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Highlights of American Heart Association/American Stroke Association guidelines updated from 2009


The American Heart Association/American Stroke Association has updated its comprehensive acute stroke care guidelines, which were previously updated in 2009. The guidelines followed the usual AHA/ASA classification of recommendations and levels of evidence. New or modified recommendations worth noting include the following:

  • Teleradiology networks are recommended for community hospitals that lack access to neurological expertise. (Class I, Level B)
  • Intravenous (IV) thrombolysis is recommended in the setting of early ischemic changes, with the exception of frank hypodensity on computed tomography (CT). (Class I, Level A)
  • A noninvasive intracranial vascular study is strongly recommended if either intra-arterial fibrinolysis or mechanical thrombectomy is being considered, but this study should not delay initiation of tissue plasminogen activator (TPA). (Class I, Level A)
  • The target door-to-needle time for patients who receive intravenous TPA is <60 minutes. (Class I, Level A)
  • IV TPA is recommended in the 3- to 4.5-hour time window — beyond the previously recommended 3-hour window — with additional exclusion criteria (age >80, use of oral anticoagulants, baseline NIH Stroke Scale score >25, imaging evidence of ischemic injury involving more than one third of the middle cerebral artery territory, or a history of both stroke and diabetes mellitus). (Class I, Level B)
  • Use of IV TPA may be considered for patients with mild stroke or those with major surgery in the last 3 months, after weighing the risks and benefits. (Class IIb, Level C)
  • Use of IV TPA is not recommended for patients taking novel anticoagulants unless clotting tests are normal or the patient has not taken medication for >2 days (with normal renal function). (Class III, Level C)
  • When mechanical thrombectomy is considered, stent retrievers are preferred to coil retrievers. (Class I, Level A) The ability of mechanical thrombectomy devices to improve patient outcomes has not yet been established.
  • Rescue intra-arterial thrombolysis or thrombectomy may be reasonable in patients who have failed IV thrombolysis, but additional randomized trial data are needed. (Class IIb, Level B)

Comment: Important themes of these updated guidelines are the “urgency of time” in patients who qualify for IV thrombolysis with TPA and reinforcement of the use of TPA for select patients in the 3- to 4.5-hour window. In addition, the evidence for mechanical thrombectomy in acute stroke for improving patient outcomes is still unsatisfactory.

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