therapy (nicotine replacement, bupropion, or varenicline) is recommended to assist in quitting smoking. (Level of Evidence: A)
2. Patients with stroke or TIA who continue to smoke tobacco should be advised to stop smoking (and, if unable, to reduce their daily smoking) to lower the risk of recurrent stroke. (Level of Evidence: B-NR)
3. In patients with stroke or TIA, avoidance of environmental (passive) tobacco smoke is recommended to reduce the risk of recurrent stroke. (Level of Evidence: B-NR)
1. Patients with ischemic stroke or TIA who drink >2 alcoholic drinks a day for men or >1 alcoholic drink a day for women should be counseled to eliminate or reduce their consumption of alcohol to reduce stroke risk. (Level of Evidence: B-NR)
2. In patients with stroke or TIA who use stimulants (eg, amphetamines, amphetamine derivatives, cocaine, or khat) and in patients with infective endocarditis (IE) in the context of intravenous drug use, it is recommended that health care providers inform them that this behavior is a health risk and counsel them to stop. (Level of Evidence: C-EO)
3. In patients with stroke or TIA who have a substance use disorder (drugs or alcohol), specialized services are recommended to help manage this dependence. (Level of Evidence: C-EO)
1. In patients with hypertension who experience a stroke or TIA, treatment with antihypertensive medication, including a thiazide diuretic, angiotensin-converting enzyme inhibitor, or angiotensin receptor blocker, or combination therapy, is recommended to reduce the risk of recurrent stroke and other vascular events. (Level of Evidence: A)
2. In patients with hypertension who experience a stroke or TIA, an office BP goal of <130/80 mm Hg is recommended for most patients to reduce the risk of recurrent stroke and vascular events. (Level of Evidence: B-R)
3. In patients with hypertension who experience a stroke or TIA, individualized drug regimens that take into account patient comorbidities, agent pharmacological class, and patient preference are recommended to maximize drug efficacy. (Level of Evidence: B-NR)
4. In patients with no history of hypertension who experience a stroke or TIA and have an average office BP of ≥130/80 mm Hg, antihypertensive medication treatment can be beneficial to reduce the risk of recurrent stroke, ICH, and other vascular events. (Level of Evidence: B-R)
TREATMENT AND MONITORING OF BLOOD LIPIDS FOR SECONDARY STROKE PREVENTION
1. In patients with ischemic stroke with no known coronary heart disease, no major cardiac sources of embolism, and LDL cholesterol (LDL-C) >100 mg/dL, atorvastatin 80 mg daily is indicated to reduce risk of stroke recurrence. (Level of Evidence: A)
2. In patients with ischemic stroke or TIA and atherosclerotic disease (intracranial, carotid, aortic, or coronary), lipid-lowering therapy with a statin and also ezetimibe, if needed, to a goal LDL-C of <70 mg/dL is recommended to reduce the risk of major cardiovascular events. (Level of Evidence: A)
1. In patients with stroke or TIA and hyperlipidemia, patients' adherence to changes in lifestyle and the effects of LDL-C–lowering medication should be assessed by measurement of fasting lipids and appropriate safety indicators 4 to 12 weeks after statin initiation or dose adjustment and every 3 to 12 months thereafter, based on the need to assess adherence or safety. (Level of Evidence: A)
1. In patients with ischemic stroke or TIA, with fasting triglycerides 135 to 499 mg/dL and LDL-C of 41 to 100 mg/dL, on moderate- or high-intensity statin therapy, with HbA1c <10%, and with no history of pancreatitis, AF, or severe heart failure, treatment with icosapent ethyl (IPE) 2 g twice a day is reasonable to reduce risk of recurrent stroke. (Level of Evidence: B-R)
2. In patients with severe hypertriglyceridemia (ie, fasting triglycerides ≥500 mg/dL [≥5.7 mmol/L]), it is reasonable to identify and address causes of hypertriglyceridemia and, if triglycerides are persistently elevated or increasing, to further reduce triglycerides in order to lower the risk of ASCVD events by the implementation of a very low-fat diet, avoidance of refined carbohydrates and alcohol, consumption of omega-3 fatty acids, and, if necessary to prevent acute pancreatitis, fibrate therapy. (Level of Evidence: B-NR)
1. In patients with an ischemic stroke or TIA who also have diabetes, the goal for glycemic control should be individualized based on the risk for adverse events, patient characteristics, and preferences, and, for most patients, especially those <65 years of age and without life-limiting comorbid illness, achieving a goal of HbA1c ≤7% is recommended to reduce the risk for microvascular complications. (Level of Evidence: A)
2. In patients with an ischemic stroke or TIA who also have diabetes, treatment of diabetes should include glucose-lowering agents with proven cardiovascular benefit to reduce the risk for future major adverse cardiovascular events (ie, stroke, MI, cardiovascular death). (Level of Evidence: B-R)
3. In patients with an ischemic stroke or TIA who also have diabetes, multidimensional care (ie, lifestyle counseling, medical nutritional therapy, diabetes self-management education, support, and medication) is indicated to achieve glycemic goals and to improve stroke risk factors. (Level of Evidence: C-EO)
4. In patients with prediabetes and ischemic stroke or TIA, lifestyle optimization (ie, healthy diet, regular physical activity, and smoking cessation) can be beneficial for the prevention of progression to diabetes. (Level of Evidence: B-R)
5. In patients with TIA or ischemic stroke, it is reasonable to screen for prediabetes/diabetes using HbA1c which, among available methods (HbA1c, fasting plasma glucose, oral glucose tolerance), has the advantage of convenience because it does not require fasting and is measured in a single blood sample. (Level of Evidence: C-EO)
6. In patients with an ischemic stroke or TIA who also have diabetes, the usefulness of achieving intensive glucose control (ie, HbA1c ≤7%) beyond the acute phase of the ischemic event for prevention of recurrent stroke is unknown. (Level of Evidence: B-R)
7. In patients with prediabetes and ischemic stroke or TIA, particularly those with a body mass index (BMI) ≥35 kg/m2, those <60 years of age, or women with a history of gestational diabetes, metformin may be beneficial to control blood sugar and to prevent progression to diabetes. (Level of Evidence: B-R)
8. In patients ≤6 months after TIA or ischemic stroke with insulin resistance, HbA1c <7.0%, and without heart failure or bladder cancer, treatment with pioglitazone may be considered to prevent recurrent stroke. (Level of Evidence: B-R)
1. In patients with ischemic stroke or TIA and who are overweight or obese, weight loss is recommended to improve the ASCVD risk factor profile. (Level of Evidence: B-R)
2. In patients with ischemic stroke or TIA who are obese, referral to an intensive, multicomponent, behavioral lifestyle-modification program is recommended to achieve sustained weight loss. (Level of Evidence: B-R)
3. In patients with ischemic stroke or ASCVD, calculation of BMI is recommended at the time of their event and annually thereafter, to screen for and to classify obesity. (Level of Evidence: C-EO)
1. In patients with an ischemic stroke or TIA and OSA, treatment with positive airway pressure (eg, continuous positive airway pressure [CPAP]) can be beneficial for improved sleep apnea, BP, sleepiness, and other apnea-related outcomes. (Level of Evidence: B-R)
1. In patients with a stroke or TIA caused by 50% to 99% stenosis of a major intracranial artery, aspirin 325 mg/d is recommended in preference to warfarin to reduce the risk of recurrent ischemic stroke and vascular death. (Level of Evidence: B-R)
2. In patients with recent stroke or TIA (within 30 days) attributable to severe stenosis (70%–99%) of a major intracranial artery, the addition of clopidogrel 75 mg/d to aspirin for up to 90 days is reasonable to further reduce recurrent stroke risk. (Level of Evidence: B-NR)
3. In patients with recent (within 24 hours) minor stroke or high-risk TIA and concomitant ipsilateral >30% stenosis of a major intracranial artery, the addition of ticagrelor 90 mg twice a day to aspirin for up to 30 days might be considered to further reduce recurrent stroke risk. (Level of Evidence: B-NR)
4. In patients with stroke or TIA attributable to 50% to 99% stenosis of a major intracranial artery, the addition of cilostazol 200 mg/day to aspirin or clopidogrel might be considered to reduce recurrent stroke risk. (Level of Evidence: C-LD)
5. In patients with stroke or TIA attributable to 50% to 99% stenosis of a major intracranial artery, the usefulness of clopidogrel alone, the combination of aspirin and dipyridamole, ticagrelor alone, or cilostazol alone for secondary stroke prevention is not well established. (Level of Evidence: C-EO)
6. In patients with a stroke or TIA attributable to 50% to 99% stenosis of a major intracranial artery, maintenance of SBP below 140 mm Hg, high-intensity statin therapy, and at least moderate physical activity are recommended to prevent recurrent stroke and vascular events. (Level of Evidence: B-NR)
7. In patients with severe stenosis (70%–99%) of a major intracranial artery and actively progressing symptoms or recurrent TIA or stroke after institution of aspirin and clopidogrel therapy, achievement of SBP <140 mm Hg, and high-intensity statin therapy (so-called medical failures), the usefulness of angioplasty alone or stent placement to prevent ischemic stroke in the territory of the stenotic artery is unknown. (Level of Evidence: C-LD)
8. In patients with stroke or TIA attributable to severe stenosis (70%–99%) of a major intracranial artery, angioplasty and stenting should not be performed as an initial treatment, even for patients who were taking an antithrombotic agent at the time of the stroke or TIA. (Level of Evidence: A)
9. In patients with a stroke or TIA attributable to moderate stenosis (50%–69%) of a major intracranial artery, angioplasty or stenting is associated with excess morbidity and mortality compared with medical management alone. (Level of Evidence: B-NR)
10. In patients with stroke or TIA attributable to 50% to 99% stenosis or occlusion of a major intracranial artery, extracranial-intracranial bypass surgery is not recommended. (Level of Evidence: B-R)
1. In patients with a TIA or nondisabling ischemic stroke within the past 6 months and ipsilateral severe (70%–99%) carotid artery stenosis, carotid endarterectomy (CEA) is recommended to reduce the risk of future stroke, provided that perioperative morbidity and mortality risk is estimated to be <6%. (Level of Evidence: A)
2. In patients with ischemic stroke or TIA and symptomatic extracranial carotid stenosis who are scheduled for carotid artery stenting (CAS) or CEA, procedures should be performed by operators with established periprocedural stroke and mortality rates of <6% to reduce the risk of surgical adverse events. (Level of Evidence: A)
3. In patients with carotid artery stenosis and a TIA or stroke, intensive medical therapy, with antiplatelet therapy, lipid-lowering therapy, and treatment of hypertension, is recommended to reduce stroke risk. (Level of Evidence: A)
4. In patients with recent TIA or ischemic stroke and ipsilateral moderate (50%–69%) carotid stenosis as documented by catheter-based imaging or noninvasive imaging, CEA is recommended to reduce the risk of future stroke, depending on patient-specific factors such as age, sex, and comorbidities, if the perioperative morbidity and mortality risk is estimated to be <6%. (Level of Evidence: B-R)
5. In patients ≥70 years of age with stroke or TIA in whom carotid revascularization is being considered, it is reasonable to select CEA over CAS to reduce the periprocedural stroke rate. (Level of Evidence: B-R)
6. In patients in whom revascularization is planned within 1 week of the index stroke, it is reasonable to choose CEA over CAS to reduce the periprocedural stroke rate. (Level of Evidence: B-R)
7. In patients with TIA or nondisabling stroke, when revascularization is indicated, it is reasonable to perform the procedure within 2 weeks of the index event rather than delay surgery to increase the likelihood of stroke-free outcome. (Level of Evidence: C-LD)
8. In patients with symptomatic severe stenosis (≥70%) in whom anatomic or medical conditions are present that increase the risk for surgery (such as radiation-induced stenosis or restenosis after CEA), it is reasonable to choose CAS to reduce the periprocedural complication rate. (Level of Evidence: C-LD)
9. In symptomatic patients at average or low risk of complications associated with endovascular intervention, when the ICA stenosis is ≥70% by noninvasive imaging or >50% by catheter-based imaging and the anticipated rate of periprocedural stroke or death is <6%, CAS may be considered as an alternative to CEA for stroke prevention, particularly in patients with significant cardiovascular comorbidities predisposing to cardiovascular complications with endarterectomy. (Level of Evidence: A)
10. In patients with a recent stroke or TIA (past 6 months), the usefulness of transcarotid artery revascularization (TCAR) for prevention of recurrent stroke and TIA is uncertain. (Level of Evidence: B-NR)
11. In patients with recent TIA or ischemic stroke and when the degree of stenosis is <50%, revascularization with CEA or CAS to reduce the risk of future stroke is not recommended. (Level of Evidence: A)
12. In patients with a recent (within 120 days) TIA or ischemic stroke ipsilateral to atherosclerotic stenosis or occlusion of the middle cerebral or carotid artery, extracranial-intracranial bypass surgery is not recommended. (Level of Evidence: B-NR)
1. In patients with recently symptomatic extracranial vertebral artery stenosis, intensive medical therapy (antiplatelet therapy, lipid lowering, BP control) is recommended to reduce stroke risk. (Level of Evidence: A)
2. In patients with ischemic stroke or TIA and extracranial vertebral artery stenosis who are having symptoms despite optimal medical treatment, the usefulness of stenting is not well established. (Level of Evidence: B-R)
3. In patients with ischemic stroke or TIA and extracranial vertebral artery stenosis who are having symptoms despite optimal medical treatment, the usefulness of open surgical procedures, including vertebral endarterectomy and vertebral artery transposition, is not well established. (Level of Evidence: C-EO)
1. In patients with a stroke or TIA and evidence of an aortic arch atheroma, intensive lipid management to an LDL cholesterol target <70 mg/dL is recommended to prevent recurrent stroke. (Level of Evidence: B-R)
2. In patients with a stroke or TIA and evidence of an aortic arch atheroma, antiplatelet therapy is recommended to prevent recurrent stroke. (Level of Evidence: C-LD)
1. In patients with moyamoya disease and a history of ischemic stroke or TIA, surgical revascularization with direct or indirect extracranial-intracranial bypass can be beneficial for the prevention of ischemic stroke or TIA. (Level of Evidence: C-LD)
2. In patients with moyamoya disease and a history of ischemic stroke or TIA, the use of antiplatelet therapy, typically aspirin monotherapy, for the prevention of ischemic stroke or TIA may be reasonable. (Level of Evidence: C-LD)
1. In patients with ischemic stroke related to small vessel disease, the usefulness of cilostazol for secondary stroke prevention is uncertain. (Level of Evidence: B-R)
1. In patients with nonvalvular AF and stroke or TIA, oral anticoagulation (eg, apixaban, dabigatran, edoxaban, rivaroxaban, or warfarin) is recommended to reduce the risk of recurrent stroke. (Level of Evidence: A)
2. In patients with AF and stroke or TIA, oral anticoagulation is indicated to reduce the risk of recurrent stroke regardless of whether the AF pattern is paroxysmal, persistent, or permanent. (Level of Evidence: B-R)
3. In patients with stroke or TIA and AF who do not have moderate to severe mitral stenosis or a mechanical heart valve, apixaban, dabigatran, edoxaban, or rivaroxaban is recommended in preference to warfarin to reduce the risk of recurrent stroke. (Level of Evidence: B-R)
4. In patients with atrial flutter and stroke or TIA, anticoagulant therapy similar to that in AF is indicated to reduce the risk of recurrent stroke. (Level of Evidence: B-NR)
5. In patients with AF and stroke or TIA, without moderate to severe mitral stenosis or a mechanical heart valve, who are unable to maintain a therapeutic INR level with warfarin, use of dabigatran, rivaroxaban, apixaban, or edoxaban is recommended to reduce the risk of recurrent stroke. (Level of Evidence: C-EO)
6. In patients with stroke at high risk of hemorrhagic conversion in the setting of AF, it is reasonable to delay initiation of oral anticoagulation beyond 14 days to reduce the risk of ICH. (Level of Evidence: B-NR)
7. In patients with TIA in the setting of nonvalvular AF, it is reasonable to initiate anticoagulation immediately after the index event to reduce the risk of recurrent stroke. (Level of Evidence: C-EO)
8. In patients with stroke or TIA in the setting of nonvalvular AF who have contraindications for lifelong anticoagulation but can tolerate at least 45 days, it may be reasonable to consider percutaneous closure of the left atrial appendage with the Watchman device to reduce the chance of recurrent stroke and bleeding. (Level of Evidence: B-R)
9. In patients with stroke at low risk for hemorrhagic conversion in the setting of AF, it may be reasonable to initiate anticoagulation 2 to 14 days after the index event to reduce the risk of recurrent stroke. (Level of Evidence: B-NR)
10. In patients with AF and stroke or TIA who have end-stage renal disease or are on dialysis, it may be reasonable to use warfarin or apixaban (dose adjusted if indicated) for anticoagulation to reduce the chance of recurrent stroke. (Level of Evidence: B-NR)
1. In patients with ischemic stroke or TIA and valvular AF (moderate to severe mitral stenosis or any mechanical heart valve), warfarin is recommended to reduce the risk of recurrent stroke or TIA. (Level of Evidence: B-R)
2. In patients with a mechanical mitral valve and a history of ischemic stroke or TIA before valve replacement, aspirin (75–100 mg/d) is recommended in addition to warfarin with an INR target of 3.0 (range, 2.5–3.5) to reduce the risk of thrombosis and recurrent stroke or TIA. (Level of Evidence: C-LD)
3. In patients with ischemic stroke or TIA and native aortic or nonrheumatic mitral valve disease (eg, mitral annular calcification or mitral valve prolapse) who do not have AF or another indication for anticoagulation, antiplatelet therapy is recommended to reduce the risk of recurrent stroke or TIA. (Level of Evidence: C-EO)
4. In patients with a bioprosthetic aortic or mitral valve, a history of ischemic stroke or TIA before valve replacement, and no other indication for anticoagulation therapy beyond 3 to 6 months from the valve placement, long-term therapy with aspirin is recommended in preference to long-term anticoagulation to reduce the risk of recurrent stroke or TIA. (Level of Evidence: C-EO)
5. In patients with ischemic stroke or TIA and IE who present with recurrent emboli and persistent vegetations despite appropriate antibiotic therapy, early surgery (during initial hospitalization before completion of a full therapeutic course of antibiotics) is reasonable to reduce the risk of recurrent embolism if there is no evidence of intracranial hemorrhage or extensive neurological damage. (Level of Evidence: B-NR)
6. In patients with history of ischemic stroke or TIA and a mechanical aortic valve, anticoagulation with higher-intensity warfarin to achieve an INR of 3.0 (range, 2.5–3.5) or the addition of aspirin (75–100 mg/d) can be beneficial to reduce the risk of thromboembolic events. (Level of Evidence: C-EO)
7. In patients with ischemic stroke or TIA and native left-sided valve endocarditis who exhibit mobile vegetations >10 mm in length, early surgery (during initial hospitalization before completion of a full therapeutic course of antibiotics) may be considered to reduce the risk of recurrent embolism if there is no evidence of intracranial hemorrhage or extensive neurological damage. (Level of Evidence: B-NR)
8. In patients with ischemic stroke or TIA and IE, early valve surgery (during initial hospitalization before completion of a full therapeutic course of antibiotics) may be considered in patients with an indication for surgery who have no evidence of intracranial hemorrhage or extensive neurological damage. (Level of Evidence: B-NR)
9. In patients with IE and major ischemic stroke, delaying valve surgery for at least 4 weeks may be considered for patients with IE and major ischemic stroke or intracranial hemorrhage if the patient is hemodynamically stable. (Level of Evidence: B-NR)
1. In patients with stroke or TIA and LV thrombus, anticoagulation with therapeutic warfarin for at least 3 months is recommended to reduce the risk of recurrent stroke. (Level of Evidence: B-NR)
2. In patients with stroke or TIA in the setting of acute MI, it is reasonable to perform advanced cardiac imaging (eg, contrasted echocardiogram or cardiac MRI) to assess for the presence of LV thrombus. (Level of Evidence: C-EO)
3. In patients with stroke or TIA and new LV thrombus (<3 months), the safety of anticoagulation with a direct oral anticoagulant to reduce the risk of recurrent stroke is uncertain. (Level of Evidence: C-LD)
4. In patients with stroke or TIA in the setting of acute anterior MI with reduced ejection fraction (EF; <50%) but no evidence of LV thrombus, empirical anticoagulation for at least 3 months might be considered to reduce the risk of recurrent cardioembolic stroke. (Level of Evidence: C-EO)
1. In patients with ischemic stroke or TIA and left atrial or left atrial appendage thrombus in the setting of ischemic, nonischemic, or restrictive cardiomyopathy and LV dysfunction, anticoagulant therapy with warfarin is recommended for at least 3 months to reduce the risk of recurrent stroke or TIA. (Level of Evidence: C-EO)
2. In patients with ischemic stroke or TIA in the setting of a mechanical assist device, treatment with warfarin and aspirin can be beneficial to reduce the risk of recurrent stroke or TIA. (Level of Evidence: C-LD)
3. In patients with ischemic stroke or TIA in the setting of LV noncompaction, treatment with warfarin can be beneficial to reduce the risk of recurrent stroke or TIA. (Level of Evidence: C-EO)
4. In patients with ischemic stroke or TIA in sinus rhythm with ischemic or nonischemic cardiomyopathy and reduced EF without evidence of left atrial or LV thrombus, the effectiveness of anticoagulation compared with antiplatelet therapy is uncertain, and the choice should be individualized. (Level of Evidence: B-R)
5. In patients with stroke or TIA and LV assist devices (LVADs), treatment with dabigatran instead of warfarin for the primary or secondary prevention of ischemic stroke or TIA causes harm. (Level of Evidence: B-R)
1. In patients with a nonlacunar ischemic stroke of undetermined cause and a PFO, recommendations for PFO closure versus medical management should be made jointly by the patient, a cardiologist, and a neurologist, taking into account the probability of a causal role for the PFO. (Level of Evidence: C-EO)
2. In patients 18 to 60 years of age with a nonlacunar ischemic stroke of undetermined cause despite a thorough evaluation and a PFO with high-risk anatomic features, it is reasonable to choose closure with a transcatheter device and long-term antiplatelet therapy over antiplatelet therapy alone for preventing recurrent stroke. (Level of Evidence: B-R)
3. In patients 18 to 60 years of age with a nonlacunar ischemic stroke of undetermined cause despite a thorough evaluation and a PFO without high-risk anatomic features, the benefit of closure with a transcatheter device and long-term antiplatelet therapy over antiplatelet therapy alone for preventing recurrent stroke is not well established. (Level of Evidence: C-LD)
4. In patients 18 to 60 years of age with a nonlacunar ischemic stroke of undetermined cause despite a thorough evaluation and a PFO, the comparative benefit of closure with a transcatheter device versus warfarin is unknown. (Level of Evidence: C-LD)
1. In patients with ischemic stroke or TIA and Fontan palliation, anticoagulation with warfarin is recommended to reduce the risk of recurrent stroke or TIA. (Level of Evidence: C-LD)
2. In patients with cyanotic congenital heart disease and other complex lesions, ischemic stroke or TIA of presumed cardioembolic origin, therapy with warfarin is reasonable to reduce the risk of recurrent stroke or TIA. (Level of Evidence: C-EO)
1. In patients with stroke or TIA found to have a left-sided cardiac tumor, resection of the tumor can be beneficial to reduce the risk of recurrent stroke. (Level of Evidence: C-LD)
1. In patients with ischemic stroke or TIA after an extracranial carotid or vertebral arterial dissection, treatment with antithrombotic therapy for at least 3 months is indicated to prevent recurrent stroke or TIA. (Level of Evidence: C-EO)
2. In patients with ischemic stroke or TIA who are <3 months after an extracranial carotid or vertebral arterial dissection, it is reasonable to use either aspirin or warfarin to prevent recurrent stroke or TIA. (Level of Evidence: B-R)
3. In patients with stroke or TIA and extracranial carotid or vertebral artery dissection who have recurrent events despite antithrombotic therapy, endovascular therapy may be considered to prevent recurrent stroke or TIA. (Level of Evidence: C-LD)
1. In patients with ischemic stroke or TIA of unknown source despite thorough diagnostic evaluation and no other thrombotic history who are found to have prothrombin 20210A mutation, activated protein C resistance, elevated factor VIII levels, or deficiencies of protein C, protein S, or antithrombin III, antiplatelet therapy is reasonable to reduce the risk of recurrent stroke or TIA. (Level of Evidence: C-LD)
1. In patients with ischemic stroke or TIA who have an isolated antiphospholipid antibody but do not fulfill the criteria for antiphospholipid syndrome, antiplatelet therapy alone is recommended to reduce the risk of recurrent stroke. (Level of Evidence: B-NR)
2. In patients with ischemic stroke or TIA with confirmed antiphospholipid syndrome treated with warfarin, it is reasonable to choose a target INR between 2 and 3 over a target INR >3 to effectively balance the risk of excessive bleeding against the risk of thrombosis. (Level of Evidence: B-R)
3. In patients with ischemic stroke or TIA who meet the criteria for the antiphospholipid syndrome, it is reasonable to anticoagulate with warfarin to reduce the risk of recurrent stroke or TIA. (Level of Evidence: C-LD)
4. In patients with ischemic stroke or TIA, antiphospholipid syndrome with a history of thrombosis and triple-positive antiphospholipid antibodies (ie, lupus anticoagulant, anticardiolipin, and anti–β2 glycoprotein-I), rivaroxaban is not recommended because it is associated with excess thrombotic events compared with warfarin. (Level of Evidence: B-R)
1. In patients with ischemic stroke or TIA with hyperhomocysteinemia, supplementation with folate, vitamin B6, and vitamin B12 is not effective for preventing subsequent stroke. (Level of Evidence: B-R)
1. In patients with ischemic stroke or TIA in the setting of AF and cancer, it is reasonable to consider anticoagulation with DOACs in preference to warfarin for stroke prevention. (Level of Evidence: B-NR)
1. In patients with sickle cell disease (SCD) and prior ischemic stroke or TIA, chronic blood transfusion(s) to reduce hemoglobin S to <30% of total hemoglobin is recommended for the prevention of recurrent ischemic stroke. (Level of Evidence: B-NR)
2. In patients with SCD with prior ischemic stroke or TIA for whom transfusion therapy is not available or practical, treatment with hydroxyurea is reasonable for the prevention of recurrent ischemic stroke. (Level of Evidence: B-R)
1. In patients with ischemic stroke or TIA and symptoms attributed to giant cell arteritis, immediate initiation of oral high-dose glucocorticoids is recommended to reduce recurrent stroke risk. (Level of Evidence: B-NR)
2. In patients with ischemic stroke or TIA and diagnosis of giant cell arteritis, methotrexate or tocilizumab therapy adjunctive to steroids is reasonable to lower the risk of recurrent stroke. (Level of Evidence: B-NR)
3. In patients with ischemic stroke or TIA and diagnosis of primary CNS angiitis, induction therapy with glucocorticoids and/or immunosuppressants followed by long-term maintenance therapy with steroid-sparing immunosuppressants is reasonable to lower the risk of stroke recurrence. (Level of Evidence: C-LD)
4. In patients with ischemic stroke or TIA and confirmed diagnosis of giant cell arteritis, infliximab is associated with recurrent ocular symptoms and markers of disease activity and should not be administered. (Level of Evidence: B-R)
1. In patients with ischemic stroke or TIA and infectious vasculitides such as varicella-zoster virus (VZV) cerebral vasculitis, neurosyphilis, or bacterial meningitis, treating the underlying infectious etiology is indicated to reduce the risk of stroke. (Level of Evidence: B-NR)
2. In patients with ischemic stroke or TIA in the context of HIV vasculopathy, daily aspirin plus HIV viral control with combined antiretroviral therapy is reasonable to reduce the risk of recurrent stroke. (Level of Evidence: C-LD)
1. In patients with ischemic stroke or TIA and cystathionine β-synthase deficiency, pyridoxine (in responsive patients) and a low-methionine, cysteine-enhanced diet supplemented with pyridoxine, vitamin B12, and folate are recommended to reduce plasma homocysteine to population normal levels and thereby reduce the risk of recurrent ischemic stroke. (Level of Evidence: C-LD)
2. In patients with ischemic stroke or TIA and Anderson-Fabry disease, agalsidase alfa or agalsidase beta is of uncertain value in preventing recurrent stroke or TIA. (Level of Evidence: B-NR)
1. In patients with a carotid web in the distribution of ischemic stroke and TIA, without other attributable causes of stroke, antiplatelet therapy is recommended to prevent recurrent ischemic stroke or TIA. (Level of Evidence: B-NR)
2. In patients with the carotid web in the distribution of ischemic stroke refractory to medical management, with no other attributable cause of stroke despite comprehensive workup, carotid stenting or CEA may be considered to prevent recurrent ischemic stroke. (Level of Evidence: C-LD)
1. In patients with fibromuscular dysplasia (FMD) and a history of ischemic stroke or TIA without other attributable causes, antiplatelet therapy, BP control, and lifestyle modification are recommended for the prevention of future ischemic events. (Level of Evidence: C-LD)
2. In patients with a history of ischemic stroke or TIA attributable to dissection, with FMD, and no evidence of intraluminal thrombus, it is reasonable to administer antiplatelet therapy for the prevention of future ischemic events. (Level of Evidence: C-EO)
3. In patients with cervical carotid artery FMD and recurrent ischemic stroke without other attributable causes despite optimal medical management, carotid angioplasty with or without stenting may be reasonable to prevent ischemic stroke. (Level of Evidence: C-LD)
1. In patients with vertebrobasilar dolichoectasia and a history of ischemic stroke or TIA without other attributable causes, the use of antiplatelet or anticoagulant therapy is reasonable for the prevention of recurrent ischemic events. (Level of Evidence: C-LD)
1. In patients with noncardioembolic ischemic stroke or TIA, antiplatelet therapy is indicated in preference to oral anticoagulation to reduce the risk of recurrent ischemic stroke and other cardiovascular events while minimizing the risk of bleeding. (Level of Evidence: A)
2. For patients with noncardioembolic ischemic stroke or TIA, aspirin 50 to 325 mg daily, clopidogrel 75 mg, or the combination of aspirin 25 mg and extended-release dipyridamole 200 mg twice daily is indicated for secondary prevention of ischemic stroke. (Level of Evidence: A)
3. For patients with recent minor (NIHSS score ≤3) noncardioembolic ischemic stroke or high-risk TIA (ABCD2 score ≥4), DAPT (aspirin plus clopidogrel) should be initiated early (ideally within 12–24 hours of symptom onset and at least within 7 days of onset) and continued for 21 to 90 days, followed by SAPT, to reduce the risk of recurrent ischemic stroke. (Level of Evidence: A)
4. For patients with recent (<24 hours) minor to moderate stroke (NIHSS score ≤5), high-risk TIA (ABCD2 score ≥6), or symptomatic intracranial or extracranial ≥30% stenosis of an artery that could account for the event, DAPT with ticagrelor plus aspirin for 30 days may be considered to reduce the risk of 30-day recurrent stroke but may also increase the risk of serious bleeding events, including ICH. (Level of Evidence: B-R)
5. For patients already taking aspirin at the time of noncardioembolic ischemic stroke or TIA, the effectiveness of increasing the dose of aspirin or changing to another antiplatelet medication is not well established. (Level of Evidence: C-LD)
6. For patients with noncardioembolic ischemic stroke or TIA, the continuous use of DAPT (aspirin plus clopidogrel) for >90 days or the use of triple antiplatelet therapy is associated with excess risk of hemorrhage. (Level of Evidence: A)
Health Systems–Based Interventions for Secondary Stroke Prevention
1. In patients with ischemic stroke or TIA, voluntary hospital-based or outpatient-focused quality monitoring and improvement programs are recommended to improve short-term and long-term adherence to nationally accepted, evidence-based guidelines for secondary stroke prevention. (Level of Evidence: C-EO)
2. In patients with ischemic stroke or TIA, a multidisciplinary outpatient team-based approach (ie, care provision with active medication adjustment from advanced practice providers, nurses, or pharmacists) can be effective to control BP, lipids, and other vascular risk factors. (Level of Evidence: B-R)
3. In patients presenting to their primary care provider as the first contact after TIA or minor stroke, it is reasonable to use a decision support tool that improves diagnostic accuracy, stratifies patients in risk categories to support appropriate triage, and prompts the initiation of medications and counseling for lifestyle modification for secondary stroke prevention to reduce the 90-day risk of recurrent stroke or TIA. (Level of Evidence: B-R)
1. In patients with ischemic stroke or TIA, behavior change interventions targeting stroke literacy, lifestyle factors, and medication adherence are recommended to reduce cardiovascular events. (Level of Evidence: B-R)
2. In patients with ischemic stroke or TIA, teaching self-management skills or using behavior change theory (eg, motivational interviewing) can be beneficial in improving medication adherence. (Level of Evidence: B-R)
3. In patients with stroke or TIA, combined exercise-based and behavior change interventions are probably indicated in preference to behavior interventions alone, exercise interventions alone, or usual care to reduce physiological stroke risk factors such as SBP. (Level of Evidence: B-R)
4. In patients with TIA or nondisabling stroke, engagement in targeted secondary prevention programs (eg, cardiac rehabilitation programs or exercise and lifestyle counseling programs) can be beneficial to reduce risk factors and recurrent ischemic events. (Level of Evidence: B-R)
5. For patients with disabling stroke who are discharged from acute services, engaging in targeted secondary prevention programs (eg, an adapted cardiac rehabilitation program or structured exercise including aerobic activity and healthy lifestyle counseling) can be beneficial to reduce vascular risk factors and mortality. (Level of Evidence: B-NR)
6. In patients with stroke or TIA, provision of health information or advice about stroke prevention is essential; however, information or advice alone, in the absence of a behavioral intervention, is not an effective means to change modifiable, lifestyle-related risk factors in order to reduce future ischemic events. (Level of Evidence: B-R)
1. In patients with stroke or TIA, evaluating and addressing social determinants of health (eg, literacy level, language proficiency, medication affordability, food insecurity, housing, and transportation barriers) when managing stroke risk factors is recommended to reduce healthcare disparities. (Level of Evidence: C-EO)
2. In patients with stroke or TIA, monitoring the achievement of nationally accepted, evidence-based performance measures is recommended to allow inequities to be identified and addressed. (Level of Evidence: C-EO)
3. In patients with stroke or TIA, systematic adoption of the Agency for Healthcare Research and Quality Universal Precautions Toolkit for Health Literacy is recommended to integrate health literacy into the secondary prevention of stroke. (Level of Evidence: C-EO)
4. In patients from urban, predominantly minority, or low-socioeconomic-status groups with stroke or TIA, the optimal intervention model for improving stroke risk factor control and reducing disparities is unknown. (Level of Evidence: B-R)
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[3]
1. Administration of IV alteplase in eligible patients without first obtaining MRI to exclude cerebral microbleeds (CMBs) is recommended(Level of Evidence: B-NR)
2.In patients eligible for IV alteplase, because benefit of therapy is time dependent, treatment should be initiated as quickly as possible and not delayed for additional multimodal neuroimaging, such as CT and MRI perfusion imaging.(Level of Evidence: B-NR)
1. In patients with AIS who awake with stroke symptoms or have unclear time of onset > 4.5 hours from last known well or at baseline state, MRI to identify diffusion-positive FLAIR-negative lesions can be useful for selecting those who can benefit from IV alteplase administration within 4.5 hours of stroke symptom recognition.(Level of Evidence: B-R)
1. In patients eligible for IV alteplase, benefit of therapy is time dependent, and treatment should be initiated as quickly as possible. (Level of Evidence: A)
2. In patients undergoing fibrinolytic therapy, physicians should be prepared to treat potential emergent adverse effects, including bleeding complications and angioedema that may cause partial airway obstruction. (Level of Evidence: B-NR)
3. The potential risks should be discussed during IV alteplase eligibility deliberation and weighed against the anticipated benefits during decision- making.Level of Evidence: C-EO)
1. IV alteplase (0.9 mg/kg, maximum dose 90 mg over 60 minutes with initial 10% of dose given as bolus over 1 minute) is recommended for selected patients who can be treated within 3 hours of ischemic stroke symptom onset or patient last known well or at baseline state. Physicians should review the criteria outlined in Table 8 to determine patient eligibility.(Level of Evidence: A)
2. IV alteplase (0.9 mg/kg, maximum dose 90 mg over 60 minutes with initial 10% of dose given as bolus over 1 minute) is also recommended for selected patients who can be treated within 3 and 4.5 hours of ischemic stroke symptom onset or patient last known well or at baseline state. Physicians should review the criteria outlined in Table 8 to determine patient eligibility. (Level of Evidence: B-R)
1.IV alteplase (0.9 mg/kg, maximum dose 90 mg over 60 minutes with initial 10% of dose given as bolus over 1 minute) administered within 4.5 hours of stroke symptom recognition can be beneficial in patients with AIS who awake with stroke symptoms or have unclear time of onset >4.5 hours from last known well or at baseline state and who have a DW-MRI lesion smaller than one-third of the MCA territory and no visible signal change on FLAIR. (Level of Evidence: B-R)
1. Administration of aspirin is recommended in patients with AIS within 24 to 48 hours after onset. For those treated with IV alteplase, aspirin administration is generally delayed until 24 hours later but might be considered in the presence of concomitant conditions for which such treatment given in the absence of IV alteplase is known to provide substantial benefit or withholding such treatment is known to cause substantial risk.(Level of Evidence: A)
2. In patients presenting with minor noncardioembolic ischemic stroke (NIHSS score ≤3) who did not receive IV alteplase, treatment with dual antiplatelet therapy (aspirin and clopidogrel) started within 24 hours after symptom onset and continued for 21 days is effective in reducing recurrent ischemic stroke for a period of up to 90 days from symptom onset. (Level of Evidence: A)
1.The efficacy of the IV glycoprotein IIb/IIIa inhibitors tirofiban and eptifibatide in the treatment of AIS is not well established.(Level of Evidence: B-R)
1. The usefulness of urgent anticoagulation in patients with severe stenosis of an internal carotid artery ipsilateral to an ischemic stroke is not well established.(Level of Evidence: B-R)
2. The safety and usefulness of short-term anticoagulation for nonocclusive, extracranial intraluminal thrombus in the setting of AIS are not well established.. (Level of Evidence: C-LD)
3. At present, the usefulness of argatroban, dabigatran, or other thrombin inhibitors for the treatment of patients with AIS is not well established. (Level of Evidence: B-R)
4. The safety and usefulness of oral factor Xa inhibitors in the treatment of AIS are not well established.(Level of Evidence: C-LD)
2018 AHA/ASA Guidelines for the early Management of Acute Ischemic Stroke
The AHA/ASA published the following guidelines for management of acute ischemic stroke in March, 2018:[4]
"1. To increase both the number of patients who are treated and the quality of care, educational stroke programs for physicians, hospital personnel, and EMS personnel are recommended. (Level of Evidence: B)"
"2. Activation of the 9-1-1 system by patients or other members of the public is strongly recommended. Dispatchers should make stroke a priority dispatch, and transport times should be minimized. (Level of Evidence: B)"
"3. Prehospital care providers should use prehospital stroke assessment tools, such as the Los Angeles, Prehospital Stroke Screen or Cincinnati Prehospital Stroke Scale . (Level of Evidence: B)"
"4. EMS personnel should begin the initial management of stroke in the field. Development of a stroke protocol to be used by EMS personnel is strongly encouraged. (Level of Evidence: B)"
"5. Patients should be transported rapidly to the closest available certified PSC or CSC or, if no such centers exist, the most appropriate institution that provides emergency stroke care as described in the statement. (Level of Evidence: A)"
"6. EMS personnel should provide prehospital notification to the receiving hospital that a potential stroke patient is en route so that the appropriate hospital resources may be mobilized before patient arrival. (Level of Evidence: B)"
Designation of Stroke Centers and Stroke Care, Quality Improvement Process
"1. The creation of PSCs is recommended. The organization of such resources will depend on local resources. The stroke system design of regional ASRHs and PSCs that provide emergency care and that are closely associated with a CSC, which provides more extensive care, has considerable appeal. (Level of Evidence: B)"
"2. Certification of stroke centers by an independent external body, such as TJC or state health department, is recommended. Additional medical centers should seek such certification. (Level of Evidence: B)"
"3. Healthcare institutions should organize a multidisciplinary quality improvement committee to review and monitor stroke care quality benchmarks, indicators, evidence-based practices, and outcomes. The formation of a clinical process improvement team and the establishment of a stroke care data bank are helpful for such quality of care assurances. The data repository can be used to identify the gaps or disparities in quality stroke care. Once the gaps have been identified, specific interventions can be initiated to address these gaps or disparities. (Level of Evidence: B)"
"4. For patients with suspected stroke, EMS should bypass hospitals that do not have resources to treat stroke and go to the closest facility most capable of treating acute stroke. (Level of Evidence: B)"
"5. For sites without in-house imaging interpretation expertise, teleradiology systems approved by the Food and Drug Administration (FDA) or equivalent organization are recommended for timely review of brain CT and MRI scans in patients with suspected acute stroke. (Level of Evidence: B)"
"6. When implemented within a telestroke network, teleradiology systems approved by the FDA (or equivalent organization) are useful in supporting rapid imaging interpretation in time for fibrinolysis decision making. (Level of Evidence: B)"
"1. Implementation of telestroke consultation in conjunction with stroke education and training for healthcare providers can be useful in increasing the use of intravenous rtPA at community hospitals without access to adequate onsite stroke expertise (Level of Evidence: B)"
"2. The creation of ASRHs can be useful. As with PSCs, the organization of such resources will depend on local resources. The stroke system design of regional ASRHs and PSCs that provide emergency care and that are closely associated with a CSC, which provides more extensive care, has considerable appeal (Level of Evidence: C)"
"1. An organized protocol for the emergency evaluation of patients with suspected stroke is recommended. The goal is to complete an evaluation and to begin fibrinolytic treatment within 60 minutes of the patient’s arrival in an ED. Designation of an acute stroke team that includes physicians, nurses, and laboratory/radiology personnel is encouraged. Patients with stroke should have a careful clinical assessment, including neurological examination. (Level of Evidence: B)"
"2. The use of a stroke rating scale, preferably the NIHSS, is recommended. (Level of Evidence: B)"
"3. A limited number of hematologic, coagulation, and biochemistry tests are recommended during the initial emergency evaluation, and only the assessment of blood glucose must precede the initiation of intravenous rtPA. (Level of Evidence: B)"
"4. Baseline electrocardiogram assessment is recommended in patients presenting with acute ischemic stroke but should not delay initiation of intravenous rtPA. (Level of Evidence: B)"
"5. Baseline troponin assessment is recommended in patients presenting with acute ischemic stroke but should not delay initiation of intravenous rtPA. (Level of Evidence: C)"
"1. The usefulness of chest radiographs in the hyperacute stroke setting in the absence of evidence of acute pulmonary, cardiac, or pulmonary vascular disease is unclear. If obtained, they should not unnecessarily delay administration of fibrinolysis. (Level of Evidence: B)"
Parenchymal Brain Imaging
Recommendations for Patients With Acute Cerebral Ischemic Symptoms That Have Not Yet Resolved
"1. Emergency imaging of the brain is recommended before initiating any specific therapy to treat acute ischemic stroke. In most instances, NECT will provide the necessary information to make decisions about emergency management. (Level of Evidence: A)"
"2. Either NECT or MRI is recommended before intravenous rtPA administration to exclude ICH (absolute contraindication) and to determine whether CT hypodensity or MRI hyperintensity of ischemia is present. (Level of Evidence: A)"
"3. Intravenous fibrinolytic therapy is recommended in the setting of early ischemic changes (other than frank hypodensity) on CT, regardless of their extent.(Level of Evidence: A)"
"4. A noninvasive intracranial vascular study is strongly recommended during the initial imaging evaluation of the acute stroke patient if either intra-arterial fibrinolysis or mechanical thrombectomy is contemplated for management but should not delay intravenous rtPA if indicated (Level of Evidence: B)"
"5. In intravenous fibrinolysis candidates, the brain imaging study should be interpreted within 45 minutes of patient arrival in the ED by a physician with expertise in reading CT and MRI studies of the brain parenchyma (Class I; Level of Evidence C) . (Level of Evidence: C)"
"1. CT perfusion and MRI perfusion and diffusion imaging, including measures of infarct core and penumbra, may be considered for the selection of patients for acute reperfusion therapy beyond the time windows for intravenous fibrinolysis. These techniques provide additional information that may improve diagnosis, mechanism, and severity of ischemic stroke and allow more informed clinical decision making. (Level of Evidence: B)"
"1. Frank hypodensity on NECT may increase the risk of hemorrhage with fibrinolysis and should be considered in treatment decisions. If frank hypodensity involves more than one third of the MCA territory, intravenous rtPA treatment should be withheld. (Level of Evidence: A)"
Recommendations for Patients With Cerebral Ischemic Symptoms That Have Resolved
"1. Noninvasive imaging of the cervical vessels should be performed routinely as part of the evaluation of patients with suspected TIAs. (Level of Evidence: A)"
"2. Noninvasive imaging by means of CTA or MRA of the intracranial vasculature is recommended to exclude the presence of proximal intracranial stenosis and/or occlusion and should be obtained when knowledge of intracranial stenoocclusive disease will alter management. Reliable diagnosis of the presence and degree of intracranial stenosis requires the performance of catheter angiography to confirm abnormalities detected with noninvasive testing.(Level of Evidence: A)"
"3. Patients with transient ischemic neurological symptoms should undergo neuroimaging evaluation within 24 hours of symptom onset or as soon as possible in patients with delayed presentations. MRI, including DWI, is the preferred brain diagnostic imaging modality. If MRI is not available, head CT should be performed. (Level of Evidence: B)"
General Supportive Care and Treatment of Acute Complications
"1. Cardiac monitoring is recommended to screen for atrial fibrillation and other potentially serious cardiac arrhythmias that would necessitate emergency cardiac interventions. Cardiac monitoring should be performed for at least the first 24 hours. (Level of Evidence: B)"
"2. Patients who have elevated blood pressure and are otherwise eligible for treatment with intravenous rtPA should have their blood pressure carefully lowered so that their systolic blood pressure is <185 mm Hg and their diastolic blood pressure is <110 mm Hg before fibrinolytic therapy is initiated. If medications are given to lower blood pressure, the clinician should be sure that the blood pressure is stabilized at the lower level before beginning treatment with intravenous rtPA and maintained below 180/105 mm Hg for at least the first 24 hours after intravenous rtPA treatment. (Level of Evidence: B)"
"3. Airway support and ventilatory assistance are recommended for the treatment of patients with acute stroke who have decreased consciousness or who have bulbar dysfunction that causes compromise of the airway. (Level of Evidence: C)"
"4. Supplemental oxygen should be provided to maintain oxygen saturation >94%. (Level of Evidence: C)"
"5. Sources of hyperthermia (temperature >38°C) should be identified and treated, and antipyretic medications should be administered to lower temperature in hyperthermic patients with stroke. (Level of Evidence: C)"
"6. 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 fibrinolysis Patients with transient ischemic neurological symptoms should undergo neuroimaging evaluation within 24 hours of symptom onset or as soon as possible in patients with delayed presentations. MRI, including DWI, is the preferred brain diagnostic imaging modality. If MRI is not available, head CT should be performed. (Level of Evidence: C )"
"7. In patients with markedly elevated blood pressure who do not receive fibrinolysis, a reasonable goal is to lower blood pressure by 15% during the first 24 hours after onset of stroke. The level of blood pressure that would mandate such treatment is not known, but consensus exists that medications should be withheld unless the systolic blood pressure is >220 mm Hg or the diastolic blood pressure is >120 mm Hg. (Level of Evidence: C)"
"8. Hypovolemia should be corrected with intravenous normal saline, and cardiac arrhythmias that might be reducing cardiac output should be corrected. (Level of Evidence: C)"
"9. Hypoglycemia (blood glucose <60 mg/dL) should be treated in patients with acute ischemic stroke. (Level of Evidence: C)"
"1. Evidence from one clinical trial indicates that initiation of antihypertensive therapy within 24 hours of stroke is relatively safe. Restarting antihypertensive medications is reasonable after the first 24 hours for patients who have preexisting hypertension and are neurologically stable unless a specific contraindication to restarting treatment is known. (Level of Evidence: B)"
"2. No data are available to guide selection of medications for the lowering of blood pressure in the setting of acute ischemic stroke.(Level of Evidence: C)"
"3. Evidence indicates that persistent in-hospital hyperglycemia during the first 24 hours after stroke is associated with worse outcomes than normoglycemia, and thus, it is reasonable to treat hyperglycemia to achieve blood glucose levels in a range of 140 to 180 mg/dL and to closely monitor to prevent hypoglycemia in patients with acute ischemic stroke. (Level of Evidence: C)"
"1. The management of arterial hypertension in patients not undergoing reperfusion strategies remains challenging. Data to guide recommendations for treatment are inconclusive or conflicting. Many patients have spontaneous declines in blood pressure during the first 24 hours after onset of stroke. Until more definitive data are available, the benefit of treating arterial hypertension in the setting of acute ischemic stroke is not well established. Patients who have malignant hypertension or other medical indications for aggressive treatment of blood pressure should be treated accordingly. (Level of Evidence: C)"
"1. Intravenous alteplase [rtPA] (0.9 mg/kg, maximum dose 90 mg over 60 minutes with initial 10% of dose given as bolus over 1 minute) is recommended for selected patients who may be treated within 3 hours of onset of ischemic stroke. (Level of Evidence: A)"
"2. In patients eligible for intravenous rtPA, benefit of therapy is time dependent, and treatment should be initiated as quickly as possible. The door-to-needle time (time of bolus administration) should be within 60 minutes from hospital arrival . (Level of Evidence: A)"
"3. Intravenous rtPA (0.9 mg/kg, maximum dose 90mg) is recommended for administration to eligible patients who can be treated in the time period of 3 to 4.5 hours after stroke onset. The eligibility criteria for treatment in this time period are similar to those for people treated at earlier time periods within 3 hours, with the following additional exclusion criteria: patients >80 years old, those taking oral anticoagulants regardless of INR, those with a baseline NIHSS score >25, those with imaging evidence of ischemic injury involving more than one third of the MCA territory, or those with a history of both stroke and diabetes mellitus. . (Level of Evidence: B)"
"4. Intravenous rtPA is reasonable in patients whose blood pressure can be lowered safely (to below 185/110 mm Hg) with antihypertensive agents, withthe physician assessing the stability of the blood pressure before starting intravenous rtPA .(Level of Evidence: B)"
"5. In patients undergoing fibrinolytic therapy, physicians should be aware of and prepared to emergently treat potential side effects, including bleeding complications and angioedema that may cause partial airway obstruction. (Level of Evidence: B)"
"1. Intravenous rtPA is reasonable in patients with a seizure at the time of onset of stroke if evidence suggests that residual impairments are secondary to stroke and not a postictal phenomenon. (Level of Evidence: C)"
"2. In otherwise eligible patients who have had a previously demonstrated small number (1–10) of CMBs on MRI, administration of intravenous alteplase is reasonable
"3. Intravenous alteplase for adults presenting with an acute ischemic stroke (AIS) with known sickle cell disease can be beneficial.
"4. Given the extremely low risk of unsuspected abnormal platelet counts or coagulation studies in a population, it is reasonable that urgent intravenous alteplase treatment not be delayed while waiting for hematologic or coagulation testing if there is no reason to suspect an abnormal test.
"1. The effectiveness of sonothrombolysis for treatment of patients with acute stroke is not well established. (Level of Evidence: B)"
"2. The usefulness of intravenous administration of tenecteplase, reteplase, desmoteplase, urokinase, or other fibrinolytic agents and the intravenous administration of ancrod or other defibrinogenating agents is not well established, and they should only be used in the setting of a clinical trial. (Level of Evidence: B)"
"3. The effectiveness of intravenous treatment with rtPA is not well established and requires further study for patients who can be treated in the time period of 3 to 4.5 hours after stroke but have 1 or more of the following exclusion criteria: (1) patients >80 years old, (2) those taking oral anticoagulants, even with INR ≤1.7, (3) those with a baseline NIHSS score >25, or (4) those with a history of both stroke and diabetes mellitus. (Level of Evidence: C)"
"4. Use of intravenous fibrinolysis in patients with conditions of mild stroke deficits, rapidly improving stroke symptoms, major surgery in the preceding 3 months, and recent myocardial infarction may be considered, and potential increased risk should be weighed against the anticipated benefits. (Level of Evidence: C)"
"5.In otherwise eligible patients who have had a previously demonstrated high burden of CMBs (>10) on MRI, treatment with IV alteplase may be associated with an increased risk of intra-cranial hemorrhage, and the benefits of treatment are uncertain. Treatment may be reasonable if there is the potential for substantial benefit
"6.The risk of antithrombotic therapy within the first 24 hours after treatment with IV alteplase (with or without EVT) is uncertain. Use might be considered in the presence of concomitant conditions for which such treatment given in the absence of IV alteplase is known to provide substantial benefit or withholding such treatment is known to cause substantial risk
"7.Tenecteplase administered as a 0.4-mg/kg single intravenous bolus has not been proven to be superior or noninferior to alteplase but might be considered as an alternative to alteplase in patients with minor neurological impairment and no major intracranial occlusion.
"1. The intravenous administration of streptokinase for treatment of stroke is not recommended. (Level of Evidence: A)"
"2. The use of intravenous rtPA in patients taking direct thrombin inhibitors or direct factor Xa inhibitors may be harmful and is not recommended unless
sensitive laboratory tests such as aPTT, INR, platelet count, and ECT, TT, or appropriate direct factor Xa activity assays are normal, or the patient has not
received a dose of these agents for >2 days (assuming normal renal metabolizing function). Similar consideration should be given to patients being considered
"3. The benefit of IV defibrinogenating agents and of IV fibrinolytic agents other than alteplase and tenecteplase is unproven; therefore, their administration is not recommended outside a clinical trial.
"4. The use of sonothrombolysis as adjuvant therapy with IV thrombolysis is not recommended.
Management after Systemic Intravenous Fibrinolytic Therapy
Admit the patient to intensive care unit or stroke unit for monitoring
If the patient develops severe headache, acute hypertension, nausea, or vomiting or has a worsening neurological examination, discontinue the infusion (if IV alteplase is being administered) and obtain emergency head CT scan
Measure BP and perform neurological assessments every 15 min during and after IV alteplase infusion for 2 h, then every 30 min for 6 h, then hourly until 24 h after IV alteplase treatment
Increase the frequency of BP measurements if SBP is >180 mmHg or if DBP is >105 mmHg; administer antihypertensive medications to maintain BP at or below these levels
Delay placement of nasogastric tubes, indwelling bladder catheters, or intraarterial pressure catheters if the patient can be safely managed without them
Obtain a follow-up CT or MRI scan at 24 h after IV alteplase before starting anticoagulants or antiplatelet agents
"1. Patients eligible for intravenous rtPA should receive intravenous rtPA even if intra-arterial treatments are being considered. (Level of Evidence: A)"
"2. Intra-arterial fibrinolysis is beneficial for treatment of carefully selected patients with major ischemic strokes of <6 hours’ duration caused by occlusions of the MCA who are not otherwise candidates for intravenous rtPA. The optimal dose of intra-arterial rtPA is not well established, and rtPA does not have FDA approval for intra-arterial use. (Level of Evidence: B)"
"3. As with intravenous fibrinolytic therapy, reduced time from symptom onset to reperfusion with intraarterial therapies is highly correlated with better clinical outcomes, and all efforts must be undertaken to minimize delays to definitive therapy. (Level of Evidence: B)"
"4.Initial treatment with intra-arterial thrombolysis is beneficial for carefully selected patients with major ischemic strokes of <6 hours’ duration caused by occlusions of the MCA (Level of Evidence B)
"5. When mechanical thrombectomy is pursued, stent retrievers such as Solitaire FR and Trevo are generally preferred to coil retrievers such as Merci. The relative effectiveness of
the Penumbra System versus stent retrievers is not yet characterized. ( (Level of Evidence: A)"
"6.Patients should receive mechanical thrombectomy with a stent retriever if they meet all the following criteria: (1) prestroke mRS score of 0 to 1; (2) causative occlusion of the internal carotid artery or MCA segment 1 (M1); (3) age ≥18 years; (4) NIHSS score of ≥6; (5) ASPECTS of ≥6; and (6) treatment can be initiated (groin puncture) within 6 hours of symptom onset
"7.In selected patients with AIS within 6 to 16 hours of last known normal who have LVO in the anterior circulation and meet other DAWN or DEFUSE 3 eligibility criteria, mechanical thrombectomy is recommended.
"8.The technical goal of the thrombectomy procedure should be reperfusion to a modified Thrombolysis in Cerebral Infarction (mTICI) 2b/3 angiographic result to maximize the probability of a good functional clinical outcome.
"9.Reduced time from symptom onset to reperfusion with endovascular therapies is highly associated with better clinical outcomes. To ensure benefit, reperfusion to TICI grade 2b/3 should be achieved as early as possible within the therapeutic window
"1. The Merci, Penumbra System, Solitaire FR, and Trevo thrombectomy devices can be useful in achieving recanalization alone or in combination with pharmacological fibrinolysis in carefully selected patients. Their ability to improve patient outcomes has not yet been established. These devices should continue to be studied in randomized controlled trials to determine the efficacy of such treatments in improving patient outcomes. (Level of Evidence: B)"
"2. Intra-arterial fibrinolysis or mechanical thrombectomy is reasonable in patients who have contraindications to the use of intravenous fibrinolysis. (Level of Evidence: C)"
"3.In selected patients with AIS within 16 to 24 hours of last known normal who have LVO in the anterior circulation and meet other DAWN eligibility criteria, mechanical thrombectomy is reasonable.
"4.The use of a proximal balloon guide catheter or a large-bore distal-access catheter, rather than a cervical guide catheter alone, in conjunction with stent retrievers may be beneficial. Future studies should examine which systems provide the highest recanalization rates with the lowest risk for nontarget embolization.
"5.Select an anesthetic technique during endovascular therapy (EVT) for AIS on the basis of individualized assessment of patient risk factors, technical performance of the procedure, and other clinical characteristics. Further randomized trial data are needed.
"6.In patients who undergo mechanical thrombectomy, it is reasonable to maintain the BP ≤180/105 mmHg during and for 24 hours after the procedure.
"1. Rescue intra-arterial fibrinolysis or mechanical thrombectomy may be reasonable approaches to recanalization in patients with large-artery occlusion who have not responded to intravenous fibrinolysis. Additional randomized trial data are needed. (Level of Evidence: B)"
"2. The usefulness of mechanical thrombectomy devices other than the Merci retriever, the Penumbra System, Solitaire FR, and Trevo is not well established. (Level of Evidence: C )"
"3. The usefulness of emergent intracranial angioplasty and/or stenting is not well established. These procedures should be used in the setting of clinical trials. (Level of Evidence: C)"
"4. The usefulness of emergent angioplasty and/or stenting of the extracranial carotid or vertebral arteries in unselected patients is not well established. Use of these techniques may be
considered in certain circumstances, such as in the treatment of acute ischemic stroke resulting from cervical atherosclerosis or dissection. Additional randomized trial data are needed (Level of Evidence: C)"
"5.Although the benefits are uncertain, the use of mechanical thrombectomy with stent retrievers may be reasonable for carefully selected patients with AIS in whom treatment can be initiated (groin puncture) within 6 hours of symptom onset and who have causative occlusion of the MCA segment 2 (M2) or MCA segment 3 (M3) portion of the MCAs
"6.Although the benefits are uncertain, the use of mechanical thrombectomy with stent retrievers may be reasonable for carefully selected patients with AIS in whom treatment can be initiated (groin puncture) within 6 hours of symptom onset and who have causative occlusion of the anterior cerebral arteries, vertebral arteries, basilar artery, or posterior cerebral arteries.
"7.Although its benefits are uncertain, the use of mechanical thrombectomy with stent retrievers may be reasonable for patients with AIS in whom treatment can be initiated (groin puncture) within 6 hours of symptom onset and who have prestroke mRS score >1, ASPECTS <6, or NIHSS score <6, and causative occlusion of the internal carotid artery (ICA) or proximal MCA (M1). Additional randomized trial data are needed.
"8.The use of mechanical thrombectomy devices other than stent retrievers as first-line devices for mechanical thrombectomy may be reasonable in some circumstances, but stent retrievers remain the first choice.
"9.Use of salvage technical adjuncts including intra-arterial thrombolysis may be reasonable to achieve mTICI 2b/3 angiographic results.
"10.Endovascular therpy (EVT) of tandem occlusions (both extracranial and intracranial occlusions) at the time of thrombectomy may be reasonable
"11.In patients who undergo mechanical thrombectomy with successful reperfusion, it might be reasonable to maintain BP at a level <180/105 mmHg.
"1. At present, the usefulness of argatroban or other thrombin inhibitors for treatment of patients with acute ischemic stroke is not well established. These agents should be used in the setting of clinical trials. (Level of Evidence: B)"
"2. The usefulness of urgent anticoagulation in patients with severe stenosis of an internal carotid artery ipsilateral to an ischemic stroke is not well established. (Level of Evidence: B)"
"1. Urgent anticoagulation, with the goal of preventing early recurrent stroke, halting neurological worsening, or improving outcomes after acute ischemic stroke, is not recommended for treatment of patients with acute ischemic stroke. (Level of Evidence: C)"
"2. Urgent anticoagulation for the management of noncerebrovascular conditions is not recommended for patients with moderate-to-severe strokes because of an increased risk of serious intracranial hemorrhagic complications. (Level of Evidence: A)"
"3. Initiation of anticoagulant therapy within 24 hours of treatment with intravenous rtPA is not recommended. (Level of Evidence: B)"
"1. Administration of aspirin is recommended in patients with AIS within 24 to 48 hours after onset. For those treated with IV alteplase, aspirin administration is generally delayed until 24 hours later but might be considered in the presence of concomitant conditions for which such treatment given in the absence of IV alteplase is known to provide substantial benefit or withholding such treatment is known to cause substantial risk.. (Level of Evidence: A)"
"1. The usefulness of clopidogrel for the treatment of acute ischemic stroke is not well established. Further research testing the usefulness of the emergency administration of clopidogrel
in the treatment of patients with acute stroke is required (Level of Evidence: C)"
"2. The efficacy of intravenous tirofiban and eptifibatide is not well established, and these agents should be used only in the setting of clinical trials. (Level of Evidence: C)"
"1. Aspirin is not recommended as a substitute for other acute interventions for treatment of stroke, including intravenous rtPA. (Level of Evidence: B)"
"2. The administration of other intravenous antiplatelet agents that inhibit the glycoprotein IIb/IIIa receptor is not recommended. Further research testing the usefulness of emergency administration
of these medications as a treatment option in patients with acute ischemic stroke is required. (Level of Evidence: B)"
"3. The administration of aspirin (or other antiplatelet agents) as an adjunctive therapy within 24 hours of intravenous fibrinolysis is not recommended. (Level of Evidence: C)"
Volume Expansion, Vasodilators, and Induced Hypertension
"1. In exceptional cases with systemic hypotension producing neurological sequelae, a physician may prescribe vasopressors to improve cerebral blood flow. If drug-induced hypertension is used, close neurological and cardiac monitoring is recommended. (Level of Evidence: C)"
"1. The administration of high-dose albumin is not well established as a treatment for most patients with acute ischemic stroke until further definitive evidence regarding efficacy becomes available. (Level of Evidence: B)"
"2. At present, use of devices to augment cerebral blood flow for the treatment of patients with acute ischemic stroke is not well established. These devices should be used in the setting of clinical trials. (Level of Evidence: B)"
"3. The usefulness of drug-induced hypertension in patients with acute ischemic stroke is not well established. Induced hypertension should be performed in the setting of clinical trials . (Level of Evidence: B)"
"1. Hemodilution by volume expansion is not recommended for treatment of patients with acute ischemic stroke (Level of Evidence: A)"
"2. The administration of vasodilatory agents, such as pentoxifylline, is not recommended for treatment of patients with acute ischemic stroke. (Level of Evidence: A)"
"1. Hemodilution by volume expansion is not recommended for treatment of patients with acute ischemic stroke (Level of Evidence: A)"
"2. The administration of vasodilatory agents, such as pentoxifylline, is not recommended for treatment of patients with acute ischemic stroke. (Level of Evidence: A)"
"3. The administration of vasodilatory agents, such as pentoxifylline, is not recommended for treatment of patients with acute ischemic stroke. (Level of Evidence: A)"
"1. Among patients already taking statins at the time of onset of ischemic stroke, continuation of statin therapy during the acute period is reasonable. (Level of Evidence: B)"
"1. The utility of induced hypothermia for the treatment of patients with ischemic stroke is not well established, and further trials are recommended. (Level of Evidence: B)"
"2. At present, transcranial near-infrared laser therapy is not well established for the treatment of acute ischemic stroke, and further trials are recommended. (Level of Evidence: B)"
"1. At present, no pharmacological agents with putative neuroprotective actions have demonstrated efficacy in improving outcomes after ischemic stroke, and therefore, other neuroprotective agents are not recommended. (Level of Evidence: A)"
"2. Data on the utility of hyperbaric oxygen are inconclusive, and some data imply that the intervention may be harmful. Thus, with the exception of stroke secondary to air embolization, this intervention is not recommended for treatment of patients with acute ischemic stroke . (Level of Evidence: B)"
"1. The usefulness of emergent or urgent CEA when clinical indicators or brain imaging suggests a small infarct core with large territory at risk (eg, penumbra), compromised by inadequate flow from a critical carotid stenosis or occlusion, or in the case of acute neurological deficit after CEA, in which acute thrombosis of the surgical site is suspected, is not well established (. (Level of Evidence: B)"
"2. In patients with unstable neurological status (either stroke-in-evolution or crescendo TIA), the efficacy of emergent or urgent CEA is not well established. (Level of Evidence: B)"
"3.Patients eligible for IV alteplase should receive IV alteplase even if EVTs are being considered.
"1. The use of comprehensive specialized stroke care (stroke units) that incorporates rehabilitation is recommended. (Level of Evidence: A)"
"2. Patients with suspected pneumonia or UTIs should be treated with appropriate antibiotics. (Level of Evidence: A)"
"3. Airway support and ventilatory assistance are recommended for the treatment of patients with acute stroke who have decreased consciousness or who have bulbar dysfunction that causes compromise of the airway. (Level of Evidence C)
"4. Supplemental oxygen should be provided to maintain oxygen saturation >94%. (Level of Evidence C)
"5. In patients with AIS, early treatment of hypertension is indicated when required by comorbid conditions (eg, concomitant acute coronary event, acute heart failure, aortic dissection, postthrombolysis sICH, or preeclampsia/eclampsia). Lowering BP initially by 15% is probably safe. (Level of Evidence C)
"6. Subcutaneous administration of anticoagulants is recommended for treatment of immobilized patients. (Level of Evidence: A)"
"7. The use of standardized stroke care order sets is recommended to improve general management. (Level of Evidence: B)"
"8. Assessment of swallowing before the patient begins eating, drinking, or receiving oral medications is recommended. (Level of Evidence: B)"
"9. Patients who cannot take solid food and liquids orally should receive NG, nasoduodenal, or PEG tube feedings to maintain hydration and nutrition while undergoing efforts to restore swallowing. (Level of Evidence: B)"
"10. Early mobilization of less severely affected patients and measures to prevent subacute complications of stroke are recommended. (Level of Evidence: C)"
"11. Treatment of concomitant medical diseases is recommended. (Level of Evidence: C)"
12. Early institution of interventions to prevent recurrent stroke is recommended. (Level of Evidence: C)"
"1. The use of aspirin is reasonable for treatment of patients who cannot receive anticoagulants for DVT prophylaxis (. (Level of Evidence: A)"
"2. In selecting between NG and PEG tube routes of feeding in patients who cannot take solid food or liquids orally, it is reasonable to prefer NG tube feeding until 2 to 3 weeks after stroke onset. (Level of Evidence: B)"
"3. The use of intermittent external compression devices is reasonable for treatment of patients who cannot receive anticoagulants. (Level of Evidence: B)"
"1. Routine use of nutritional supplements has not been shown to be beneficial. (Level of Evidence: B)"
"2. Routine use of prophylactic antibiotics has not been shown to be beneficial. (Level of Evidence: B)"
"3. Routine placement of indwelling bladder catheters is not recommended because of the associated risk of catheter-associated UTIs. (Level of Evidence: C)"
"1. Patients with major infarctions are at high risk for complicating brain edema and increased ICP. Measures to lessen the risk of edema and close monitoring of the patient for signs of neurological worsening during the first days after stroke are recommended. Early transfer of patients at risk for malignant brain edema to an institution with neurosurgical expertise should be considered. (Level of Evidence: A)"
"2. Decompressive surgical evacuation of a space-occupying cerebellar infarction is effective in preventing and treating herniation and brain stem compression. (Level of Evidence: B)"
"3. Decompressive surgery for malignant edema of the cerebral hemisphere is effective and potentially lifesaving. Advanced patient age and patient/family valuations of achievable outcome states may affect decisions regarding surgery. (Level of Evidence: B)"
"4. Recurrent seizures after stroke should be treated in a manner similar to other acute neurological conditions, and antiepileptic agents should be selected by specific patient characteristics. (Level of Evidence: B)"
"5. Placement of a ventricular drain is useful in patients with acute hydrocephalus secondary to ischemic stroke. (Level of Evidence: C)"
"1. Although aggressive medical measures have been recommended for treatment of deteriorating patients with malignant brain edema after large cerebral infarction, the usefulness of these measures is not well established. (Level of Evidence: C)"
"1. Because of lack of evidence of efficacy and the potential to increase the risk of infectious complications, corticosteroids (in conventional or large doses) are not recommended for treatment of cerebral edema and increased ICP complicating ischemic stroke. (Level of Evidence: A)"
"2. Prophylactic use of anticonvulsants is not recommended. (Level of Evidence: C)"
References
↑Prabhakaran S, Gonzalez NR, Zachrison KS, Adeoye O, Alexandrov AW, Ansari SA, Chapman S, Czap AL, Dumitrascu OM, Ishida K, Jadhav AP, Johnson B, Johnston KC, Khatri P, Kimberly WT, Lee VH, Leslie-Mazwi TM, Mac Grory B, Madsen TE, Menon B, Mistry EA, Park S, Parker S, Pérez de la Ossa N, Reeves M, Saiz T, Scott PA, Schwartzberg D, Sheth SA, Sporns PB, Times S, Tjoumakaris S, Wolfe SQ, Yaghi S; et al. (2026). "2026 Guideline for the Early Management of Patients With Acute Ischemic Stroke: A Guideline From the American Heart Association/American Stroke Association". Stroke. 57. doi:10.1161/STR.0000000000000513. PMID41582814Check |pmid= value (help).CS1 maint: Multiple names: authors list (link)
↑Kleindorfer DO, Towfighi A, Chaturvedi S, Cockroft KM, Gutierrez J, Lombardi-Hill D, Kamel H, Kernan WN, Kittner SJ, Leira EC, Lennon O, Meschia JF, Nguyen TN, Pollak PM, Santangeli P, Sharrief AZ, Smith SC, Turan TN, Williams LS (July 2021). "2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack: A Guideline From the American Heart Association/American Stroke Association". Stroke. 52 (7): e364–e467. doi:10.1161/STR.0000000000000375. PMID34024117Check |pmid= value (help).
↑Powers, William J.; Rabinstein, Alejandro A.; Ackerson, Teri; Adeoye, Opeolu M.; Bambakidis, Nicholas C.; Becker, Kyra; Biller, José; Brown, Michael; Demaerschalk, Bart M.; Hoh, Brian; Jauch, Edward C.; Kidwell, Chelsea S.; Leslie-Mazwi, Thabele M.; Ovbiagele, Bruce; Scott, Phillip A.; Sheth, Kevin N.; Southerland, Andrew M.; Summers, Deborah V.; Tirschwell, David L. (2018). "2018 Guidelines for the Early Management of Patients With Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association". Stroke. 49 (3). doi:10.1161/STR.0000000000000158. ISSN0039-2499.