Hospitalist Clinical Practice Guidelines: 2018 Midyear Review

John Anello; Brian Feinberg; John Heinegg; Yonah Korngold; Richard Lindsey; Cristina Wojdylo; Olivia Wong, DO


July 03, 2018

In This Article

Acute Ischemic Stroke

American Heart Association/American Stroke Association

Patients should be considered for thrombectomy in under 6 hours after stroke onset if they have a large clot in one of the large vessels at the base of the brain and these other criteria:

  • Prestroke modified Rankin Scale (mRS) score of 0 to 1

  • Causative occlusion of the internal carotid artery or middle cerebral artery segment 1 (M1)

  • Age over 18 years

  • National Institutes of Health Stroke Scale score of 6 or greater

  • Alberta Stroke Program Early CT Score of 6 or greater

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 middle cerebral artery (MCA) segment 2 (M2) or MCA segment 3 (M3) portion of the MCAs.

In selected patients with AIS within 6 to 16 hours of last known normal who have large vessel occlusion (LVO) in the anterior circulation and meet other DAWN or DEFUSE 3 eligibility criteria, mechanical thrombectomy is recommended.

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.

In patients who undergo mechanical thrombectomy, it is reasonable to maintain the BP ≤180/105 mm Hg during and for 24 hours after the procedure.

In patients presenting with minor stroke, treatment for 21 days with dual antiplatelet therapy (aspirin and clopidogrel) begun within 24 hours can be beneficial for early secondary stroke prevention for a period of up to 90 days from symptom onset.

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 symptomatic intracerebral hemorrhage [sICH], or preeclampsia/eclampsia). Lowering BP initially by 15% is probably safe.

In patients with BP <220/120 mm Hg who did not receive IV alteplase or endovascular therapy (EVT) and do not have a comorbid condition requiring acute antihypertensive treatment, initiating or reinitiating treatment of hypertension within the first 48 to 72 hours after an AIS is not effective to prevent death or dependency.

In patients with BP ≥220/120 mm Hg who did not receive IV alteplase or EVT and have no comorbid conditions requiring acute antihypertensive treatment, the benefit of initiating or reinitiating treatment of hypertension within the first 48 to 72 hours is uncertain. It might be reasonable to lower BP by 15% during the first 24 hours after onset of stroke.

Systems should be established so that brain imaging studies can be performed within 20 minutes of arrival in the ED in at least 50% of patients who may be candidates for IV alteplase and/or mechanical thrombectomy.

In selected patients with AIS within 6 to 24 hours of last known normal who have LVO in the anterior circulation, obtaining CT perfusion (CTP), diffusion-weighted MRI (DW-MRI), or MRI perfusion is recommended to aid in patient selection for mechanical thrombectomy, but only when imaging and other eligibility criteria from randomized clinical trials showing benefit are being strictly applied in selecting patients for mechanical thrombectomy.

For patients with non-cardioembolic AIS, the use of antiplatelet agents rather than oral anticoagulation is recommended to reduce the risk of recurrent stroke and other cardiovascular events.

For patients who have a noncardioembolic AIS while taking antiplatelet therapy, switching to warfarin is not beneficial for secondary stroke prevention.



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