New Treatment Guidelines for Acute Ischemic Stroke Open the “Golden Window” for Treatment to 6-24 Hours

 

The American Heart Association (AHA) and the American Stroke Association announced new evidence-based guidelines (Stroke. 2018;49:published online January 24, 2018.) for treatment of adults with acute ischemic stroke (AIS) replacing previous guidelines published in 2013 (Stroke. 2013;44:870–947). The new guidelines are endorsed by the American Association of Neurologic Surgeons, the Congress of Neurologic Surgeons, and the Society of Academic Emergency Physicians. 

Prehospital-, urgent-, and emergent-treatment are addressed and include intravenous and intra-arterial therapy and in-hospital management, including secondary stroke prevention measures in the first two weeks poststroke. Implementation of regional stroke systems is supported. 

The following strong recommendations with level A evidence are new: development of regional stroke care systems, quality improvement projects for emergency department personnel and multidisciplinary teams to increase safety of IV thrombolytic treatment, use of teleradiology for rapid diagnosis, and participation in stroke-data repositories. Mechanical thrombectomy with the goal of reperfusion is recommended for patients who meet specific criteria and can be initiated within 6-24 hours of symptom onset. 

In addition it is recommended that multimodal CT and MRI, including after perfusion imaging should not delay administration of IV alteplase, the CT hyperdense sign should not be used as a criterion for withholding alteplase therapy, and sonothrombosis should not be used as adjuvent therapy with IV alteplase. 

Although most new evidence for the guidelines was previously incorporated into focused updates, scientific statements, and published guidelines by the AHA, these new guidelines are comprehensive and updated. 

Simultaneously, the AHA published articles by Smith et al on accuracy in prediction of diagnosing large vessel occlusion in adults with suspected stroke, a systematic review for the early management of adults with AIS (Stroke. 2018;49:published online January 24, 2018.), and on the effect of dysphagia screening strategies on outcomes for patients after AIS (Stroke. 2018;49:published online January 24, 2018.) 

The American College of Cardiology/AHA class of recommendations are given for every recommendation in a large collection of tables that also briefly summarize the evidence for new or revised guidelines. Unchanged guidelines are included for comprehensiveness, though without the evidence for the previously published guideline included, unless new evidence is available.

 

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