April 19, 2007 -- The American Heart Association/American Stroke Association has released new guidelines for the early management of acute ischemic stroke. The guidelines continue to endorse the use of intravenous tissue-type plasminogen activator (tPA) but note that other modalities such as intra-arterial tPA show promise. For the first time, the authors have included recommendations for palliative care.

"Our goal was to focus on the first few hours after stroke onset where we think time is so critical," Harold P. Adams Jr., MD, from the University of Iowa Stroke Center in Iowa City, chair of the guidelines writing committee, told Medscape. "The audience is primarily physicians, but we've also included information for general emergency medical services, and some things for the public as well, focusing on the idea that from the first symptom, time is brain, and everything we can do to expedite the process to hopefully treat the patients and reduce the likelihood of an unfavorable outcome is crucial," he said.

The guidelines were published in the April 12 Stroke ASAP issue and will appear in the May print issue of Stroke.

"Time Is Brain"

The new guidelines were extensively revised since 2003. Members of the panel were appointed by the American Heart Association Stroke Council's Scientific Statement Oversight Committee and represented different areas of expertise, including imaging and interventional experts.

"Management of patients with acute ischemic stroke remains multifaceted and includes several aspects of care that have not been tested in clinical trials," the authors write. Recommendations have been made using an evidence-grading algorithm.

The panel considered aspects of care beginning in the prehospital setting, Dr. Adams said, including recommendations for more public education about the symptoms of stroke, and recommendations about how emergency medical services should interface with hospitals. For example, they recommend that patients should be taken to hospitals with facilities for emergency stroke care, even if this means bypassing closer hospitals. To this end, the authors recommend that more medical centers should consider seeking certification as primary or comprehensive stroke centers from the Joint Commission on Accreditation of Healthcare Organizations.

The "Engine for Emergency Stroke Care"

Intravenous tPA is still recommended as the key treatment of stroke, Dr. Adams noted, "and remains the engine for emergency stroke care." However, the guidelines discuss the use of intra-arterial tPA, he said, "which is becoming an important alternative for patients who cannot receive IV [intravenous] tPA."

The guidelines also discuss the use of mechanical devices such as the Mechanical Embolus Removal in Cerebral Embolism (MERCI) retriever that has been approved for clot removal in the setting of stroke. "We emphasize that this is approved by the FDA [Food and Drug Administration] but we also suggest that there needs to be more evidence to show these sorts of interventions help to improve outcomes," Dr. Adams commented. There has been some controversy that devices are held to a lower standard in this regard compared with drugs, where it must be shown that they not only recanalize a vessel but also result in an improved clinical outcome.

In terms of imaging, there is expanded discussion of magnetic resonance imaging (MRI) for the assessment of acute stroke. "While CT [computed tomography] remains the preferred diagnostic study because it can be done quickly and is more readily available, we also recognize there are advantages from MRI as well, and those are mentioned," Dr. Adams noted.

There also is discussion of general emergent treatment, including a recommendation for aggressive management of hyperglycemia, although this is, "I must admit, based on no definitive data," Dr. Adams added. Other areas of acute treatment such as blood pressure management are still "fertile areas for research," although some recommendations are made.

Finally, for the first time, the authors include discussion of palliative care for patients who have had acute stroke. "For those patients who have such horrendous brain injuries from stroke, who we may not be able to successfully treat, there are options that physicians and families may need to consider in that very difficult situation," Dr. Adams said.

The guidelines note that the American Academy of Neurology "affirms the value" of the document as an educational tool for neurologists.

Dr. Adams has disclosed receiving research grants from Boehringer Ingelheim, Centocor (Johnson & Johnson), Eli Lilly, Merck, NMT Medical, Sanofi, Bristol-Myers Squibb, and GlaxoSmithKline, among other disclosures. Disclosure information for the other coauthors appears in the original article.

Stroke. 2007;38:1655-1711.

Clinical Context

The American Heart Association/American Stroke Association updated its guidelines for the management of acute stroke in 2003 and 2005. Its current guidelines highlight findings in the medical literature since 2003, and the authors state a goal of updating these guidelines again in 3 years. Their principal recommendations are summarized below.

Study Highlights

• The rate of activation of emergency medical services among patients with acute stroke is as low as 29%. As emergency medical services offers the most prompt care, all patients with the acute onset of stroke symptoms should use services such as telephoning 911 (in the United States).
  
• During initial evaluation, the single most important point in the patient's history is the time of symptom onset. Patients with acute stroke symptoms should receive testing for blood glucose, coagulation times, and complete blood count with platelets, along with 12-lead electrocardiogram and serum cardiac enzymes. However, chest radiography may be withheld if there are no signs of pulmonary or cardiac disease. The evaluation of the patient should be concluded within 60 minutes of arrival in the emergency department.
  
• CT remains the most common imaging modality for the evaluation of acute stroke, and, besides hemorrhage, there is no CT finding that is specific enough to preclude treatment with recombinant tPA (rtPA). MRI also is acceptable in the evaluation of acute stroke.
  
• Patients' blood pressure may decline spontaneously in the first 24 hours after stroke. Patients who are candidates for rtPA should have their systolic blood pressure lowered to at least 185 mm Hg and their diastolic blood pressure lowered to at least 110 mm Hg. Consensus opinions state that patients with persistent elevations in systolic blood pressure higher than 220 mm Hg or diastolic blood pressure higher than 120 mm Hg should receive antihypertension therapy.
  
• Hyperglycemia in the range of 140 to 185 mg/dL in the stroke patient should prompt consideration of insulin therapy.
  
• Hyperbaric oxygen should not be used in the acute stroke patient except in cases of air embolus.
  
• rtPA is the treatment of choice for thrombolysis in acute stroke. Treatment with streptokinase is not recommended, and reteplase, urokinase, and other thrombolytic agents should not be used outside of the setting of a clinical trial.
  
• Intra-arterial thrombolysis may be used for patients with occlusions of the middle cerebral artery who can be treated within 6 hours of symptom onset.
  
• Urgent anticoagulation generally is not recommended in lieu of intravenous thrombolysis and should be withheld in patients with moderate or severe stroke because of an increased risk for intracranial hemorrhage.
  
• Aspirin therapy at a dose of 325 mg may be initiated within 24 to 48 hours after stroke onset. Based on current evidence, the authors recommend against the routine use of clopidogrel following stroke.
  
• During hospitalization, stroke patients should receive a swallowing evaluation as well as prophylaxis against deep venous thrombosis with heparin or low-molecular-weight heparin.

• The current guidelines recommend that the initial workup of patients with possible stroke include testing for blood glucose, coagulation times, intracranial imaging, and complete blood count, along with 12-lead electrocardiogram and serum cardiac enzymes. However, chest radiography may be withheld if there are no signs of pulmonary or cardiac disease.
  
• rtPA is the treatment of choice for patients who present within 3 hours of the onset of stroke symptoms.