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






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títuloA guideline for Healthcare Professionals From the American Heart Association/American Stroke Association
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Intravenous Fibrinolysis
1. Intravenous rtPA (0.9 mg/kg, maximum dose 90 mg) is

recommended for selected patients who may be treated

within 3 hours of onset of ischemic stroke (Class I; Level

of Evidence A).

Physicians should review the criteria outlined in Tables 10 and 11 in the full text of the guideline (which are modeled on those used in the National Institute of Neurologic Disorders and Stroke rt-PA Stroke Study) to determine the eligibility of the patient.

A recommended regimen for observation and treatment

of patients who receive intravenous rtPA is described in

Table 12 in the full text of the guideline. (Unchanged

from the previous guideline)
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 (Class I; Level of Evidence A). (New

recommendation)
3. Intravenous rtPA (0.9 mg/kg, maximum dose 90 mg) is

recommended for administration to eligible patients who

can be treated in the time period of 3 to 4.5 hours after

stroke onset (Class I; Level of Evidence B). 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 middle cerebral artery territory,

. or those with a history of both stroke and diabetes mellitus. (Revised from the 2009 IV rtPA Science Advisory)
4. Intravenous rtPA is reasonable in patients whose blood

pressure can be lowered safely (to below 185/110

mm Hg) with antihypertensive agents, with the physician

assessing the stability of the blood pressure before

starting intravenous rtPA (Class I; Level of Evidence B).

(Unchanged from the previous guideline)
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

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

previous guideline)
6. 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 (Class IIa; Level of Evidence C).

(Unchanged from the previous guideline)
7. The effectiveness of sonothrombolysis for treatment of

patients with acute stroke is not well established (Class

IIb; Level of Evidence B). (New recommendation)
8. 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 (Class IIb; Level of Evidence B).

(Revised from the previous guideline)
9. 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 international

normalized ratio ≤1.7,

(3) those with a baseline NIHSS score >25, or

(4) those with a history of both stroke and diabetes mellitus, the effectiveness of intravenous treatment with rtPA is not well-established, (Class IIb, Level of Evidence C), and requires further study.
10. 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 (Class IIb; Level of Evidence C). These circumstance require further study. (New recommendation)
11. The intravenous administration of streptokinase for

treatment of stroke is not recommended (Class III; Level

of Evidence A). (Revised from the previous guideline)
12. 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 activated partial thromboplastin time,

international normalized ratio, platelet count, and ecarin

clotting time, thrombin time, 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 for

intra-arterial rtPA (Class III; Level of Evidence C). (New

recommendation) Further study is required.
Endovascular Interventions
1. Patients eligible for intravenous rtPA should receive

intravenous rtPA even if intra-arterial treatments

are being considered (Class I; Level of Evidence A).

(Unchanged from the previous guideline)
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 middle cerebral artery who are not otherwise candidates for intravenous rtPA (Class I; Level of Evidence B). The optimal dose of intra-arterial rtPA is not well established and rtPA does not have Food and Drug Administration approval for intra-arterial use. (Revised from the previousguideline)
3. As with intravenous fibrinolytic therapy, reduced time

from symptom onset to reperfusion with intra-arterial

therapies is highly correlated with better clinical outcomes,

and all efforts must be undertaken to minimize

delays to definitive therapy (Class I; Level of Evidence

B). (New recommendation)
4. Intra-arterial treatment requires the patient to be at an

experienced stroke center with rapid access to cerebral

angiography and qualified interventionalists. An emphasis

on expeditious assessment and treatment should be

made. Facilities are encouraged to define criteria that

can be used to credential individuals who can perform

intra-arterial revascularization procedures. Outcomes on

all patients should be tracked (Class I; Level of Evidence

C). (Revised from the previous guideline)
5. When mechanical thrombectomy is pursued, stent retrievers such as Solitaire FR and Trevo are generally

preferred to coil retrievers such as Merci (Class I;Level of Evidence A). The relative effectiveness of the Penumbra System versus stent retrievers is not yet characterized. (New recommendation)
6. 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 (Class IIa; Level of Evidence B). 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. (Revised from the previous guideline)
7. Intra-arterial fibrinolysis or mechanical thrombectomy

is reasonable in patients who have contraindications to

the use of intravenous fibrinolysis (Class IIa; Level of

Evidence C). (Revised from the previous guideline)
8. 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 (Class IIb; Level of

Evidence B). (New recommendation)
9. The usefulness of mechanical thrombectomy devices other than the Merci retriever, the Penumbra System, Solitaire FR, and Trevo is not well established (Class IIb; Level of Evidence C). These devices should be used in the setting of clinical trials. (Revised from the previous guideline)
10. The usefulness of emergent intracranial angioplasty

and/or stenting is not well established. These procedures

should be used in the setting of clinical trials (Class IIb;

Level of Evidence C). (New recommendation)
11. The usefulness of emergent angioplasty and/or stenting

of the extracranial carotid or vertebral arteries in

unselected patients is not well established (Class IIb;

Level of Evidence C). 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 (Class IIb; Level

of Evidence C). Additional randomized trial data are

needed. (New recommendation)

Anticoagulants
1. At present, the usefulness of argatroban or other thrombin

inhibitors for treatment of patients with acute ischemic

stroke is not well established (Class IIb; Level of

Evidence B). These agents should be used in the setting

of clinical trials. (New recommendation)
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 (Class IIb;

Level of Evidence B). (New recommendation)
3. Urgent anticoagulation, with the goal of preventing early

recurrent stroke, halting neurological worsening, or improvig outcomes after acute ischemic stroke, is not recommended for treatment of patients with acute ischemic stroke (Class III; Level of Evidence A). (Unchanged from the previous guide)
4. Urgent anticoagulation for the management of noncerebro vascular conditions is not recommended for patients with moderate-to-severe strokes because of an increased

risk of serious intracranial hemorrhagic complications

(Class III; Level of Evidence A). (Unchanged from the

previous guideline)
5. Initiation of anticoagulant therapy within 24 hours of

treatment with intravenous rtPA is not recommended

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

previous guideline)

Antiplatelet Agents
1. Oral administration of aspirin (initial dose is 325 mg)

within 24 to 48 hours after stroke onset is recommended

for treatment of most patients (Class I; Level of Evidence

A). (Unchanged from the previous guideline)
2. The usefulness of clopidogrel for the treatment of acute

ischemic stroke is not well established (Class IIb; Level

of Evidence C). Further research testing the usefulness of

the emergency administration of clopidogrel in the treatment

of patients with acute stroke is required. (Revised

from the previous guideline)
3. The efficacy of intravenous tirofiban and eptifibatide is

not well established, and these agents should be used

only in the setting of clinical trials (Class IIb; Level of

Evidence C). (New recommendation)
4. Aspirin is not recommended as a substitute for other

acute interventions for treatment of stroke, including

intravenous rtPA (Class III; Level of Evidence B).

(Unchanged from the previous guideline)
5. The administration of other intravenous antiplatelet

agents that inhibit the glycoprotein IIb/IIIa receptor is not recommended (Class III; Level of Evidence B).

(Revised from the previous guideline) . Further research

testing the usefulness of emergency administration of

these medications as a treatment option in patients with

acute ischemic stroke is required.
6. The administration of aspirin (or other antiplatelet agents) as an adjunctive therapy within 24 hours of intravenous

fibrinolysis is not recommended (Class III; Level

of Evidence C). (Revised from the previous guideline)


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 druginduced

hypertension is used, close neurological and

cardiac monitoring is recommended (Class I; Level of

Evidence C). (Revised from the previous guideline)
2. 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 (Class IIb; Level of

Evidence B). (New recommendation)


3. At present, use of devices to augment cerebral blood flow

for the treatment of patients with acute ischemic stroke

is not well established (Class IIb; Level of Evidence B).

These devices should be used in the setting of clinical

trials. (New recommendation)
4. The usefulness of drug-induced hypertension in patients

with acute ischemic stroke is not well established (Class

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

guideline) Induced hypertension should be performed in

the setting of clinical trials.
5. Hemodilution by volume expansion is not recommended

for treatment of patients with acute ischemic stroke (Class III; Level of Evidence A). (Revised from the previous guideline)
6. The administration of vasodilatory agents, such as pentoxifylline, is not recommended for treatment of patients

with acute ischemic stroke (Class III; Level of Evidence

A). (Unchanged from the previous guideline)
Neuroprotective Agents
1. Among patients already taking statins at the time of

onset of ischemic stroke, continuation of statin therapy

during the acute period is reasonable (Class IIa; Level of

Evidence B). (New recommendation)
2. The utility of induced hypothermia for the treatment of

patients with ischemic stroke is not well established,

and further trials are recommended (Class IIb; Level of

Evidence B). (Revised from the previous guideline)
3. At present, transcranial near-infrared laser therapy is

not well established for the treatment of acute ischemic

stroke (Class IIb; Level of Evidence B), and further trials

are recommended. (New recommendation)
4. 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 (Class III ;Level of Evidence A). (Revised from the previous guideline)
5. 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 emboli-zation , this intervention is not recommended for treatment of patients with acute ischemic stroke (Class III; Level of Evidence B). (Unchanged from the previous guideline)
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