Written by Clay Smith
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This is an update to the Stroke Guidelines released in 2018. We will focus on what’s new since last year.
Why does the matter?
Several new studies have resulted in the need for an update already. The field of stroke care is in the process of rapid change. Here is what’s new. This post is much longer than usual. The guidelines were 75 pages long.
Faster than reading 75 pages…
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Public education and hospital personnel education should focus on having patients call 911 sooner in order to allow more patients to receive treatment, especially thrombectomy.
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It is not clear if bypassing the nearest stroke center with thrombolysis capability in favor of one with both thrombolysis and thrombectomy is beneficial to patients. Procedures should be developed to help EMS better determine if a stroke could be a large vessel occlusion (LVO) to decide such things. Rob Orman just did a great podcast on this.
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QI, including ED education to safely increase fibrinolytic treatment is recommended. This includes feedback, setting and monitoring goal times, such as time to CT, time to tPA.
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Telemedicine can make a big impact on stroke care in remote locations by assessing tPA eligibility, advising administration, or determining if a patient may be a thrombectomy candidate, especially when local stroke teams are not available.
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Systems should optimize the speed and efficiency of obtaining brain imaging.
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An MRI to assess for microbleeds prior to tPA is not recommended.
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Multimodal CT or MR imaging is not needed prior to tPA if the non-contrast CT is negative.
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WAKE-UP led to this recommendation: “In patients with AIS who awake with stroke symptoms or have unclear time of onset > 4.5 hours from last known well or at baseline state, MRI to identify diffusion-positive FLAIR-negative lesions can be useful for selecting those who can benefit from IV alteplase administration within 4.5 hours of stroke symptom recognition.”
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If LVO is suspected, a CTA may be performed without a serum creatinine.
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If patients may be candidates for thrombectomy, it is reasonable to image the extracranial vertebrals and carotids for pre-procedural planning purposes.
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DAWN and DEFUSE 3 led to this change: “When selecting patients with AIS within 6 to 24 hours of last known normal who have LVO in the anterior circulation, obtaining CTP or DW-MRI, with or without MRI perfusion, is recommended to aid in patient selection for mechanical thrombectomy, but only when patients meet other eligibility criteria from one of the RCTs that showed benefit from mechanical thrombectomy in this extended time window.”
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Hypotension and hypovolemia should be corrected to maintain systemic perfusion.
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Most tPA recommendations were the same except this: “IV alteplase (0.9 mg/kg, maximum dose 90 mg over 60 minutes with initial 10% of dose given as bolus over 1 minute) administered within 4.5 hours of stroke symptom recognition can be beneficial in patients with AIS who awake with stroke symptoms or have unclear time of onset >4.5 hours from last known well or at baseline state and who have a DW-MRI lesion smaller than one-third of the MCA territory and no visible signal change on FLAIR.”
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Also related to tPA, it may be reasonable for mild disabling stroke from 3-4.5 hours but should not be given for mild non-disabling stroke at all. Also, tPA may be given to patients with sickle cell anemia and stroke as well as those with dense MCA sign.
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Patients with 1-10 cerebral microbleeds on MRI may still receive tPA, but those with >10 are at greater risk for major bleed and likely should not.
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Do not give IV ASA within 90 minutes of tPA.
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Tenecteplace may be used instead of alteplase.
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“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.” I A recommendation and “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.” IIa LOE B-R
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In the 6-24h window, evaluation and treatment should proceed as quickly as possible.
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Brief hyperventilation to a PCO2 of 30-34 for severe edema is reasonable as a bridge to more definitive treatment.
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There were many more new recommendations, but this is enough and covers the most important for EM.
Source
Guidelines for the Early Management of Patients With Acute Ischemic Stroke: 2019 Update to the 2018 Guidelines for the Early Management of Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke. 2019 Dec;50(12):e344-e418. doi: 10.1161/STR.0000000000000211. Epub 2019 Oct 30.
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