A guideline for Healthcare Professionals From the American Heart Association/American Stroke Association






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  • AHA/ASA Guideline


Guidelines for the Early Management of Patients With Acute Ischemic Stroke
A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association

( American Heart Association Stroke Council, Council on Cardiovascular Nursing, Council on Peripheral Vascular Disease, and Council on Clinical Cardiology ) .


Edward C. Jauch, et al *
Stroke. 2013;44:870-947.

_______________________________________________________________

Recopilacion y Traducción:



JC. Vergara. (Marzo 2013)



Jauch et al, Early Management of Acute Ischemic Stroke
Recommendations
Prehospital Stroke Management
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 (Class I; Level of Evidence B).

(Unchanged from the previous guideline)
2. Activation of the 911 system by patients or other members

of the public is strongly recommended (Class I;

Level of Evidence B). 911 Dispatchers should make

stroke a priority dispatch, and transport times should be

minimized. (Unchanged from the previous guideline)
3. Prehospital care providers should use prehospital stroke

assessment tools, such as the Los Angeles Prehospital

Stroke Screen or Cincinnati Prehospital Stroke Scale

(Class I; Level of Evidence B). (Unchanged from the

previous guideline)
4. EMS personnel should begin the initial management

of stroke in the field, as outlined in Table 4 in the full

text of the guideline (Class I; Level of Evidence B).

Development of a stroke protocol to be used by EMS

personnel is strongly encouraged. (Unchanged from the

previous guideline)
5. Patients should be transported rapidly to the closest

available certified primary stroke center or comprehensive

stroke center or, if no such centers exist, the most

appropriate institution that provides emergency stroke

care as described in the statement (Class I; Level of

Evidence A). In some instances, this may involve air

medical transport and hospital bypass. (Revised from the

previous guideline)
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 (Class I; Level of

Evidence B). (Revised from the previous guideline)

Designation of Stroke Centers and Stroke Care

Quality Improvement Process
1. The creation of primary stroke centers is recommended

(Class I; Level of Evidence B). The organization of such

resources will depend on local resources….. .
2. …
3. Healthcare institutions should organize a multidisciplinary

quality improvement committee to review and

monitor stroke care quality benchmarks, indicators,

evidence-based practices, and outcomes (Class I; 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 (Class I; Level of Evidence B). (Unchanged from

the previous guideline)
5. For sites without in-house imaging interpretation expertise,

teleradiology systems approved by the Food and

Drug Administration (or equivalent organization) are

recommended for timely review of brain computed

tomography (CT) and magnetic resonance imaging

(MRI) scans in patients with suspected acute stroke

(Class I; Level of Evidence B). (New recommendation)
6. When implemented within a telestroke network, teleradiology systems approved by the Food and Drug

Administration (or equivalent organization) are useful in

supporting rapid imaging interpretation in time for fibrinolysis

decision making (Class I; Level of Evidence B).

(New recommendation)
7. The development of comprehensive stroke centers is recommended (Class I; Level of Evidence C). (Unchanged

from the previous guideline)
8.…
9….

Emergency Evaluation and Diagnosis of Acute

Ischemic Stroke
1. An organized protocol for the emergency evaluation of

patients with suspected stroke is recommended (Class I;

Level of Evidence B). The goal is to complete an evaluation

and to begin fibrinolytic treatment within 60 minutes

of the patient’s arrival in an emergency department.

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.

(Unchanged from the previous guideline)
2. The use of a stroke rating scale, preferably the National

Institutes of Health Stroke Scale (NIHSS), is recommended

(Class I; Level of Evidence B). (Unchanged

from the previous guideline)
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

(Table 8 in the full text of the guideline) (Class I; Level

of Evidence B). (Revised from the previous guideline)
4. Baseline electrocardiogram assessment is recommended

in patients presenting with acute ischemic stroke but

should not delay initiation of intravenous rtPA (Class

I; Level of Evidence B). (Revised from the previous

guideline)
5. Baseline troponin assessment is recommended in

patients presenting with acute ischemic stroke but should

not delay initiation of intravenous rtPA (Class I; Level of

Evidence C). (Revised from the previous guideline)

6. 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 (Class IIb; Level of Evidence B).

(Revised from the previous guideline)

Early Diagnosis: Brain and Vascular Imaging
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 (Class I; Level of Evidence A). In most instances,

non–contrast-enhanced CT will provide the necessary

information to make decisions about emergency management.

(Unchanged from the previous guideline)
2. Either non–contrast-enhanced CT or MRI is recommende before intravenous rtPA administration to exclude intracerebral hemorrhage (absolute contraindication) and to determine whether CT hypodensity or MRI hyperintensity of ischemia is present (Class I; Level of Evidence A). (Revised from the 2009 imaging scientific statement)
3. Intravenous fibrinolytic therapy is recommended in

the setting of early ischemic changes (other than frank

hypodensity) on CT, regardless of their extent (Class I;

Level of Evidence A). (Revised from the 2009 imaging

scientific statement)

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 (Class I; Level of Evidence A). (Revised from the 2009 imaging scientific statement)
5. In intravenous fibrinolysis candidates, the brain imaging

study should be interpreted within 45 minutes of patient

arrival in the emergency department by a physician with

expertise in reading CT and MRI studies of the brain

parenchyma (Class I; Level of Evidence C). (Revised

from the previous guideline)
6. 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 (Class IIb; Level of Evidence

B). (Revised from the 2009 imaging scientific statement)

7. Frank hypodensity on non–contrast-enhanced CT 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 middle

cerebral artery territory, intravenous rtPA treatment

should be withheld (Class III; Level of Evidence A).

(Revised from the 2009 imaging scientific statement)

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 (Class I; Level of Evidence A).

(Unchanged from the 2009 TIA scientific statement)
2. Noninvasive imaging by means of CT angiography or

magnetic resonance angiography of the intracranial vasculature is recommended to exclude the presence of proximal intracranial stenosis and/or occlusion (Class I; level of Evidence A) and should be obtained when knowledge of intracranial steno-occlusive 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. (Revised from the 2009 TIA scientific statement)
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

diffusion-weighted imaging, is the preferred brain diagnostic

imaging modality. If MRI is not available, head

CT should be performed (Class I; Level of Evidence B).

(Unchanged from the 2009 TIA scientific statement)

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 (Class I; Level

of Evidence B). (Revised from the previous guideline)
2. Patients who have elevated blood pressure and are otherwise eligible for treatment with intravenous rtPA should

have their blood pressure carefully lowered (Table 9 in the full text of the guideline) so that their systolic blood pressure is <185 mm Hg and their diastolic blood pressure is <110 mm Hg (Class I; Level of Evidence B) 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. (Unchanged from the previous guideline)
3. Airway support and ventilatory assistance are recommend for the treatment of patients with acute stroke who have decreased consciousness or who have bulbar dysfunction that causes compromise of the airway (Class I; Level of Evidence C). (Unchanged from the previous guideline)
4. Supplemental oxygen should be provided to maintain

oxygen saturation >94% (Class I; Level of Evidence C).

(Revised from the previous guideline)
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 (Class I; Level of Evidence

C). (Unchanged from the previous guideline)

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 (Class I; Level of

Evidence C). (Unchanged from the previous guideline)
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 medication should be withheld unless the systolic blood pressure is>220 mm Hg or the diastolic blood pressure is >120 mm Hg (Class I; Level ofEvidence C). (Revised from the previous guideline)
8. Hypovolemia should be corrected with intravenous normal

saline, and cardiac arrhythmias that might be reducing

cardiac output should be corrected (Class I; Level of

Evidence C). (Revised from the previous guideline)
9. Hypoglycemia (blood glucose <60 mg/dL) should be

treated in patients with acute ischemic stroke (Class I;

Level of Evidence C). The goal is to achieve normoglycemia.

(Revised from the previous guideline)
10. Evidence from one clinical trial indicates that initiation of antihypertensive therapy within 24 hours of stroke is relative 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 (Class IIa; Level ofEvidence B). (Revised from the previous guideline)
11. No data are available to guide selection of medications

for the lowering of blood pressure in the setting of acute

ischemic stroke. The antihypertensive medications and

doses included in Table 9 in the full text of the guideline

are reasonable choices based on general consensus

(Class IIa; Level of Evidence C). (Revised from the previous

guideline)
12. 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 (Class IIa; Level of Evidence

C). (Revised from the previous guideline)
13. 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 (Class

IIb; Level of Evidence C).

Patients who have malignant hypertension or other medical indications for aggressive treatment of blood pressure should be treated accordingly.

(Revised from the previous guideline)
14. Supplemental oxygen is not recommended in nonhypoxic

patients with acute ischemic stroke (Class III; Level of Evidence B). (Unchanged from the previous guideline)
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