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## Complete Summary

#### GUIDELINE TITLE

Guidelines for the early management of adults with ischemic stroke. A
guideline from the American Heart Association/American Stroke
Association Stroke Council, Clinical Cardiology Council, Cardiovascular
Radiology and Intervention Council, and the Atherosclerotic Peripheral
Vascular Disease and Quality of Care Outcomes in Research
Interdisciplinary Working Groups.

#### BIBLIOGRAPHIC SOURCE(S)

Adams HP Jr, del Zoppo G, Alberts MJ, Bhatt DL, Brass L, Furlan A, Grubb
RL, Higashida RT, Jauch EC, Kidwell C, Lyden PD, Morgenstern LB, Qureshi
AI, Rosenwasser RH, Scott PA, Wijdicks EFM, American Heart Association,
American Stroke Association Stroke Council, Clinical Cardiology Council.
Guidelines for the early management of adults with ischemic stroke: a
guideline from the American Heart Association/American Stroke
Association Stroke Council, Clinical Cardiology Council, Cardiovascular
Radiology \[trunc\]. Stroke 2007 May;38(5):1655-711. \[738 references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=17431204)

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: Adams HP Jr, Adams RJ, Brott
T, del Zoppo GJ, Furlan A, Goldstein LB, Grubb RL, Higashida R, Kidwell
C, Kwiatkowski TG, Marler JR, Hademenos GJ. Guidelines for the early
management of patients with ischemic stroke: a scientific statement from
the Stroke Council of the American Stroke Association. Stroke 2003
Apr;34(4):1056-83 and Adams H, Adams R, del Zoppo G, Goldstein LB.
Guidelines for the early management of patients with ischemic stroke:
2005 guidelines update: a scientific statement from the Stroke Council
of the American Heart Association/American Stroke Association. Stroke
2005 Apr;36:916-23

It is intended that this guideline be fully updated in 3 years.

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 CONTRAINDICATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Acute ischemic stroke

#### GUIDELINE CATEGORY

Diagnosis\
Management\
Prevention\
Treatment

#### CLINICAL SPECIALTY

Emergency Medicine\
Neurological Surgery\
Neurology

#### INTENDED USERS

Advanced Practice Nurses\
Emergency Medical Technicians/Paramedics\
Health Care Providers\
Health Plans\
Hospitals\
Nurses\
Physician Assistants\
Physicians

#### GUIDELINE OBJECTIVE(S)

-   To provide an overview of the current evidence about components of
    the evaluation and treatment of adults with acute ischemic stroke

-   To provide updated recommendations that may be used by physicians
    who provide acute stroke care within the first hours to time of
    initial diagnosis, treatment, and initial hospitalization

#### TARGET POPULATION

Adults with ischemic stroke

#### INTERVENTIONS AND PRACTICES CONSIDERED

**Assessment**

1.  Prehospital evaluation

    -   Brief assessments by emergency medical services (EMS) personnel

    -   Use of a stroke identification instrument, such as the Los
        Angeles or Cincinnati screens

    -   Initial management of stroke in the field

    -   Development of stroke protocols

2.  Emergency evaluation

    -   Establishment of a protocol for the emergency evaluation of
        patients with suspected stroke

    -   Designation of an acute stroke team

    -   Use of a stroke rating scale (National Institutes of Health
        Stroke Scale)

    -   Hematologic, coagulation, and biochemistry tests

    -   Additional tests as indicated

3.  Brain and vascular imaging

    -   Computed tomography (CT), multimodal CT, multimodal magnetic
        resonance imaging (MRI)

    -   Vascular imaging

**Management/Treatment**

1.  Prehospital management and field treatment

    -   Activation of the 9-1-1 system by patients or other members of
        the public

    -   Educational programs to increase public awareness of stroke

    -   Educational programs for physicians, hospital personnel, and EMS
        personnel

    -   Rapid transport of patients to the closet facility capable of
        treating acute stroke for evaluation and treatment (including
        notification of the receiving Emergency Department)

    -   Telemedicine

2.  Creation and certification of stroke centers

    -   Primary stroke centers

    -   Comprehensive stroke centers

3.  General supportive care and treatment of acute complications

    -   Airway support and ventilatory assistance

    -   Supplemental oxygen

    -   Treatment of sources of fever with antipyretic medications

    -   Cardiac monitoring to screen for atrial fibrillation and other
        potentially serious cardiac arrhythmias

    -   Management of arterial hypertension

    -   Correction of hypovolemia and optimization of cardiac output
        (normal saline)

    -   Treatment of hypoglycemia and hyperglycemia

4.  Intravenous recombinant tissue plasminogen activator

5.  Intra-arterial thrombolysis

6.  Administration of anticoagulants/antiplatelet agents

7.  Volume expansion

8.  Vasodilators

9.  Vasopressors (in exceptional circumstances as indicated)

10. Mechanical Embolus Removal in Cerebral Ischemia (MERCI) device for
    extraction of intra-arterial thrombi (in selected patients)

11. Hospitalization

    -   Comprehensive specialized stroke care following admission to
        stroke units, incorporating rehabilitation

    -   Standardized stroke care order sets

    -   Early mobilization of less severely affected patients

    -   Measures to prevent subacute complications

    -   Assessment of swallowing

    -   Use of nasogastric, nasoduodenal, or percutaneous endoscopic
        gastrostomy (PEG) feedings to maintain hydration and nutrition

    -   Antibiotic treatment of patients with suspected pneumonia or
        urinary tract infections

    -   Prevention of deep vein thrombosis

        -   Aspirin

        -   Subcutaneous anticoagulants (in immobilized patients)

    -   Treatment of concomitant medical diseases

    -   Interventions to prevent recurrent stroke

    -   Intermittent external compression devices

    -   Indwelling bladder catheters

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12. Treatment of acute neurological complications

    -   Measures to lessen the risk of edema and close monitoring of the
        patient for signs of neurological worsening

    -   Ventricular drain placement for acute hydrocephalus

    -   Decompressive surgical evacuation of a space-occupying
        cerebellar infarction

    -   Treatment of recurrent seizures after stroke

    -   Hyperventilation

13. Palliative care

    -   Honoring patient\'s advanced directives

    -   Discussion of prognosis and treatment options with family

#### MAJOR OUTCOMES CONSIDERED

-   Stroke-related morbidity and mortality

-   Adverse events associated with treatment

-   Vascular events following stroke

-   Neurologic complications

-   Functionality

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Hand-searches of Published Literature (Primary Sources)\
Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

The data were collected through a systematic review of the literature.
Members of the writing panel were appointed by the American Heart
Association Stroke Council\'s Scientific Statement Oversight Committee
and represented different areas of expertise. The panel reviewed the
relevant literature with an emphasis on reports published since 2003.

#### NUMBER OF SOURCE DOCUMENTS

Not stated

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Weighting According to a Rating Scheme (Scheme Given)

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

**Level of Evidence**

A.  Data derived from multiple randomized clinical trials

B.  Data derived from a single randomized trial or nonrandomized studies

C.  Consensus opinion of experts

**Level of Evidence for Diagnostic Recommendation**

A.  Data derived from multiple prospective cohort studies that used a
    reference standard applied by a masked evaluator

B.  Data derived from a single grade A study or one or more
    case--control studies or studies that used a reference standard
    applied by an unmasked evaluator

C.  Consensus opinion of experts

#### METHODS USED TO ANALYZE THE EVIDENCE

Systematic Review with Evidence Tables

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

Data were synthesized with the use of evidence tables. The American
Heart Association\'s Levels of Evidence grading algorithm was used to
grade each recommendation.

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

These guidelines have been developed by a panel of physicians with a
broad range of expertise, including vascular neurology, neurocritical
care, emergency medicine, neurosurgery, and interventional
neuroradiology/endovascular neurosurgery.

Because of the wide scope of the guidelines, the members of the writing
panel were assigned primary reviews for individual sections. Then the
panel assessed the complete guidelines. If the panel concluded that data
supported or did not support the use of a specific intervention,
appropriate recommendations were made. In some cases in which definitive
data were not available, no specific recommendation was made.

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

**Classification**

**Class I** Conditions for which there is evidence for and/or general
agreement that the procedure or treatment is useful and effective

**Class II** Conditions for which there is conflicting evidence and/or a
divergence of opinion about the usefulness/efficacy of a procedure or
treatment

**Class IIa** The weight of evidence or opinion is in favor of the
procedure or treatment

**Class IIb** Usefulness/efficacy is less well established by evidence
or opinion

**Class III** Conditions for which there is evidence and/or general
agreement that the procedure or treatment is not useful/effective and in
some cases may be harmful

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

The guideline was approved by the American Heart Association Science
Advisory and Coordinating Committee January 6, 2007.

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

Definitions of the recommendation classes (**I, II, III**) and levels of
evidence (**A, B, C**) are provided at the end of the \"Major
Recommendations\" field.

**Recommendations for Prehospital Management and Field Treatment**

*The recommendations that follow were not included in the previous
guidelines*.

*Class I Recommendations*

1.  Activation of the 9-1-1 system by patients or other members of the
    public is strongly supported because it speeds treatment of stroke
    (**Class I, Level of Evidence B**). 9-1-1 Dispatchers should make
    stroke a priority dispatch.

2.  To increase the number of patients who can be seen and treated
    within the first few hours after stroke, educational programs to
    increase public awareness of stroke are recommended (**Class I,
    Level of Evidence B**).

3.  To increase the number of patients who are treated, educational
    programs for physicians, hospital personnel, and emergency medical
    services (EMS) personnel also are recommended (**Class I, Level of
    Evidence B**).

4.  Brief assessments by EMS personnel as outlined in the table below
    titled \"Guidelines for EMS Management of Patients With Suspected
    Stroke\" and in Table 5 of the original guideline document are
    recommended (**Class I, Level of Evidence B**).

5.  The use of a stroke identification algorithm such as the Los Angeles
    or Cincinnati screens is encouraged (**Class I, Level of Evidence
    B**).

6.  The panel recommends that EMS personnel begin the initial management
    of stroke in the field, as outlined in the table \"Guidelines for
    EMS Management of Patients With Suspected Stroke\" (**Class I, Level
    of Evidence B**). The development of stroke protocols to be used by
    EMS personnel is strongly encouraged.

7.  Patients should be transported rapidly for evaluation and treatment
    to the closest institution that provides emergency stroke care as
    described in the statement (**Class I, Level of Evidence B**). In
    some instances, this may involve air evacuation. EMS personnel
    should notify the receiving emergency department (ED) so that the
    appropriate resources may be mobilized.

**Table**. Guidelines for EMS Management of Patients With Suspected
Stroke

  -----------------------------------------------------------------------
  **Recommended**                        **Not Recommended**
  -------------------------------------- --------------------------------
  Manage ABCs                            Dextrose-containing fluids in
                                         nonhypoglycemic patients

  Cardiac monitoring                     Hypotension/excessive blood
                                         pressure reduction

  Intravenous access\                    Excessive intravenous fluids
  \                                      
  Oxygen (as required if O~2~ saturation 
  \<92%)\                                
  \                                      
  Assess for hypoglycemia\               
  \                                      
  *Nil per os* (NPO)\                    
  \                                      
  Alert receiving ED\                    
  \                                      
  Rapid transport to closest appropriate 
  facility capable of treating acute     
  stroke                                 
  -----------------------------------------------------------------------

*Class II Recommendation*

1.  Telemedicine can be an effective method to provide expert stroke
    care to patients located in rural areas (**Class IIa, Level of
    Evidence B**). Additional research and experience on the usefulness
    of telemedicine are encouraged.

**Recommendations for Designation of Stroke Centers**

*The following recommendations were not included in the prior stroke
guidelines.*

*Class I Recommendations*

1.  The creation of primary stroke centers (PSCs) is strongly
    recommended (**Class I, Level of Evidence B**). The organization of
    such resources will depend on local variables. The design of several
    community-based PSCs that provide emergency care and that are
    closely associated with a comprehensive stroke center (CSC), which
    provides more extensive care, has considerable appeal.

2.  The development of CSCs is recommended (**Class I, Level of Evidence
    C**).

3.  Certification of stroke centers by an external body, such as the
    Joint Commission on Accreditation of Healthcare Organizations, is
    encouraged (**Class I, Level of Evidence B**). The panel encourages
    additional medical centers to seek such certification.

4.  For patients with suspected stroke, EMS should bypass hospitals that
    do not have resources to treat stroke and go to the closest facility
    capable of treating acute stroke (**Class I, Level of Evidence B**).

**Recommendations for Emergency Evaluation and Diagnosis of Acute
Ischemic Stroke**

*The recommendations that follow are similar to those included in
previous statements except recommendation 1 under Class III.*

*Class I Recommendations*

1.  An organized protocol for the emergency evaluation of patients with
    suspected stroke is recommended (**Class I, Level of Evidence B**).
    The goal is to complete an evaluation and to decide treatment within
    60 minutes of the patient\'s arrival in an ED. Designation of an
    acute stroke team that includes physicians, nurses, and
    laboratory/radiology personnel is encouraged. Patients with stroke
    should have a careful clinical assessment, including neurological
    examination.

2.  The use of a stroke rating scale, preferably the National Institutes
    of Health Stroke Scale NIHSS, is recommended (**Class I, Level of
    Evidence B**). Hospitals (i.e., administration) must provide the
    necessary resources to use such a scale.

3.  A limited number of hematologic, coagulation, and biochemistry tests
    are recommended during the initial emergency evaluation (see table
    below titled \"Immediate Diagnostic Studies: Evaluation of a Patient
    With Suspected Acute Ischemic Stroke\") (**Class I, Level of
    Evidence B**).

4.  Patients with clinical or other evidence of acute cardiac or
    pulmonary disease may warrant chest x-ray (**Class I, Level of
    Evidence B**).

5.  An electrocardiogram (ECG) is recommended because of the high
    incidence of heart disease in patients with stroke (**Class I, Level
    of Evidence B**).

**Table**. Immediate Diagnostic Studies: Evaluation of a Patient With
Suspected Acute Ischemic Stroke

+-----------------------------------------------------------------------+
| All patients                                                          |
|                                                                       |
| Noncontrast brain CT or brain MRI                                     |
|                                                                       |
| Blood glucose                                                         |
|                                                                       |
| Serum electrolytes/renal function tests                               |
|                                                                       |
| ECG                                                                   |
|                                                                       |
| Markers of cardiac ischemia                                           |
|                                                                       |
| Complete blood count, including platelet count\*                      |
|                                                                       |
| Prothrombin time/international normalized ratio (INR)\*               |
|                                                                       |
| Activated partial thromboplastin time\*                               |
|                                                                       |
| Oxygen saturation                                                     |
|                                                                       |
| Selected patients                                                     |
|                                                                       |
| Hepatic function tests                                                |
|                                                                       |
| Toxicology screen                                                     |
|                                                                       |
| Blood alcohol level                                                   |
|                                                                       |
| Pregnancy test                                                        |
|                                                                       |
| Arterial blood gas tests (if hypoxia is suspected)                    |
|                                                                       |
| Chest radiography (if lung disease is suspected)                      |
|                                                                       |
| Lumbar puncture (if subarachnoid hemorrhage is suspected and CT scan  |
| is negative for blood)                                                |
|                                                                       |
| Electroencephalogram (if seizures are suspected)                      |
+-----------------------------------------------------------------------+

MRI indicates magnetic resonance imaging.

\*Although it is desirable to know the results of these tests before
giving rtPA, thrombolytic therapy should not be delayed while awaiting
the results unless: (1) there is clinical suspicion of a bleeding
abnormality or thrombocytopenia, (2) the patient has received heparin or
warfarin, or (3) use of anticoagulants is not known.

*Class III Recommendations*

1.  Most patients with stroke do not need a chest x-ray as part of their
    initial evaluation (**Class III, Level of Evidence B**). *This is a
    change from the previous guideline.*

2.  Most patients with stroke do not need an examination of the
    cerebrospinal fluid (**Class III, Level of Evidence B**). The yield
    of brain imaging is very high for detection of intracranial
    hemorrhage. The clinical course of subarachnoid hemorrhage or acute
    central nervous system infections usually is distinct from that of
    ischemic stroke. Examination of the cerebrospinal fluid may be
    indicated for evaluation of a patient with a stroke that may be
    secondary to an infectious illness.

**Recommendations for Early Diagnosis: Brain and Vascular Imaging**

*Class I Recommendations*

1.  Imaging of the brain is recommended before initiating any specific
    therapy to treat acute ischemic stroke (**Class I, Level of Evidence
    A**). *This recommendation has not changed from the previous
    guideline.*

2.  In most instances, computed tomography (CT) will provide the
    information to make decisions about emergency management (**Class I,
    Level of Evidence A**). *This recommendation has not changed from
    the previous guideline.*

3.  The brain imaging study should be interpreted by a physician with
    expertise in reading CT or magnetic resonance imaging (MRI) studies
    of the brain (**Class I, Level of Evidence C**). *This
    recommendation has been added since the previous guideline.*

4.  Some findings on CT, including the presence of a dense artery sign,
    are associated with poor outcomes after stroke (**Class I, Level of
    Evidence A**). *This recommendation has not changed from the
    previous guideline.*

5.  Multimodal CT and MRI may provide additional information that will
    improve diagnosis of ischemic stroke (**Class I, Level of Evidence
    A**). *This recommendation has been added since the previous
    guideline.*

*Class II Recommendations*

1.  Nevertheless, data are insufficient to state that, with the
    exception of hemorrhage, any specific CT finding (including evidence
    of ischemia affecting more than one third of a cerebral hemisphere)
    should preclude treatment with recombinant tissue plasminogen
    activator (rtPA) within 3 hours of onset of stroke (**Class IIb,
    Level of Evidence A**). *This recommendation has not changed from
    the previous guideline.*

2.  Vascular imaging is necessary as a preliminary step for
    intra-arterial administration of pharmacological agents, surgical
    procedures, or endovascular interventions (**Class IIa, Level of
    Evidence B**). *This recommendation has not changed from the
    previous guideline.*

*Class III Recommendations*

1.  Emergency treatment of stroke should not be delayed in order to
    obtain multimodal imaging studies (**Class III, Level of Evidence
    C**). *This recommendation has been added since the previous
    guideline.*

2.  Vascular imaging should not delay treatment of patients whose
    symptoms started \<3 hours ago and who have acute ischemic stroke
    (**Class III, Level of Evidence B**). *This recommendation has been
    added since the previous guideline.*

**Recommendations for General Supportive Care and Treatment of Acute
Complications**

*Class I Recommendations*

1.  Airway support and ventilatory assistance are recommended for the
    treatment of patients with acute stroke who have decreased
    consciousness or who have bulbar dysfunction causing compromise of
    the airway (**Class I, Level of Evidence C**). *This recommendation
    has not changed from previous statements.*

2.  Hypoxic patients with stroke should receive supplemental oxygen
    (**Class I, Level of Evidence C**). *This recommendation has not
    changed since the previous guideline.*

3.  It is generally agreed that sources of fever should be treated and
    antipyretic medications should be administered to lower temperature
    in febrile patients with stroke (**Class I, Level of Evidence C**).
    *This recommendation has not changed from previous statements*.
    Medications such as acetaminophen can lower body temperature
    modestly, but the effectiveness of treating either febrile or
    nonfebrile patients to improve neurological outcomes is not
    established. Additional research on utility of emergency
    administration of antipyretic medications is under way.

4.  General agreement supports the use of cardiac monitoring to screen
    for atrial fibrillation and other potentially serious cardiac
    arrhythmias that would necessitate emergency cardiac interventions.
    It is generally agreed that cardiac monitoring should be performed
    during the first 24 hours after onset of ischemic stroke (**Class I,
    Level of Evidence B**). *This recommendation has not changed from
    previous statements.*

5.  The management of arterial hypertension remains controversial. Data
    to guide recommendations for treatment are inconclusive or
    conflicting. Many patients have spontaneous declines in blood
    pressure during the first 24 hours after onset of stroke. Until more
    definitive data are available, it is generally agreed that a
    cautious approach to the treatment of arterial hypertension should
    be recommended (**Class I, Level of Evidence C**). Patients who have
    other medical indications for aggressive treatment of blood pressure
    should be treated. *This recommendation has not changed from
    previous statements.*

6.  Patients who have elevated blood pressure and are otherwise eligible
    for treatment of rtPA may have their blood pressure lowered so that
    their systolic blood pressure is [\<]{.underline}185 mm Hg and their
    diastolic blood pressure is [\<]{.underline}110 mm Hg (**Class I,
    Level of Evidence B**) before lytic therapy is started. *This
    recommendation has not changed from previous statements.* If
    medications are given to lower blood pressure the clinician should
    be sure that the blood pressure is stabilized at the lower level
    before treating with rtPA and maintained below 180/105 mm Hg for at
    least the first 24 hours after intravenous rtPA treatment. Because
    the maximum interval from stroke onset until treatment with rtPA is
    short, many patients with sustained hypertension above recommended
    levels cannot be treated with intravenous rtPA.

7.  Until other data become available, consensus exists that the
    previously described blood pressure recommendations should be
    followed in patients undergoing other acute interventions to
    recanalize occluded vessels, including intra-arterial thrombolysis
    (**Class I, Level of Evidence C**). *This recommendation has been
    added since the previous guideline.*

8.  It is generally agreed that patients with markedly elevated blood
    pressure may have their blood pressure lowered. A reasonable goal
    would be to lower blood pressure by approximately 15% during the
    first 24 hours after onset of stroke. The level of blood pressure
    that would mandate such treatment is not known, but consensus exists
    that medications should be withheld unless the systolic blood
    pressure is \>220 mm Hg or the diastolic blood pressure is \>120 mm
    Hg (**Class I, Level of Evidence C**). *This recommendation has
    changed from previous statements in that a potential goal for
    lowering blood pressure is now included.* Research testing the
    effects of early treatment of arterial hypertension on outcomes
    after stroke is under way. The panel looks forward to any data that
    will clarify this management decision.

9.  It is generally agreed that the cause of arterial hypotension in the
    setting of acute stroke should be sought. Hypovolemia should be
    corrected with normal saline, and cardiac arrhythmias that might be
    reducing cardiac output should be corrected (**Class I, Level of
    Evidence C**). *This recommendation was not included in previous
    statements.* The utility of volume expansion and the use of
    medications to increase blood pressure to treat ischemic stroke are
    discussed elsewhere in the present guideline.

10. It is generally agreed that hypoglycemia should be treated in
    patients with acute ischemic stroke (**Class I, Level of Evidence
    C**). The goal is to achieve normoglycemia. Marked elevation of
    blood glucose levels should be avoided. *This recommendation was
    included in previous statements.*

*Class II Recommendations*

1.  No data are available to guide selection of medications for the
    lowering of blood pressure in the setting of acute ischemic stroke.
    The recommended medications and doses included in the table below
    titled \"Approach to Arterial Hypertension in Acute Ischemic
    Stroke\" are based on general consensus (**Class IIa, Level of
    Evidence C**). *The recommendations in the table have changed from
    the previous statements.*

2.  Evidence from one clinical trial indicates that initiation of
    antihypertensive therapy within 24 hours of stroke is relatively
    safe. Thus, it is generally agreed that antihypertensive medications
    should be restarted at approximately 24 hours for patients who have
    preexisting hypertension and are neurologically stable unless a
    specific contraindication to restarting treatment is known (**Class
    IIa, Level of Evidence B**). *This recommendation was not included
    in previous statements.*

3.  Evidence indicates that persistent hyperglycemia (\>140 mg/dL)
    during the first 24 hours after stroke is associated with poor
    outcomes, and thus it is generally agreed that hyperglycemia should
    be treated in patients with acute ischemic stroke. The minimum
    threshold described in previous statements likely was too high, and
    lower serum glucose concentrations (possibly \>140 to 185 mg/dL)
    probably should trigger administration of insulin, similar to the
    procedure in other acute situations accompanied by hyperglycemia
    (**Class IIa, Level of Evidence C**). *This is a change from
    previous statements.* Close monitoring of glucose concentrations
    with adjustment of insulin doses to avoid hypoglycemia is
    recommended. Simultaneous administration of glucose and potassium
    also may be appropriate. The results of ongoing research should
    clarify the management of hyperglycemia after stroke.

**Table**. Approach to Arterial Hypertension in Acute Ischemic Stroke

+-----------------------------------------------------------------------+
| **Indication that patient is eligible for treatment with intravenous  |
| rtPA or other acute reperfusion intervention**\                       |
| \                                                                     |
| *Blood pressure level*\                                               |
| \                                                                     |
| Systolic \>185 mm Hg or diastolic \>110 mm Hg                         |
|                                                                       |
| Labetalol 10 to 20 mg IV over 1 to 2 minutes, may repeat X1;          |
|                                                                       |
| or                                                                    |
|                                                                       |
| Nitropaste 1 to 2 inches;                                             |
|                                                                       |
| or                                                                    |
|                                                                       |
| Nicardipine infusion, 5 mg/h, titrate up by 2.5 mg/h at 5- to         |
| 15-minute intervals, maximum dose 15 mg/h; when desired blood         |
| pressure attained, reduce to 3 mg/h                                   |
|                                                                       |
| If blood pressure does not decline and remains \>185/110 mm Hg, do    |
| not administer rtPA\                                                  |
| \                                                                     |
| **Management of blood pressure during and after treatment with rtPA   |
| or other acute reperfusion intervention**\                            |
| \                                                                     |
| *Monitor blood pressure every 15 minutes during treatment and then    |
| for another 2 hours, then every 30 minutes for 6 hours, and then      |
| every hour for 16 hours*\                                             |
| \                                                                     |
| [Blood pressure level]{.underline}\                                   |
| \                                                                     |
| Systolic 180 to 230 mm Hg or diastolic 105 to 120 mm Hg               |
|                                                                       |
| Labetalol 10 mg IV over 1 to 2 minutes, may repeat every 10 to 20     |
| minutes, maximum dose of 300 mg;                                      |
|                                                                       |
| or                                                                    |
|                                                                       |
| Labetalol 10 mg IV followed by an infusion at 2 to 8 mg/min           |
|                                                                       |
| Systolic \>230 mm Hg or diastolic 121 to 140 mm Hg                    |
|                                                                       |
| Labetalol 10 mg IV over 1 to 2 minutes, may repeat every 10 to 20     |
| minutes, maximum dose of 300 mg;                                      |
|                                                                       |
| or                                                                    |
|                                                                       |
| Labetalol 10 mg IV followed by an infusion at 2 to 8 mg/min;          |
|                                                                       |
| or                                                                    |
|                                                                       |
| Nicardipine infusion, 5 mg/h, titrate up to desired effect by         |
| increasing 2.5 mg/h every 5 minutes to maximum of 15 mg/h             |
|                                                                       |
| If blood pressure not controlled, consider sodium nitroprusside       |
+-----------------------------------------------------------------------+

*Class III Recommendations*

1.  Nonhypoxic patients with acute ischemic stroke do not need
    supplemental oxygen therapy (**Class III, Level of Evidence B**).
    *This recommendation has not changed from previous statements.*

2.  Data on the utility of hyperbaric oxygen are inconclusive, and some
    data imply that the intervention may be harmful. Thus, with the
    exception of stroke secondary to air embolization, this intervention
    is not recommended for treatment of patients with acute ischemic
    stroke (**Class III, Level of Evidence B**). *This recommendation
    has changed from previous statements.*

3.  Although data demonstrate the efficacy of hypothermia for improving
    neurological outcomes after cardiac arrest, the utility of induced
    hypothermia for the treatment of patients with ischemic stroke is
    not established. At the present time, insufficient evidence exists
    to recommend hypothermia for treatment of patients with acute stroke
    (**Class III, Level of Evidence B**). *This recommendation has not
    changed from previous statements.* Additional research on the safety
    and efficacy of induced hypothermia for treatment of patients with
    stroke is under way.

**Recommendations for Intravenous Thrombolysis**

*Class I Recommendations*

1.  Intravenous rtPA (0.9 mg/kg, maximum dose 90 mg) is recommended for
    selected patients who may be treated within 3 hours of onset of
    ischemic stroke (**Class I, Level of Evidence A**). Physicians
    should review the criteria outlined in the table \"Characteristics
    of Patients With Ischemic Stroke Who Could Be Treated With rtPA\"
    (which are modeled on those used in the National Institute of
    Neurological Disorders and Stroke trial) to determine the
    eligibility of the patient. A recommended regimen for observation
    and treatment of the patient is described in the table \"Treatment
    of Acute Ischemic Stroke: Intravenous Administration of rtPA.\"
    *This recommendation has not changed from previous statements.*

2.  Besides bleeding complications, physicians should be aware of the
    potential side effect of angioedema that may cause partial airway
    obstruction (**Class I, Level of Evidence C**). *This recommendation
    has been added since the previous guidelines.*

**Characteristics of Patients With Ischemic Stroke Who Could Be Treated
With rtPA**

  -----------------------------------------------------------------------
  Diagnosis of ischemic stroke causing measurable neurological deficit\
  \
  The neurological signs should not be clearing spontaneously.\
  \
  The neurological signs should not be minor and isolated.\
  \
  Caution should be exercised in treating a patient with major deficits.\
  \
  The symptoms of stroke should not be suggestive of subarachnoid
  hemorrhage.\
  \
  Onset of symptoms \<3 hours before beginning treatment\
  \
  No head trauma or prior stroke in previous 3 months\
  \
  No myocardial infarction in the previous 3 months\
  \
  No gastrointestinal or urinary tract hemorrhage in previous 21 days\
  \
  No major surgery in the previous 14 days\
  \
  No arterial puncture at a noncompressible site in the previous 7 days\
  \
  No history of previous intracranial hemorrhage\
  \
  Blood pressure not elevated (systolic \<185 mm Hg and diastolic \<110
  mm Hg)\
  \
  No evidence of active bleeding or acute trauma (fracture) on
  examination\
  \
  Not taking an oral anticoagulant or, if anticoagulant being taken, INR
  [\<]{.underline}1.7\
  \
  If receiving heparin in previous 48 hours, aPTT must be in normal
  range.\
  \
  Platelet count [\>]{.underline}100 000 mm^3^\
  \
  Blood glucose concentration [\>]{.underline}50 mg/dL (2.7 mmol/L)\
  \
  No seizure with postictal residual neurological impairments\
  \
  CT does not show a multilobar infarction (hypodensity \>1/3 cerebral
  hemisphere).\
  \
  The patient or family members understand the potential risks and
  benefits from treatment.

  -----------------------------------------------------------------------

INR indicates international normalized ratio; aPTT, activated partial
thromboplastin time.

**Treatment of Acute Ischemic Stroke: Intravenous Administration of
rtPA**

  -----------------------------------------------------------------------
  Infuse 0.9 mg/kg (maximum dose 90 mg) over 60 minutes with 10% of the
  dose given as a bolus over 1 minute.\
  \
  Admit the patient to an intensive care or stroke unit for monitoring.\
  \
  Perform neurological assessments every 15 minutes during the infusion
  and every 30 minutes thereafter for the next 6 hours, then hourly until
  24 hours after treatment.\
  \
  If the patient develops severe headache, acute hypertension, nausea, or
  vomiting, discontinue the infusion (if rtPA is being administered) and
  obtain emergency CT scan.\
  \
  Measure blood pressure every 15 minutes for the first 2 hours and
  subsequently every 30 minutes for the next 6 hours, then hourly until
  24 hours after treatment.\
  \
  Increase the frequency of blood pressure measurements if a systolic
  blood pressure is [\>]{.underline}180 mm Hg or if a diastolic blood
  pressure is [\>]{.underline}105 mm Hg; administer antihypertensive
  medications to maintain blood pressure at or below these levels (see
  table \"Approach to Arterial Hypertension in Acute Ischemic Stroke\").\
  \
  Delay placement of nasogastric tubes, indwelling bladder catheters, or
  intra-arterial pressure catheters.\
  \
  Obtain a follow-up CT scan at 24 hours before starting anticoagulants
  or antiplatelet agents.

  -----------------------------------------------------------------------

*Class II Recommendations*

1.  A patient whose blood pressure can be lowered safely with
    antihypertensive agents may be eligible for treatment, and the
    physician should assess the stability of the blood pressure before
    starting rtPA (**Class IIa, Level of Evidence B**). An elevated
    blood pressure that requires a continuous infusion of sodium
    nitroprusside may not be sufficiently stable for the patient to
    receive rtPA. However, because time is limited, most patients with
    markedly elevated blood pressure cannot be managed adequately and
    still meet the 3-hour requirement. *This recommendation has not
    changed from previous guidelines.*

2.  A patient with a seizure at the time of onset of stroke may be
    eligible for treatment as long as the physician is convinced that
    residual impairments are secondary to stroke and not a postictal
    phenomenon (**Class IIa, Level of Evidence C**). *This
    recommendation differs from the previous statements and represents a
    broadening of eligibility for treatment with rtPA.*

*Class III Recommendations*

1.  The intravenous administration of streptokinase for treatment of
    stroke is not recommended (**Class III, Level of Evidence A**).
    *This recommendation has not changed from previous guidelines.*

2.  The intravenous administration of ancrod, tenecteplase, reteplase,
    desmoteplase, urokinase, or other thrombolytic agents outside the
    setting of a clinical trial is not recommended (**Class III, Level
    of Evidence C**). *This recommendation is new.*

**Recommendations for Intra-Arterial Thrombolysis**

*Class I Recommendations*

1.  Intra-arterial thrombolysis is an option for treatment of selected
    patients who have major stroke of \<6 hours\' duration due to
    occlusions of the middle cerebral artery (MCA) and who are not
    otherwise candidates for intravenous rtPA (**Class I, Level of
    Evidence B**). *This recommendation has not changed since previous
    guidelines.*

2.  Treatment requires the patient to be at an experienced stroke center
    with immediate access to cerebral angiography and qualified
    interventionalists. Facilities are encouraged to define criteria to
    credential individuals who can perform intra-arterial thrombolysis
    (**Class I, Level of Evidence C**). *This recommendation has been
    added since previous guidelines.*

*Class II Recommendation*

1.  Intra-arterial thrombolysis is reasonable in patients who have
    contraindications to use of intravenous thrombolysis, such as recent
    surgery (**Class IIa, Level of Evidence C**). *This recommendation
    was not included in the previous guideline.*

*Class III Recommendation*

1.  The availability of intra-arterial thrombolysis should generally not
    preclude the intravenous administration of rtPA in otherwise
    eligible patients (**Class III, Level of Evidence C**). *This
    recommendation has not changed from previous guidelines.*

**Recommendations for Anticoagulants**

*The following recommendations have not changed from previous
guidelines.*

*Class III Recommendations*

1.  Urgent anticoagulation with the goal of preventing early recurrent
    stroke, halting neurological worsening, or improving outcomes after
    acute ischemic stroke is not recommended for treatment of patients
    with acute ischemic stroke (**Class III, Level of Evidence A**).
    This recommendation may change if additional data demonstrate the
    usefulness of very early intravenous administration of
    anticoagulants for treatment of patients with infarctions secondary
    to large-artery thrombosis or cardioembolism. Urgent anticoagulation
    should not be used in lieu of intravenous thrombolysis for treatment
    of otherwise eligible patients (**Class III, Level of Evidence A**).

2.  Urgent anticoagulation is not recommended for patients with moderate
    to severe strokes because of an increased risk of serious
    intracranial hemorrhagic complications (**Class III, Level of
    Evidence A**).

3.  Initiation of anticoagulant therapy within 24 hours of treatment
    with intravenously administered rtPA is not recommended (**Class
    III, Level of Evidence B**).

**Recommendations for Antiplatelet Agents**

*Class I Recommendation*

1.  The oral administration of aspirin (initial dose is 325 mg) within
    24 to 48 hours after stroke onset is recommended for treatment of
    most patients (**Class I, Level of Evidence A**). *This
    recommendation has changed in that a dose of aspirin is now
    included.*

*Class III Recommendations*

1.  Aspirin should not be considered a substitute for other acute
    interventions for treatment of stroke, including the intravenous
    administration of rtPA (**Class III, Level of Evidence B**). *These
    recommendations have not changed from previous statements.*

2.  The administration of aspirin as an adjunctive therapy within 24
    hours of thrombolytic therapy is not recommended (**Class III, Level
    of Evidence A**). *This recommendation has not changed.*

3.  The administration of clopidogrel alone or in combination with
    aspirin is not recommended for the treatment of acute ischemic
    stroke (**Class III, Level of Evidence C**). *This recommendation
    was not included in the previous statement.* The panel supports
    research testing the usefulness of emergency administration of
    clopidogrel in the treatment of patients with acute stroke.

4.  Outside the setting of clinical trials, the intravenous
    administration of antiplatelet agents that inhibit the glycoprotein
    IIb/IIIa receptor is not recommended (**Class III, Level of Evidence
    B**). *This recommendation has been added since the last guideline
    was published.*

**Recommendations for Volume Expansion, Vasodilators, and Induced
Hypertension**

A.  **Hemodilution in Acute Ischemic Stroke**

> *Class III Recommendation*

1.  Hemodilution with or without venesection and volume expansion is not
    recommended for treatment of patients with acute ischemic stroke
    (**Class III, Level of Evidence A**). *This recommendation has not
    changed since the previous guidelines were published.*

```{=html}
<!-- -->
```
B.  **Vasodilators in Acute Ischemic Stroke**

> *Class III Recommendation*

1.  The administration of medications such as pentoxifylline is not
    recommended for treatment of patients with acute ischemic stroke
    (**Class III, Level of Evidence A**). *This recommendation has not
    changed since the previous guideline was published.*

```{=html}
<!-- -->
```
C.  **Induced Hypertension for the Management of Acute Ischemic Stroke**

> *Class I Recommendation*

1.  In exceptional cases, a physician may prescribe vasopressors to
    improve cerebral blood flow. If drug-induced hypertension is used,
    close neurological and cardiac monitoring is recommended (**Class I,
    Level of Evidence C**). *This recommendation has been added since
    the previous guideline was published.*

> *Class III Recommendation*

1.  Drug-induced hypertension, outside the setting of clinical trials,
    is not recommended for treatment of most patients with acute
    ischemic stroke (**Class III, Level of Evidence B**). *This
    recommendation has been added since the previous guideline was
    published.*

**Recommendations for Surgical Interventions**

Data on the safety and effectiveness of carotid endarterectomy and other
operations for treatment of patients with acute ischemic stroke are not
sufficient to permit a recommendation. Surgical procedures may have
serious risks and may not favorably alter the outcome of the patient.

**Recommendations for Endovascular Interventions**

*Class II Recommendations*

1.  Although the Mechanical Embolus Removal in Cerebral Ischemia (MERCI)
    device is a reasonable intervention for extraction of intra-arterial
    thrombi in carefully selected patients, the panel also recognizes
    that the utility of the device in improving outcomes after stroke is
    unclear (**Class IIb, Level of Evidence B**). *This recommendation
    has been added since the previous guideline.* The panel also
    recommends that the device be studied in additional clinical trials
    that will define its role in the emergency management of stroke.
    *This is the first time that a panel has made a recommendation about
    endovascular treatment of patients with acute ischemic stroke.*

2.  The usefulness of other mechanical endovascular treatments is not
    established (**Class IIb, Level of Evidence C**). These devices
    should be used in the setting of clinical trials. *This
    recommendation has not changed from previous guidelines.*

**Recommendation for Combination Reperfusion Therapy in Acute Stroke**

*Class III Recommendation*

1.  At present, combinations of interventions to restore perfusion
    cannot be recommended outside the setting of clinical trials
    (**Class III, Level of Evidence B**). *This recommendation has been
    added since the previous* *guidelines were published.*

**Recommendation for Neuroprotective Agents**

*Class III Recommendation*

1.  At present, no intervention with putative neuroprotective actions
    has been established as effective in improving outcomes after
    stroke, and therefore none currently can be recommended (**Class
    III, Level of Evidence A**). *This recommendation has not changed
    from previous guidelines.*

**Recommendations for Admission to the Hospital and General Acute
Treatment (After Hospitalization)**

*Class I Recommendations*

1.  The use of comprehensive specialized stroke care (stroke units)
    incorporating rehabilitation is recommended (**Class I, Level of
    Evidence A**). *This recommendation is unchanged from the previous
    guideline.*

2.  The use of standardized stroke care order sets is recommended to
    improve general management (**Class I, Level of Evidence B**). *This
    recommendation was not in previous guidelines.*

3.  Early mobilization of less severely affected patients and measures
    to prevent subacute complications of stroke are recommended (**Class
    I, Level of Evidence C**). *This recommendation is unchanged from
    the previous guideline.*

4.  Assessment of swallowing before starting eating or drinking is
    recommended (**Class I, Level of Evidence B**). *This recommendation
    is new.*

5.  Patients with suspected pneumonia or urinary tract infections should
    be treated with antibiotics (**Class I, Level of Evidence B**).
    *This recommendation is similar to previous guidelines.*

6.  Subcutaneous administration of anticoagulants is recommended for
    treatment of immobilized patients to prevent deep vein thrombosis
    (**Class I, Level of Evidence A**). The ideal timing for starting
    these medications is not known. *This recommendation is unchanged
    from the previous guideline.*

7.  Treatment of concomitant medical diseases is recommended (**Class I,
    Level of Evidence C**). *This recommendation is unchanged from the
    previous guideline.*

8.  Early institution of interventions to prevent recurrent stroke is
    recommended (**Class I, Level of Evidence C**). *This recommendation
    is similar to previous guidelines.*

*Class II Recommendations*

1.  Patients who cannot take food and fluids orally should receive
    nasogastric, nasoduodenal, or percutaneous endoscopic gastrostomy
    (PEG) feedings to maintain hydration and nutrition while undergoing
    efforts to restore swallowing (**Class IIa, Level of Evidence B**).
    The timing of the placement of a PEG is uncertain. *This
    recommendation is new.*

2.  Aspirin is a potential intervention to prevent deep vein thrombosis
    but is less effective than anticoagulants (**Class IIa, Level of
    Evidence A**). *This recommendation has been strengthened.*

3.  The use of intermittent external compression devices is recommended
    for treatment of patients who cannot receive anticoagulants (**Class
    IIa, Level of Evidence B**). *This recommendation is unchanged from
    the previous guideline.*

*Class III Recommendations*

1.  Nutritional supplements are not needed (**Class III, Level of
    Evidence B**). *This recommendation is new.*

2.  Prophylactic administration of antibiotics is not recommended
    (**Class III, Level of Evidence B**). *This recommendation is new.*

3.  If possible, the placement of indwelling bladder catheters should be
    avoided because of the associated risk of urinary tract infections
    (**Class III, Level of Evidence C**). Some patients may need
    prolonged catheter drainage of the bladder, and measures to lower
    risk of infection should be taken. *This recommendation is similar
    to previous guidelines.*

**Recommendations for Treatment of Acute Neurological Complications**

*Class I Recommendations*

1.  Patients with major infarctions affecting the cerebral hemisphere or
    cerebellum are at high risk for complicating brain edema and
    increased intracranial pressure. Measures to lessen the risk of
    edema and close monitoring of the patient for signs of neurological
    worsening during the first days after stroke are recommended
    (**Class I, Level of Evidence B**). *This recommendation has not
    changed since the previous guidelines.* Because many hospitals may
    not have neurosurgical expertise, transfer of patients at risk for
    malignant brain edema to an institution that has such expertise
    should be considered. *This recommendation is new.*

2.  Patients with acute hydrocephalus secondary to an ischemic stroke
    most commonly affecting the cerebellum can be treated with placement
    of a ventricular drain (**Class I, Level of Evidence B**). *This
    recommendation has not changed since the previous guidelines.*

3.  Decompressive surgical evacuation of a space-occupying cerebellar
    infarction is a potentially life-saving measure, and clinical
    recovery may be very good (**Class I, Level of Evidence B**).
    Although data from clinical trials are not available, it is
    recommended for patients with major cerebellar infarction. *This
    recommendation has not changed since the previous guidelines.*

4.  Recurrent seizures after stroke should be treated in a manner
    similar to other acute neurological conditions (**Class I, Level of
    Evidence B**). *This recommendation has not changed since the
    previous guidelines.*

*Class II Recommendations*

1.  Although aggressive medical measures, including osmotherapy, have
    been recommended for treatment of deteriorating patients with
    malignant brain edema after large cerebral infarction, these
    measures are unproven (**Class IIa, Level of Evidence C**).
    Hyperventilation is a short-lived intervention. Medical measures may
    delay decompressive surgery. *This recommendation has not changed
    since the previous guidelines.*

2.  Decompressive surgery for malignant edema of the cerebral hemisphere
    may be life-saving, but the impact of morbidity is unknown. Both the
    age of the patient and the side of the infarction (dominant versus
    nondominant hemisphere) may affect decisions about surgery. Although
    the surgery may be recommended for treatment of seriously affected
    patients, the physician should advise the patient\'s family about
    the potential outcomes, including survival with severe disability
    (**Class IIa, Level of Evidence B**). *This recommendation has been
    modified.*

3.  No specific recommendation is made for treatment of patients with
    asymptomatic hemorrhagic transformation after ischemic stroke
    (**Class IIb, Level of Evidence C**). *This recommendation is new.*
    Treatment of symptomatic hemorrhagic transformation is addressed in
    the intracerebral hemorrhage management guideline being issued
    contemporaneously with this statement. Measures to lessen the
    likelihood of hemorrhagic complications of thrombolytic agents or
    other interventions to restore or improve perfusion such as careful
    control of arterial blood pressure are recommended.

*Class III Recommendations*

1.  Because of lack of evidence of efficacy and the potential to
    increase the risk of infectious complications, corticosteroids (in
    conventional or large doses) are not recommended for treatment of
    cerebral edema and increased intracranial pressure complicating
    ischemic stroke (**Class III, Level of Evidence A**). *This
    recommendation has not changed since the previous guidelines.*

2.  Prophylactic administration of anticonvulsants to patients with
    stroke but who have not had seizures is not recommended (**Class
    III, Level of Evidence C**). *This recommendation has not changed
    since the previous guidelines.*

**Palliative Care**

Unfortunately, some patients with stroke have a fatal brain injury.
These critically ill persons have profound neurological impairments such
as a persistent vegetative state or evidence of unstable vital signs.
Other patients with stroke have serious preexisting medical or
neurological illnesses, such as dementia, that have caused severe
impairments, and the new cerebrovascular event may add more disability.
Despite the interventions that are described in this outline, the
prognosis of such patients often is very poor. Many people would not
want to survive if a devastating stroke would lead to a persistent
vegetative state or other condition of devastating incapacity.

An increasing number of patients have advanced directive statements that
provide instructions about emergency treatment in a situation such as a
massive stroke. Physicians should honor those directives. In other
circumstances, such directives may not be available, and the patient\'s
neurological status usually precludes decision making. Occasionally, a
guardian with medical power of attorney can make the decision.
Otherwise, the physician should involve family members. The physician
should provide clear information about the nature of the stroke, the
prognosis, and the treatment options. The family should be given the
opportunity to select or withhold medical interventions. In such
situation, the medical care may emphasize measures to keep the patient
comfortable and to support the family during the terminal aspects of the
stroke.

**[Definitions]{.underline}**:

**Classification**

**Class I** Conditions for which there is evidence for and/or general
agreement that the procedure or treatment is useful and effective

**Class II** Conditions for which there is conflicting evidence and/or a
divergence of opinion about the usefulness/efficacy of a procedure or
treatment

**Class IIa** The weight of evidence or opinion is in favor of the
procedure or treatment

**Class IIb** Usefulness/efficacy is less well established by evidence
or opinion

**Class III** Conditions for which there is evidence and/or general
agreement that the procedure or treatment is not useful/effective and in
some cases may be harmful

**Level of Evidence**

A.  Data derived from multiple randomized clinical trials

B.  Data derived from a single randomized trial or nonrandomized studies

C.  Consensus opinion of experts

**Level of Evidence for Diagnostic Recommendation**

A.  Data derived from multiple prospective cohort studies that used a
    reference standard applied by a masked evaluator

B.  Data derived from a single grade A study or one or more
    case--control studies or studies that used a reference standard
    applied by an unmasked evaluator

C.  Consensus opinion of experts

#### CLINICAL ALGORITHM(S)

None provided

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of supporting evidence is identified and graded for each
recommendation (see \"Major Recommendations\").

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

Appropriate diagnosis and early management of patients with ischemic
stroke

#### POTENTIAL HARMS

-   Aggressive treatment of blood pressure may lead to neurological
    worsening by reducing perfusion pressure to ischemic areas of the
    brain.

-   The administration of *vasopressors* may be complicated by side
    effects, including myocardial ischemia, in some patients with
    stroke.

-   Treatment of increased intracranial pressure may result in a decline
    in arterial blood pressure.

-   Early administration of *antihypertensive agents* to patients with
    systolic blood pressures \>180 mm Hg was associated with a marked
    increase in likelihood of early deterioration, poor neurological
    outcome, or death.

-   Because the risk of hemorrhage is considerable among patients with
    severe deficits, the decision to treat with *recombinant tissue
    plasminogen activator (rtPA)* should be made with caution. Treatment
    with rtPA is associated with symptomatic intracranial hemorrhage,
    which may be fatal. Besides a risk of intracranial hemorrhage, other
    potential adverse experiences include systemic bleeding, myocardial
    rupture if the agent is given within a few days of acute myocardial
    infarction, and reactions such as anaphylaxis or angioedema,
    although these events are rare.

### CONTRAINDICATIONS

#### CONTRAINDICATIONS

-   Seizure in the absence of imaging confirmation of acute ischemia is
    a relative contraindication for the use of recombinant tissue
    plasminogen activator (rtPA) in acute ischemic stroke.

-   Patient contraindications to magnetic resonance imaging (MRI)
    include claustrophobia, cardiac pacemakers, or metal implants.

-   A systolic blood pressure \>185 mm Hg or a diastolic blood pressure
    \>110 mm Hg is a contraindication to intravenous administration of
    rtPA.

-   The presence of asthma would contraindicate the administration of a
    beta-blocker.

-   The administration of anticoagulants or antiplatelet agents is
    currently contraindicated during the first 24 hours after treatment
    with intravenous rtPA.

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

The present document is a comprehensive guideline statement on the
management of patients with acute ischemic stroke that supersedes the
prior statement and interim updates.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

#### IMPLEMENTATION TOOLS

Tool Kits

For information about
[availability](#identifying-information-and-availability), see the
\"Availability of Companion Documents\" and \"Patient Resources\" fields
below.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

End of Life Care\
Getting Better\
Living with Illness

#### IOM DOMAIN

Effectiveness\
Safety\
Timeliness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Adams HP Jr, del Zoppo G, Alberts MJ, Bhatt DL, Brass L, Furlan A, Grubb
RL, Higashida RT, Jauch EC, Kidwell C, Lyden PD, Morgenstern LB, Qureshi
AI, Rosenwasser RH, Scott PA, Wijdicks EFM, American Heart Association,
American Stroke Association Stroke Council, Clinical Cardiology Council.
Guidelines for the early management of adults with ischemic stroke: a
guideline from the American Heart Association/American Stroke
Association Stroke Council, Clinical Cardiology Council, Cardiovascular
Radiology \[trunc\]. Stroke 2007 May;38(5):1655-711. \[738 references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=17431204)

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

2007 Apr 12

#### GUIDELINE DEVELOPER(S)

American Heart Association - Professional Association\
American Stroke Association - Disease Specific Society

#### SOURCE(S) OF FUNDING

American Heart Association

#### GUIDELINE COMMITTEE

American Heart Association/American Stroke Association Stroke Council,
Clinical Cardiology Council, Cardiovascular Radiology and Intervention
Council

Atherosclerotic Peripheral Vascular Disease and Quality of Care Outcomes
in Research Interdisciplinary Working Groups

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Members*: Harold P. Adams, Jr, MD, FAHA, *Chair*; Gregory del Zoppo,
MD, FAHA, *Vice Chair*; Mark J. Alberts, MD, FAHA; Deepak L. Bhatt, MD;
Lawrence Brass, MD, FAHA; Anthony Furlan, MD, FAHA; Robert L. Grubb, MD,
FAHA; Randall T. Higashida, MD, FAHA; Edward C. Jauch, MD, FAHA; Chelsea
Kidwell, MD, FAHA; Patrick D. Lyden, MD; Lewis B. Morgenstern, MD, FAHA;
Adnan I. Qureshi, MD, FAHA; Robert H. Rosenwasser, MD, FAHA; Phillip A.
Scott, MD, FAHA; Eelco F.M. Wijdicks, MD, FAHA

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

The American Heart Association makes every effort to avoid any actual or
potential conflicts of interest that may arise as a result of an outside
relationship or a personal, professional, or business interest of a
member of the writing panel. Specifically, all members of the writing
group are required to complete and submit a Disclosure Questionnaire
showing all such relationships that might be perceived as real or
potential conflicts of interest.

**Writing Group Disclosures**

  ---------------------------------------------------------------------------------------------------------------------------------------------------
  **Writing     **Employment**   **Research Grant**    **Other         **Speakers\'           **Ownership   **Consultant/Advisory   **Other**
  Group                                                Research        Bureau/Honoraria**     Interest**    Board**                 
  Member**                                             Support**                                                                    
  ------------- ---------------- --------------------- --------------- ---------------------- ------------- ----------------------- -----------------
  Harold P.     University of    Boehringer            AstraZeneca†;   Bayer\*                None          American Board of       None
  Adams, Jr     Iowa; Carver     Ingelheim†; Centocor  Merck\*                                              Psychiatry and          
                College of       (Johnson & Johnson)†;                                                      Neurology               
                Medicine         Eli Lilly†; Merck†;                                                                                
                                 NMT Medical†;                                                                                      
                                 Sanofi†;                                                                                           
                                 Bristol-Myers                                                                                      
                                 Squibb†;                                                                                           
                                 GlaxoSmithKline\*                                                                                  

  Gregory del   Scripps Research None                  None            None                   None          Boehringer Ingelheim    None
  Zoppo         Institute                                                                                   (overseas product for   
                                                                                                            fibrinolysis)\*         

  Mark J.       Northwestern     Boehringer            None            AstraZeneca\*;         None          AstraZeneca\*;          None
  Alberts       University       Ingelheim\*;                          Boehringer                           Boehringer Ingelheim\*; 
                Medical School   Bristol-Myers                         Ingelheim\*;                         Bristol-Myers Squibb†;  
                                 Squibb\*;                             Bristol-Myers Squibb†;               Sanofi-Synthelabo†      
                                 Sanofi-Synthelabo\*                   Sanofi-Synthelabo†                                           

  Deepak L.     Cleveland Clinic Bristol-Myers         None            AstraZeneca\*;         None          AstraZeneca\*;          Provider expert
  Bhatt         Foundation       Squibb†; Eisai†;                      Bristol-Myers                        Bristol-Myers Squibb\*; testimony
                                 Ethicon†;                             Squibb\*; Cardax\*;                  Cardax\*; Centocor\*;   regarding
                                 Sanofi-Aventis†; The                  Centocor\*;                          Daiichi-Sankyo\*;       anti-thrombotic
                                 Medicines Company†                    Daiichi-Sankyo\*;                    Eisai\*; Eli Lilly\*;   therapy
                                                                       Eisai\*; Eli Lilly\*;                GlaxoSmithKline\*;      
                                                                       GlaxoSmithKline\*;                   Millenium\*; Otsuka\*;  
                                                                       Millenium\*; Otsuka\*;               ParinGenix\*; PDL\*;    
                                                                       ParinGenix\*; PDL\*;                 Sanofi- Aventis\*;      
                                                                       Sanofi-Aventis\*;                    Schering-Plough\*; The  
                                                                       Schering-Plough\*; The               Medicines Company\*;    
                                                                       Medicines Company\*;                 tns Healthcare\*        
                                                                       tns Healthcare\*                                             

  Lawrence      Yale University  Bristol-Myers         None            Bristol-Myers          None          AstraZeneca\*;          None
  Brass                          Squibb\*;                             Squibb\*;                            Bristol-Myers Squibb\*; 
  (deceased)                     Sanofi-Synthelabo\*                   Sanofi-Synthelabo\*;                 Merck\*; ONO            
                                                                       Solvay                               Pharmaceuticals\*;      
                                                                       Pharmaceuticals\*;                   Sanofi-Synthelabo\*;    
                                                                       Wyeth\*                              Solvay                  
                                                                                                            Pharmaceuticals\*;      
                                                                                                            Wyeth\*                 

  Anthony       Cleveland Clinic Bristol-Myers         None            None                   None          Paion\*                 None
  Furlan        Foundation       Squibb†; Sanofi†;                                                                                  
                                 Possis\*                                                                                           

  Robert L.     Washington       None                  None            None                   None          None                    None
  Grubb         University                                                                                                          

  Randall T.    University of    Concentric Medical\*  None            None                   None          Concentric Medical\*    None
  Higashida     California at                                                                                                       
                San Francisco                                                                                                       
                Medical Center                                                                                                      

  Edward C.     University of    Biosite\*             None            Boehringer Ingelheim\* None          AstraZeneca\*;          None
  Jauch         Cincinnati                                                                                  Biosite\*; Genentech\*; 
                College of                                                                                  Johnson & Johnson\*;    
                Medicine                                                                                    Novo Nordisk            

  Chelsea       Washington       None                  None            None                   None          Bristol-Myers Squibb\*; None
  Kidwell       Hospital Center                                                                             GlaxoSmithKline\*;      
                Stroke Center                                                                               Millenium               
                                                                                                            Pharmaceuticals\*; S.   
                                                                                                            Daichi Arbio            
                                                                                                            Pharmaceuticals\*;      
                                                                                                            Sanofi\*                

  Patrick D.    University of    AstraZeneca\*;        None            None                   None          Merck\*, Mitsubishi\*   None
  Lyden         California at    Bayer\*; Merck\*;                                                                                  
                San Diego Stroke Yamanouchi\*                                                                                       
                Center                                                                                                              

  Lewis B.      University of    None                  None            AstraZeneca\*; Novo    None          Merck\*                 None
  Morgenstern   Michigan                                               Nordisk\*                                                    

  Adnan I.      University of    Centocor              None            Bristol-Myers          None          Pfizer\*; Protein       None
  Qureshi       Minnesota,       Therapeutic†; ESP                     Squibb\*; Sanofi                     Design Laboratories\*   
                Minneapolis      Pharma\*                              Pharmaceuticals\*                                            

  Robert H.     Thomas Jefferson None                  None            None                   None          None                    None
  Rosenwasser   University                                                                                                          

  Phillip A.    University of    None                  None            None                   None          AstraZeneca\*           None
  Scott         Michigan                                                                                                            

  Eelco F.M.    Mayo Clinic      None                  None            None                   None          None                    None
  Wijdicks                                                                                                                          
  ---------------------------------------------------------------------------------------------------------------------------------------------------

This table represents the relationships of writing group members that
may be perceived as actual or reasonably perceived conflicts of interest
as reported on the Disclosure Questionnaire that all members of the
writing group are required to complete and submit. A relationship is
considered to be \"Significant\" if (1) the person receives \$10 000 or
more during any 12-month period, or 5% or more of the person\'s gross
income; or (2) the person owns 5% or more of the voting stock or share
of the entity, or owns \$10 000 or more of the fair market value of the
entity. A relationship is considered to be \"Modest\" if it is less than
\"Significant\" under the preceding definition.

\*Modest.

†Significant

**Reviewer Disclosures**

  -------------------------------------------------------------------------------------------------------------------------------------------------
  **Reviewer**   **Employment**   **Research Grant** **Other     **Speakers\'         **Expert    **Ownership   **Consultant/Advisory   **Other**
                                                     Research    Bureau/Honoraria**   Witness**   Interest**    Board**                 
                                                     Support**                                                                          
  -------------- ---------------- ------------------ ----------- -------------------- ----------- ------------- ----------------------- -----------
  S. Claiborne   University of    Sanofi             None        None                 None        None          Boehringer Ingelheim    None
  Johnston       California at    Aventis/Bristol-                                                              for Secondary Stroke    
                 San Francisco    Myers Squibb†                                                                 Prevention Trials†      

  Ralph Sacco    Columbia         NINDS grants for   None        None                 None        None          None                    None
                 University       stroke research†                                                                                      

  Stanley Tuhrim Mount Sinai      None               None        None                 None        None          None                    None
                 Medical Center                                                                                                         
  -------------------------------------------------------------------------------------------------------------------------------------------------

This table represents the relationships of reviewers that may be
perceived as actual or reasonably perceived conflicts of interest as
reported on the Disclosure Questionnaire that all reviewers are required
to complete and submit. A relationship is considered to be
\"Significant\" if (1) the person receives \$10 000 or more during any
12-month period, or 5% or more of the person\'s gross income; or (2) the
person owns 5% or more of the voting stock or share of the entity, or
owns \$10 000 or more of the fair market value of the entity. A
relationship is considered to be \"Modest\" if it is less than
\"Significant\" under the preceding definition.

†Significant.

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: Adams HP Jr, Adams RJ, Brott
T, del Zoppo GJ, Furlan A, Goldstein LB, Grubb RL, Higashida R, Kidwell
C, Kwiatkowski TG, Marler JR, Hademenos GJ. Guidelines for the early
management of patients with ischemic stroke: a scientific statement from
the Stroke Council of the American Stroke Association. Stroke 2003
Apr;34(4):1056-83 and Adams H, Adams R, del Zoppo G, Goldstein LB.
Guidelines for the early management of patients with ischemic stroke:
2005 guidelines update: a scientific statement from the Stroke Council
of the American Heart Association/American Stroke Association. Stroke
2005 Apr;36:916-23

It is intended that this guideline be fully updated in 3 years.

#### GUIDELINE AVAILABILITY

Electronic copies: Available from the [American Heart Association Web
site](http://stroke.ahajournals.org/cgi/content/full/38/5/1655).

Print copies: Available from the American Heart Association, Public
Information, 7272 Greenville Ave, Dallas, TX 75231-4596; Phone:
800-242-8721

#### AVAILABILITY OF COMPANION DOCUMENTS

Get With the Guidelines (GWTG) provides disease-specific process
documents and tools for in-house quality improvement. See the [American
Heart Association Web
site](http://www.americanheart.org/presenter.jhtml?identifier=3013970)
for more information. See the related QualityTool summary on the [Health
Care Innovations Exchange Web
site](http://www.innovations.ahrq.gov/content.aspx?id=1995) for this
related tool set.

#### PATIENT RESOURCES

None available

#### NGC STATUS

This summary was completed by ECRI Institute on July 26, 2007. The
information was verified by the guideline developer on August 23, 2007.

#### COPYRIGHT STATEMENT

Copyright to the original guideline is owned by the American Heart
Association, Inc. (AHA). Reproduction of the AHA Guideline without
permission is prohibited. Single reprint is available by calling
800-242-8721 (US only) or writing the American Heart Association, Public
Information, 7272 Greenville Ave., Dallas, TX 75231-4596. Ask for
reprint No. 71-0398. To purchase additional reprints: up to 999 copies,
call 800-611-6083 (US only) or fax 413-665-2671; 1000 or more copies,
call 410-528-4121, fax 410-528-4264, or email <kgray@lww.com>.  To make
photocopies for personal or educational use, call the Copyright
Clearance Center, 978-750-8400.

### DISCLAIMER

#### NGC DISCLAIMER

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Date Modified: 11/3/2008