The American Heart Association (AHA) and the American Stroke Association (ASA) empathetically recommend that all stroke patients receive their immediate post-acute care in the Inpatient Rehabilitation Facility (IRF) setting. The ASA/AHA guidelines are based on years of clinical analysis, including the most comprehensive independent analysis ever undertaken in the field.
The following are key points to remember from the American Heart Association (AHA)/American Stroke Association (ASA) 2018 Guidelines for the Early Management of Patients with Acute Ischemic Stroke:
- These 2018 guidelines are an update to the 2013 guidelines, which 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. In addition, in the last 3 months, two trials (DAWN and DEFUSE 3) showed a clear benefit of “extended window” mechanical thrombectomy for certain patients with large vessel occlusion who could be treated out to 16-24 hours.
- The benefits of intravenous (IV) tissue plasminogen activator (tPA) are time-dependent, and treatment for eligible patients should be initiated as quickly as possible (even for 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. Centers should attempt to achieve door-to-needle times of <60 minutes in ≥50% of stroke patients treated with IV tPA.
- Prior to initiation of IV tPA in most patients, a noncontrast head computed tomography (CT) and glucose are the only required tests. An international normalized ratio, partial thromboplastin time, and platelet count do not need to have resulted prior to IV tPA initiation if there is no suspicion for underlying coagulopathy. 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.
- For 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.
- Patients ≥18 years should undergo mechanical thrombectomy with a stent retriever if they have minimal prestroke 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. No perfusion imaging (CT-P or MR-P) is required in these patients.
- 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.