Stroke 2018 Update

In March New Stroke guidelines came out. Wow are they aggressive! tPA and endovascular therapy (EVT) for all… forget what the literature says! Well We NEED to know these so I’ve listed them here for reference. Sorry about the format. I’ll pretty it up soon!

Stroke. 2018;49:e46–e99. DOI: 10.1161/STR.0000000000000158.)

1. A primary goal of achieving door-to-needle (DTN) times within 60 minutes in ≥50% of AIS patients treated with IV alteplase should be established.
2. It may be reasonable to establish a secondary DTN time goal of achieving DTN times within 45 minutes in ≥50% of patients with AIS who were treated with IV alteplase.
3. 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.
4. The CT hyperdense MCA sign should not be used as a criterion to withhold IV alteplase from patients who otherwise qualify.
5. Routine use of magnetic resonance imaging (MRI) to exclude cerebral microbleeds (CMBs) before administration of IV alteplase is not recommended.
6. Use of imaging criteria to select ischemic stroke patients who awoke with stroke or have unclear time of symptom onset for treatment with IV alteplase is not recommended outside a clinical trial.
7. For patients who otherwise meet criteria for EVT, it is reasonable to proceed with CTA if indicated in patients with suspected intracranial LVO before obtaining a serum creatinine concentration in patients without a history of renal impairment.
8. In selected patients with AIS within 6 to 24 hours of last known normal who have LVO in the anterior circulation, obtaining CTP, DW-MRI, or MRI perfusion is recommended to aid in patient selection for mechanical thrombectomy, but only when imaging and other eligibility criteria from RCTs showing bene t are being strictly applied in selecting patients for mechanical thrombectomy.
9. Only the assessment of blood glucose must precede the initiation of IV alteplase in all patients.
10. Supplemental oxygen is not recommended in nonhypoxic patients with AIS.
11. Patients who have elevated BP and are otherwise eligible for treatment with IV alteplase should have their BP carefully lowered so that their systolic BP is <185 mm Hg and their diastolic BP is <110 mm Hg before IV brinolytic therapy is initiated.
12. Hypoglycemia (blood glucose <60 mg/dL) should be treated in patients with AIS.
13. IV alteplase (0.9 mg/kg, maximum dose 90 mg over 60 minutes with initial 10% of dose given as bolus over 1 minute) is recommended for selected patients who may be treated within 3 hours of ischemic stroke symptom onset or patient last known well or at baseline state. Physicians should review the criteria outlined in Table 6 to determine patient eligibility.
14. IV alteplase (0.9 mg/kg, maximum dose 90 mg over 60 minutes with initial 10% of dose given as bolus over 1 minute) is also recommended for selected patients who can be treated within 3 and 4.5 hours of ischemic stroke symptom onset or patient last known well. Physicians should review the criteria outlined in Table 6 determine patient eligibility.
15. For otherwise eligible patients with mild stroke presenting in the 3- to 4.5-hour window, treatment with IV alteplase may be reasonable. Treatment risks should be weighed against possible bene ts.
16. In otherwise eligible patients who have had a previously demonstrated small number (1–10) of CMBs on MRI, administration of IV alteplase is reasonable.

17. In otherwise eligible patients who have had a previously demonstrated high burden of CMBs (>10) on MRI, treatment with IV alteplase may be associated with an increased risk of sICH, and the bene ts of treatment are uncertain. Treatment may be
18. IV alteplase for adults presenting with an AIS with known sickle cell disease can be bene cial.

19. IV alteplase should not be administered to patients who have received a treatment dose of low-molecular-weight heparin (LMWH) within the previous 24 hours.
20. Patients should receive mechanical thrombectomy with a stent retriever if they meet all the following criteria: (1) prestroke mRS score of 0 to 1; (2) causative occlusion of the internal carotid artery or MCA segment 1 (M1); (3) age ≥18 years; (4) NIHSS score of ≥6; (5) ASPECTS of ≥6; and (6) treatment can be initiated (groin puncture) within 6 hours of symptom onset.
21. Although the bene ts 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 MCA segment 2 (M2) or MCA segment 3 (M3) portion of the MCAs.
22. Although the bene ts 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 anterior cerebral arteries, vertebral arteries, basilar artery, or posterior cerebral arteries.
23. Although its bene ts are uncertain, the use of mechanical thrombectomy with stent retrievers may be reasonable for patients with AIS in whom treatment can be initiated (groin puncture) within 6 hours of symptom onset and who have prestroke mRS score >1, ASPECTS <6, or NIHSS score <6, and causative occlusion of the internal carotid artery (ICA) or proximal MCA (M1). Additional randomized trial data are needed.
24. In selected patients with AIS within 6 to 16 hours of last known normal who have LVO in the anterior circulation and meet other DAWN or DEFUSE 3 eligibility criteria, mechanical thrombectomy is recommended. (LEVEL I recommendation)
25. In selected patients with AIS within 16 to 24 hours of last known normal who have LVO in the anterior circulation and meet other DAWN eligibility criteria, mechanical thrombectomy is reasonable. (Level IIA Recommendation)
26. Defuse Critereia: Age 18-90 years; NIHSSS ≥ 6; femoral puncture within 6 -16 hours of stroke onset/last known well; pre- morbid mRS2≤2; ICA or M1 occlusion by MRA or CTA AND Target Mismatch Profile on CT perfusion or MRI (ischemic core volume is <70 ml, mismatch ratio is >1.8 and mismatch volume is >15 ml)
27. Dawn Criteria: Age 18;
failed or contraindicated for IV t-PA; NIHSS ≥10; Pre-stroke -mRS 0-1; Time last seen well to Randomization: 6-24h; <1/3 MCA territory by CT or MRI; ICA- T and/or MCA- M1 occlusion;- Clinical Imaging Mismatch:
A. 80 y/o, NIHSS 10 + core <21 mL B. <80 y/o, NIHSS 10 + core <31 mL C. < 80 y/o, NIHSS 20 + core <51 mL
28. Administration of aspirin is recommended in patients with
AIS within 24 to 48 hours after onset. For those treated with
IV alteplase, aspirin administration is generally delayed until
24 hours later but might be considered in the presence of concomitant conditions for which such treatment given in the absence of IV alteplase is known to provide substantial bene t or withholding such treatment is known to cause substantial risk.
29. In patients presenting with minor stroke, treatment for 21 days with dual antiplatelet therapy (aspirin and clopidogrel) begun within 24 hours can be bene cial for early secondary stroke prevention for a period of up to 90 days from symptom onset. The generalizability of this intervention in non-Asian populations remains to be established, and a large phase III multicenter trial in the United States, Canada, Europe, and Australia is ongoing.195
30. 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 bene t of initiating or reinitiating treatment of hypertension within the rst 48 to 72 hours is uncertain. It might be reasonable to lower BP by 15% during the rst 24 hours after onset of stroke.
31. Routine placement of indwelling bladder catheters should not be performed because of the associated risk of catheter-associated urinary tract infections.
32. Use of brief moderate hyperventilation (Pco2 target 30–34
mm Hg) is a reasonable treatment for patients with acute severe neurological decline from brain swelling as a bridge to more de nitive therapy.
33. Hypothermia or barbiturates in the setting of ischemic cerebral or cerebellar swelling are not recommended.
34. Because of a lack of evidence of ef cacy and the potential to increase the risk of infectious complications, corticosteroids (in conventional or large doses) should not be administered for the treatment of cerebral edema and increased intracranial pressure complicating ischemic stroke.
35. Prophylactic use of anti-seizure drugs is not recommended.