Early management of patients with acute ischemic stroke#

[Patel et al., 2020]

MFtva0_2022_05_05

IV alteplase eligibility#

Indications (Class I Recommendations– Recommended Care)

  • If within 3 hours of onset and:

    • ≥ 18 years of age

    • Severe stroke

    • Mild but disabiling stroke

  • If 3-4.5 hours from onset,18-80 years of age, and:

    • Without a history of both diabetes mellitus and prior stroke

    • NIHSS score ≤25

    • Not taking any OACs

    • Without imaging evidence of ischemic injury involving more than one third of the MCA territory

  • If BP can be lowered safely and maintained < 185/110 mm Hg

  • With blood glucose > 50 mg/dL

  • With mild to moderate early ischemic changes on NCCT

  • With antiplatelet drug monotherapy or combination therapy

  • With end stage renal disease with normal aPTT

Additional Recommendations (Class IIa and IIb).

Situations requiring individual patient risk benefit assessment for which administration of IV alteplase may be considered

details see [Warner et al., 2019]

Evaluate for Mechanical Thrombectomy (< 24 hours)#

  • Evaluation for IV alteplase and evaluation for mechanical thrombectomy happens simultaneously

  • Within 6 hours:

    • Prestroke mRS score 0–1

    • Causative occlusion of the ICA or proximal MCA (M1)

    • Age ≥18 years

    • NIHSS score of ≥6

    • ASPECTS of ≥6

    • Within 6-24 hours

    • Causative occlusion of the ICA or M1

    • Meets eligibility criteria for DAWN or DEFUSE3 trials

  • 6 to 24 hours: see figure above

[PYK20]

Pratit Patel, Dileep Yavagal, and Priyank Khandelwal. Hyperacute management of ischemic strokes: jacc focus seminar. Journal of the American College of Cardiology, 75(15):1844–1856, 2020.

[WHSE19]

John J Warner, Robert A Harrington, Ralph L Sacco, and Mitchell SV Elkind. 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. 2019.