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 ====== Stroke management ======
+see [[Ischemic Stroke Management]].
-===== Key concepts =====
-Level I
-((Powers WJ, Rabinstein AA, Ackerson T, et al. 2018
-Guidelines for the Early Management of Patients
-With Acute Ischemic Stroke: A Guideline for
-Healthcare Professionals From the American Heart
-Association/American Stroke Association. Stroke.
-; 49:e46–e110)).
-● [[Medical history]]/[[physical examination]]: include [[stroke scales]] (preferrably [[NIHSS]])
-● ✔ [[blood glucose]]: essential lab to obtain in case IV tPA is indicated
-● noncontrast brain CT: the usual initial diagnostic tool of choice (image in ≤ 20 mins)
-○ to rule out: hemorrhage (SAH, ICH, EDH, SDH), mass (tumor, abscess…)
-○ to calculate ASPECTS (to identify candidates for thrombectomy)
-● [[CTA]] for patients with NIHSS score ≥ 10 (correlates with [[large vessel occlusion]] [LVO]) to identify candidates for thrombectomy (do not delay IV tPA to get CTA)
-● thrombectomy is the standard of care for eligible patients: cerebral ischemia (including infarct) caused by LVO of the ICA or M1 segment of the MCA, 1) when it can be initiated within 6 hours of symptom onset, or 2) if perfusion studies identify viable tissue 6–24 hours from onset
-● IV tPA (tissue plasminogen activator, alteplase)
-○ within 4.5 hours of onset when thrombectomy not being done immediately or for patients who are not thrombectomy candidates
-○ goal:“door-to-needle” (DTN) time ≤ 60 minutes
-===== Rapid initial evaluation/management =====
-Upon presentation of a patient with symptoms of a potential stroke.
-. history & physical exam: key components
-a) onset or last known well (LKW) time (the last time the patient was seen to be normal): stroke
-on awakening (“wake-up stroke”) may require additional considerations for management
-b) c) current deficit and clinical presentation
-★ NIH Stroke Scale score (or Canadian Neurological Scale) assessed and recorded
-(Level I)
-. laboratories:
-a) ★ blood glucose is the only essential lab to get immediately since it aﬀects eligibility for IV tPA (Level I)
-b) see Admitting orders for subsequent detailed labs (including cardiac troponins…)
-. imaging:
-a) ★ STAT noncontrast head CT scan: AHA goal: image the brain in ≤ 20 minutes of arrival in the
-E/R in ≥ 50% of eligible patients (Level I1). In most cases this provides the necessary informa-
-tion for management (Level I).
-● rule out hemorrhage (ICH, SAH, subdural, epidural…) or other lesions (e.g., tumor).
-● determine Alberta stroke program early CT score (ASPECTS)
-b) a noninvasive intracranial vascular study (usually a CTA) is obtained in potential candidates
-for endovascular therapy (EVT) (viz. patients with large vessel occlusion (LVO)) who are best dentified by the NIHSS score:
-• NIHSS score ≥ 10: is 73% sensitive & 74% specific for LVO
-• NIHSS score ≥ 6: is 87% sensitive and 52% specific for LVO
-This study should not delay IV tPA if indicated; the CTA can be obtained ASAP after IV tPA.
-It is reasonable to image the extracranial carotid and vertebral circulations in addition to
-intracranial vessels in potential candidates for EVT to help determine patient eligibility and to
-plan the procedure (Level II).
-intervention: depending on results of above
-a) candidates for EVT (essentially mechanical thrombectomy or IA tPA) should be taken immediately to angio suite
-b) if there is going to be a delay, or if the patient is not eligible for EVT, IV tPA is given if indicated
-----
-====== 2018 Guidelines for the Early Management of Patients With Acute Ischemic Stroke ======
-In a Clinical Practice Guideline
-Powers et al. (American Heart Association Stroke Council, various U.S. centers)
-published in the Stroke Journal
-to update and standardize recommendations for the early (pre‑hospital and emergency) management of acute ischemic stroke patients across healthcare settings.
-They provides evidence‑based algorithms covering rapid recognition, IV thrombolysis, mechanical thrombectomy, imaging, blood pressure/glucose management, and systems of care to optimize early stroke outcomes.
-===== Critical Review =====
-* **Scope & Methodology:** Anchored in a robust literature review and expert consensus. However, grading of evidence for certain recommendations (e.g., advanced imaging selection, perfusion thresholds) relies heavily on smaller trials and registries, limiting universal applicability.
-* **Clarity & Usability:** Strongly organized with clear flowcharts (e.g., IV tPA eligibility, thrombectomy criteria), though the density of algorithmic detail may challenge timely ED implementation without pre‑existing stroke pathways.
-* **Balance of Strength vs. Risk:** Generally robust; recommendations on BP management before thrombolysis (permissive hypertension) are evidence‑backed. Some newer domains – such as anesthesia strategies during thrombectomy – are treated briefly with class IIb recommendations.
-* **Innovation & Evidence Gaps:** Notable improvement over 2013 guidelines. Highlights recent trials (e.g., DAWN, DEFUSE‑3) extending EVT window. Still, identification of salvageable penumbra via perfusion imaging lacks uniform thresholds across centers.
-* **Criticisms:**
-  * Evidence for wake‑up stroke treatment remains underrepresented since key trials (WAKE‑UP) were published shortly after guideline cut‑off.
-  * Recommendations on rural/underserved systems of care emphasize telestroke but lack concrete frameworks for implementation.
-  * No clear guidance on system‑level quality benchmarks (e.g., door‑to‑needle time accountability), which are critical in stroke systems.
-===== Final Verdict =====
-A vital, practical guideline that significantly enhances stroke management protocols—though adoption demands local adaptation, and emerging late‑breaking trials must be integrated in future updates.
-===== Takeaway for the Practicing Neurosurgeon =====
-Ensure your stroke pathway incorporates rapid triage, IV tPA protocol, and mechanical thrombectomy criteria; invest in imaging and telestroke infrastructure; and stay alert to new data on wake‑up strokes and perfusion‑guided treatment windows.
-===== Bottom Line =====
-A comprehensive and up-to-date framework that sharpens early stroke care—essential reading, but should not supplant local protocols or upcoming trial data.
-===== Score =====
-.0 / 10 — Strong, evidence‑based, with areas for future refinement.
-<blogcategory>Guidelines, Stroke, AcuteCare</blogcategory>
-<tag>acute ischemic stroke, IV tPA, thrombectomy, stroke guidelines, AHA/ASA, early management</tag>
--- *2018 Guidelines for the Early Management of Patients With Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association*, Powers WJ et al. Stroke 2018 Mar;49(3):e46‑e110. Published online 24 Jan 2018. Corresponding author contact available via neurosurgerywiki.com internal directory. PMID: 29367334 DOI: 10.1161/STR.0000000000000158
-----
-----
-====== Updates to AHA/ASA Stroke Guidelines (2019 & 2024) ======
-===== 2019 Focused Update – Early Management of Acute Ischemic Stroke =====
-**Reference:**
-*Powers WJ, Rabinstein AA, Ackerson T, et al.*
-*Guidelines for the Early Management of Patients With Acute Ischemic Stroke: 2019 Update to the 2018 Guidelines.*
-*Stroke*. 2019;50(12):e344–e418. doi:10.1161/STR.0000000000000211
-PMID: 31662037
-**Key Updates:**
-- Expanded criteria for **mechanical thrombectomy (6–16 h)** in patients selected by perfusion imaging (based on DAWN and DEFUSE‑3).
-- Clarified use of **IV alteplase in wake-up strokes** and strokes of unknown onset, integrating MRI-based selection (DWI-FLAIR mismatch).
-- Emphasized **prehospital triage systems** and **telemedicine** to streamline stroke identification and transfer.
-- Updated evidence levels (Class of Recommendation / Level of Evidence) to reflect recent trials.
-- Provided **flowcharts and decision pathways** for ED teams to facilitate early thrombolysis and thrombectomy decisions.
-**Summary:** A technical refinement of the 2018 guideline, incorporating new trial data to strengthen recommendations for EVT and alteplase in broader clinical scenarios.
-===== 2024 Guideline – Primary Prevention of Stroke =====
-**Reference:**
-*Meschia JF, Bushnell C, Boden-Albala B, et al.*
-*2024 Guideline for the Primary Prevention of Stroke: A Guideline From the American Heart Association/American Stroke Association.*
-*Stroke*. Published online October 20, 2024. doi:10.1161/STR.0000000000000475
-**Key Recommendations:**
-- Integrates the **Life’s Essential 8** model for cardiovascular health (includes sleep, BP, diet, physical activity, cholesterol, blood sugar, smoking, and BMI).
-- Advocates use of **GLP-1 receptor agonists** (e.g., semaglutide) in diabetic patients at high cardiovascular risk.
-- Recommends **PCSK9 inhibitors** for patients intolerant to statins or needing additional LDL reduction.
-- Endorses **Mediterranean-style diets** rich in olive oil and nuts for stroke risk reduction.
-- Suggests **blood pressure targets <130/80 mm Hg**, with first-line agents being thiazides, ACE inhibitors, ARBs, and calcium channel blockers.
-- Includes **gender-specific guidance**, addressing risks during pregnancy, hormone use, and among transgender populations.
-- Strong emphasis on **social determinants of health** (SDOH) and **health equity**.
-- 150 minutes/week of moderate-intensity aerobic exercise remains a cornerstone.
-**Summary:** A comprehensive and contemporary approach to preventing first-time stroke through evidence-based lifestyle, pharmacologic, and societal interventions.
-===== Tags & Categories =====
-<blogcategory>Guidelines, Stroke, Prevention, AcuteCare</blogcategory>
-<tag>stroke prevention, GLP-1, PCSK9, alteplase, thrombectomy, wake-up stroke, AHA, ASA, guideline update</tag>