AHA/ASA 2018 Guidelines for Early Management of Stroke have been released which are an update to the 2013 guidelines. The earlier ones were published prior to the six positive “early window” mechanical thrombectomy trials (MR CLEAN, ESCAPE, EXTEND-IA, REVASCAT, SWIFT PRIME, THRACE) that emerged in 2015 and 2016. Moreover, lately two trials (DAWN and DEFUSE 3) have shown a clear benefit of “extended window” mechanical thrombectomy for certain patients with large vessel occlusion who could be treated out to 16-24 hours. These guidelines detail prehospital care, urgent and emergency evaluation and treatment with intravenous and intra-arterial therapies, and in-hospital management, including secondary prevention measures that are appropriately instituted within the first 2 weeks.
Major recommendations are as follows:
- The treatment with intravenous (IV) tissue plasminogen activator (tPA) for eligible patients should be initiated as quickly as possible even in patients who may also be candidates for mechanical thrombectomy.
- IV tPA should be administered to all eligible acute stroke patients within 3 hours of last known normal and to a more selective group of eligible acute stroke patients (based on ECASS III exclusion criteria) within 4.5 hours of last known normal.
- All the centers should attempt to achieve door-to-needle times of <60 minutes in ≥50% of stroke patients treated with IV tPA.
- A noncontrast head computed tomography (CT) and glucose are the only required tests prior to the initiation of IV tPA in most patients.
- All centers should attempt to obtain a noncontrast head CT within 20 minutes of arrival in ≥50% of stroke patients who may be candidates for IV tPA or mechanical thrombectomy.
- In patients who may be candidates for mechanical thrombectomy, an urgent CT angiogram or magnetic resonance (MR) angiogram (to look for large vessel occlusion) is recommended, but this study should not delay treatment with IV tPA if indicated.
- All patients ≥18 years should be subjected to mechanical thrombectomy with a stent retriever if they have minimal pre-stroke disability, have a causative occlusion of the internal carotid artery or proximal middle cerebral artery, have a National Institutes of Health stroke scale score of ≥6, have a reassuring noncontrast head CT (ASPECT score of ≥6), and if they can be treated within 6 hours of last known normal. There is no need for these patients to have perfusion imaging (CT-P or MR-P).
- In selected acute stroke patients within 6-24 hours of last known normal who have evidence of a large vessel occlusion in the anterior circulation and would have been eligible for DAWN or DEFUSE 3, obtaining perfusion imaging (CT-P or MR-P) or an MRI with diffusion-weighted imaging (DWI) sequence is recommended to help determine whether the patient is a candidate for mechanical thrombectomy.
- In selected acute stroke patients within 6-16 hours of last known normal who have a large vessel occlusion in the anterior circulation and meet other DAWN or DEFUSE 3 eligibility criteria, mechanical thrombectomy is recommended. In selected acute stroke patients within 6-24 hours of last known normal who have large vessel occlusion in the anterior circulation and meet other DAWN eligibility criteria, mechanical thrombectomy with a stent retriever is reasonable.
- As with IV tPA, treatment with mechanical thrombectomy should be initiated as quickly as possible.
- Administration of aspirin is recommended in acute stroke patients within 24-48 hours after stroke onset. For patients treated with IV tPA, aspirin administration is generally delayed for 24 hours. Urgent anticoagulation (e.g., heparin drip) for most stroke patients is not indicated.
- The use of stroke units that incorporate rehabilitation is recommended for all acute stroke patients.
- It remains unknown whether it would be beneficial for emergency medical services to bypass a closer IV tPA-capable hospital for a thrombectomy-capable hospital. While such an approach may delay IV tPA administration for patients who are and who are not mechanical thrombectomy candidates, this approach would expedite thrombectomy for those who are mechanical thrombectomy candidates.
These guidelines are based on the best evidence currently available and there is an urgent need for continued research on treatment of acute ischemic stroke.
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Dr. Kamal Kant Kohli
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