5/17/2016 AcuteManagementofStroke:InitialTreatment,ThrombolyticTherapy,StabilizationofAirwayandBreathing

AcuteManagementofStroke
Author:EdwardCJauch,MD,MS,FAHA,FACEPChiefEditor:HelmiLLutsep,MDmore...

Updated:Oct14,2015

InitialTreatment
Thegoalfortheacutemanagementofpatientswithstrokeistostabilizethepatient
andtocompleteinitialevaluationandassessment,includingimagingandlaboratory
studies,within60minutesofpatientarrival. [1](SeeTable1,below.)Critical
decisionsfocusontheneedforintubation,bloodpressurecontrol,and
determinationofrisk/benefitforthrombolyticintervention.

Table1.NINDS*andACLS**RecommendedStrokeEvaluationTimeBenchmarks
forPotentialThrombolysisCandidate(OpenTableinanewwindow)

TimeInterval TimeTarget
Doortodoctor 10min
Accesstoneurologicexpertise 15min
DoortoCTscancompletion 25min
DoortoCTscaninterpretation 45min
Doortotreatment 60min
AdmissiontostrokeunitorICU 3h
*NationalInstituteofNeurologicalDisordersandStroke

**AdvancedCardiacLifeSupportguidelines

Hypoglycemiaandhyperglycemianeedtobeidentifiedandtreatedearlyinthe
evaluation.Notonlycanbothproducesymptomsthatmimicischemicstroke,but
theycanalsoaggravateongoingneuronalischemia.Administrationofglucosein
hypoglycemiaproducesprofoundandpromptimprovement,whileinsulinshouldbe
startedforpatientswithstrokeandhyperglycemia.Ongoingstudieswillhelpto
determinetheoptimallevelofglycemiccontrol. [2]

Hyperthermiaisinfrequentlyassociatedwithstrokebutcanincreasemorbidity.
Administrationofacetaminophen,bymouthorperrectum,isindicatedinthe
presenceoffever(temperature>100.4F[38C]).

Supplementaloxygenisrecommendedwhenthepatienthasadocumentedoxygen
requirement.Todate,thereisconflictingevidencewhethersupernormal
oxygenationimprovesoutcome.

Optimalbloodpressuretargetsremaintobedetermined.Manypatientsare
hypertensiveonarrival.AmericanStrokeAssociationguidelineshavereinforcedthe
needforcautioninloweringbloodpressuresacutely.

Inthesmallproportionofpatientswithstrokewhoarerelativelyhypotensive,
pharmacologicallyincreasingbloodpressuremayimproveflowthroughcritical
stenoses.

Serialmonitoringandinterventionswhennecessaryearlyintheclinicalcourseand
eventualstrokerehabilitationandphysicalandoccupationaltherapyaretheideals
ofmanagement.(SeeTable2,below.)

Inpatientswithtransientischemicattacks(TIAs),failuretorecognizethepotential
forneartermstroke,failuretoperformatimelyassessmentforstrokeriskfactors,
andfailuretoinitiateprimaryandsecondarystrokepreventionexposesthepatient
toundueriskofstrokeandexposesclinicianstopotentiallitigation.TIAsconfera
10%riskofstrokewithin30days,andonehalfofthestrokesoccurringafteraTIA,
occurredwithin48hours. [3]

Table2.GeneralManagementofPatientsWithAcuteStroke[1,4](OpenTableina
newwindow)

TreathypoglycemiawithD50

Blood
glucose Treathyperglycemiawithinsulinifserumglucose>200mg/dL

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Blood Seerecommendationsforthrombolysiscandidatesand
pressure noncandidates(Table3)
Cardiac
Continuousmonitoringforischemicchangesoratrialfibrillation
monitor
AvoidD5Wandexcessivefluidadministration

Intravenous
IVisotonicsodiumchloridesolutionat50mL/hunlessotherwise
fluids
indicated

NPOinitiallyaspirationriskisgreat,avoidoralintakeuntil
Oralintake
swallowingassessed
Oxygen Supplementifindicated(Sa02<94%)
Avoidhyperthermiauseoralorrectalacetaminophenandcooling
Temperature
blanketsasneeded

ThrombolyticTherapy
CurrenttreatmentsforacuteischemicstrokeincludeIVthrombolytictherapywith
tissuetypeplasminogenactivator(tPA)andendovasculartherapiesusingstent
retrieverdevices. [5].A2015updateoftheAmericanHeartAssociation/American
StrokeAssociationguidelinesfortheearlymanagementofpatientswithacute
ischemicstrokerecommendsthatpatientseligibleforintravenoustPAshould
receiveintravenoustPAevenifendovasculartreatmentsarebeingconsideredand
thatpatientsshouldreceiveendovasculartherapywithastentretrieveriftheymeet
criteria. [5]

Newerstroketrialshaveshownthebenefitofusingneuroimagingtoselectpatients
whoaremostlikelytobenefitfromthrombolytictherapyandthepotentialbenefits
ofextendingthewindowforthrombolytictherapybeyondtheguidelineof3hours
withtPAandneweragents.CTangiographymaydemonstratethelocationof
vascularocclusion.CTperfusionstudiesarecapableofproducingperfusionimages
andtogetherwithCTangiographyarebecomingmoreavailableandutilizedinthe
acuteevaluationofstrokepatients. [6]

TheDiffusionandPerfusionImagingEvaluationforUnderstandingStrokeEvolution
(DEFUSE)trialdemonstratedthebenefitofadministeringIVtPAwithin36hours
ofstrokeonsetinpatientswithsmallischemiccoresondiffusionweightedmagnetic
resonanceimaging(MRI)andlargerperfusionabnormalities(largeischemic
penumbras). [7]

TheDesmoteplaseInAcuteIschemicStroke(DIAS)trialsimilarlydemonstratedthe
benefitofadministeringdesmoteplaseinpatientswithin39hoursofonsetofacute
strokeinpatientswithasignificantmismatch(>20%)betweenperfusion
abnormalitiesandischemiccoreondiffusionweightedMRI. [8]

Muchadaetalperformedastudyon581consecutivepatientstreatedwithalteplase
toidentifytheimpactoftimetotreatmentaccordingtostrokeseverityonfunctional
outcomeinpatientswithacuteischemicstroke.Theyfoundthatthewindowfor
favorableoutcomewas120minutesorlessformoderatestrokes,buttimeto
treatmentseemedunrelatedtofunctionaloutcomeinmildandseverestroke. [9]

Inastudyof285patientswhoreceivedintravenousrecombinanttissuetype
plasminogenactivator,revascularization(modifiedThrombolysisInCerebral
Infarctionscores,2band3)occurredin73.9%5.6%developedsymptomatic
intracerebralhemorrhages43.3%achievedgoodfunctionaloutcomeand22.2%
diedwithin90days.Accordingtotheauthors,adjustedcomparisonsbysubgroups
(ageor>80yronsettogroinpunctureor>6hranteriororposteriorstrokes
previousIVrecombinanttissuetypeplasminogenactivatororisolatedendovascular
treatment/therapyrevascularizationornorevascularization)systematicallyfavored
revascularization(lowerproportionofsymptomaticintracerebralhemorrhagesand
deathratesandhigherproportionofgoodoutcome),andmultivariateanalyses
confirmedtheindependentprotectiveeffectofrevascularization. [10]

AstudybyJovinetalshowedsuccessfulendovasculartherapybeyond8hoursfrom
timelastseenwellinpatientsselectedfortreatmentbasedonMRIorCTperfusion
imaging.Revascularizationwassuccessfulinabout73%ofpatients. [11]

Advancedneuroimagingwithdiffusionandperfusionimagingmaythenservean
importantroleinidentifyingpotentiallysalvageabletissueatriskandguidingclinical
decisionmakingregardingtherapy. [8,12,13,14,15]

TheiScoremayalsobeusedinpatientswithanacuteischemicstroketopredict
clinicalresponseandriskofhemorrhagiccomplicationsfollowingIVthrombolytic
therapy. [16]

StabilizationofAirwayandBreathing

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PatientspresentingwithGlasgowComaScalescoresof8orless,rapidly
decreasingGlasgowComaScalescores,orinadequateairwayprotectionor
ventilationrequireemergentairwaycontrolviarapidsequenceintubation.

Whenincreasedintracranialpressure(ICP)issuspected,rapidsequenceinduction
shouldbedirectedatminimizingthepotentiallyadverseeffectsofintubation.

Inunusualcasesofpotentialimminentbrainherniation,wherethegoalof
mechanicalventilationishyperventilationtodecreaseICPbydecreasingcerebral
bloodflow,therecommendedendpointisanarterialpCO2of3236mmHg.IV
mannitolcanbeconsideredaswell.

Supplementaloxygenuseshouldbeguidedbypulseoximetry.Patientsshould
receivesupplementaloxygeniftheirpulseoximetryreadingorarterialbloodgas
measurementrevealsthattheyarehypoxic(SaO2<94%).Themostcommon
causesofhypoxiainthepatientwithacutestrokearepartialairwayobstruction,
hypoventilation,atelectasis,oraspirationofstomachororopharyngealcontents. [17,
18]

IntravenousAccessandCardiacMonitoring
PatientswithacutestrokerequireIVaccessandcardiacmonitoringinthe
emergencydepartment(ED).Patientswithacutestrokeareatriskforcardiac
arrhythmias.Inaddition,atrialfibrillationmaybeassociatedwithacutestrokeas
eitherthecause(embolicdisease)orasacomplication.

BloodGlucoseControl
Severehyperglycemiaappearstobeindependentlyassociatedwithpooroutcome
andreducedreperfusioninthrombolysis,aswellasextensionoftheinfarcted
territory. [19,20,21]Additionally,normoglycemicpatientsshouldnotbegiven
excessiveglucosecontainingIVfluids,asthismayleadtohyperglycemiaandmay
exacerbateischemiccerebralinjury.

Bloodsugarcontrolshouldbetightlymaintainedwithinsulintherapy,withthegoal
ofestablishingnormoglycemia(90140mg/dL).Additionally,closemonitoringof
bloodsugarlevelshouldcontinuethroughouthospitalizationtoavoidhypoglycemia.
[1]

PatientPositioning
Studieshaveshownthatcerebralperfusionpressureismaximizedwhenpatients
aremaintainedinasupineposition.However,lyingflatmayservetoincreaseICP
andthusisnotrecommendedincasesofsubarachnoidorotherintracranial
hemorrhage.Becauseprolongedimmobilizationmayleadtoitsowncomplications,
includingdeepvenousthrombosis,pressureulceraspiration,andpneumonia,
patientsshouldnotbekeptflatforlongerthan24hours. [22]

BloodPressureControl
Inpoorflowstateswhichoccurwiththromboticandembolicischemicstroke,as
wellaswithincreasedICPduetocerebraledemathecerebralvasculatureloses
vasoregulatorycapabilityandthusreliesdirectlyonmeanarterialpressure(MAP)
andcardiacoutputformaintenanceofcerebralbloodflow.Therefore,aggressive
effortstolowerbloodpressuremaydecreaseperfusionpressureandmayprolongor
worsenischemia.Rapidreductionofbloodpressure,nomatterthedegreeof
hypertension,mayinfactbeharmful.Bothelevatedandlowbloodpressuresare
associatedwithpooroutcomesinpatientswithacutestroke. [23](SeeTable3,
below.)

Studieshavedemonstratedthatbloodpressuretypicallydropsinthefirst24hours
afteracutestroke,whetherornotantihypertensivesareadministered.Furthermore,
studieshaverevealedpooreroutcomesinpatientswithlowerbloodpressures,with
theseoutcomescorrelatingwiththedegreeofpressuredecline. [23,24]

Ina2012analysisofdatafromTheScandinavianCandesartanAcuteStrokeTrial,
acutestrokepatientswithalargedecreaseorincreaseornochangeinsystolic
bloodpressureexperiencedanincreasedriskofearlyadverseeventscomparedwith
patientswithasmalldecrease,andpatientswithanincreaseornochangein
systolicbloodpressurehadanincreasedriskofpoorneurologicaloutcome
comparedwithotherpatients.Routineattemptstolowerbloodpressureintheacute
phaseofstrokeshouldprobablybeavoided. [25]

Theconsensusrecommendationistolowerbloodpressureonlyifsystolicpressure
isinexcessof220mmHgorifdiastolicpressureisgreaterthan120mmHg. [18]
However,asystolicbloodpressuregreaterthan185mmHgoradiastolicpressure
greaterthan110mmHgisacontraindicationtotheuseofthrombolytics.
Therefore,themanagementofelevatedbloodpressureinacuteischemicstroke
mayvary,dependingonwhetherthepatientisacandidateforthrombolytictherapy.

HypertensioncontrolinnonrtPAcandidates

ForpatientswhoarenotcandidatesforthrombolysiswithrecombinanttPA(rtPA)
andwhohaveasystolicbloodpressureoflessthan220mmHgandadiastolic

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bloodpressureoflessthan120mmHgintheabsenceofevidenceofendorgan
involvement(ie,pulmonaryedema,aorticdissection,hypertensiveencephalopathy),
bloodpressureshouldbemonitored(withoutacuteintervention)andstroke
symptomsandcomplications(eg,increasedICP,seizures)shouldbetreated.

Forpatientswithasystolicbloodpressureabove220mmHgoradiastolicblood
pressuregreaterthan120mmHg,labetalol(1020mgIVfor12min)shouldbethe
initialdrugofchoice,unlessacontraindicationtoitsuseexists.Dosingmaybe
repeatedordoubledevery10minutestoamaximumdoseof300mg.

Alternatively,nicardipinemaybeusedforbloodpressurecontrol.Nicardipineis
givenintravenouslyataninitialrateof5mg/handtitratedtoeffectbyincreasing
theinfusionrate2.5mg/hevery5minutes,toamaximumof15mg/h.Lastly,
nitroprussideat0.5mcg/kg/minIVinfusionmaybeusedinthesettingof
continuousbloodpressuremonitoring.Thegoalofinterventionisareductionin
bloodpressureof1015%.

HypertensioncontrolinrtPAcandidates

ForpatientswhowillbereceivingrtPA,systolicbloodpressuregreaterthan185
mmHganddiastolicbloodpressuregreaterthan110mmHgrequireintervention.
Monitoringandcontrolofbloodpressureduringandafterthrombolytic
administrationarevital,becauseuncontrolledhypertensionisassociatedwith
hemorrhagiccomplication. [26]

Theinitialdrugofchoice,labetalol(1020mgIVfor12min),mayberepeated
(maximumdose300mg).Oneto2inchesoftransdermalnitropaste(see
nitroglycerintopical)mayalsobeused.Asanalternativetothesechoices,
nicardipineinfusionat5mg/h,titrateduptoamaximumdoseof15mg/h,canbe
used. [18]

Monitoringofbloodpressureiscrucialforthefirst2hours,bloodpressureshould
becheckedevery15minutes,thenevery30minutesfor6hours,andfinally,every
hourfor16hours.Thegoaloftherapyshouldbetoreducebloodpressureby15
25%inthefirstday,withcontinuedbloodpressurecontrolduringhospitalization.

Forpatientswithsystolicbloodpressureof185230mmHgordiastolicblood
pressureof110120mmHg,labetalolisgivenatadoseof1020mgIVover12
minutesthedosemayberepeatedevery1020minutes,upto300mgtotal,oran
infusionrateofupto28mg/minmaybeused. [1]

Forsystolicbloodpressureofgreaterthan230mmHgordiastolicbloodpressureof
121140mmHg,labetalolattheabovedosescanbeconsidered.However,
nicardipineinfusionadministeredatarateof5mg/h,toamaximumof15mg/h,
mightbeabetterfirstchoice.Fordifficulttocontrolbloodpressure,sodium
nitroprussidecanbeconsidered. [1]

TheuseofsublingualnifedipinetolowerbloodpressureintheEDisdiscouraged,
sinceextremehypotensionmayresult.Trialsofnimodipine,initiallythoughttobe
beneficialgivenitsvasodilatoryeffectasacalciumchannelblocker,havefailedto
demonstrateanybeneficialoutcomeincomparisonwithplacebo. [17]

Consensusagreementisthatthesebloodpressureguidelinesshouldbemaintained
inthefaceofotherinterventionstorestoreperfusion,suchasintraarterial
thrombolysis. [1]

Table3.BloodPressureManagementinPatientsWithStroke*(OpenTableina
newwindow)

Blood
Treatment
Pressure
Labetalol1020mgIVPrepeatedevery1020
minutes

Pretreatment:
or

Candidatesfor SBP>185or
Nicardipine5mg/h,titrateby2.5mg/hevery5
fibrinolysis DBP>110mm
15min,maximum15mg/hwhendesiredblood
Hg
pressurereached,lowerto3mg/hor

Enalapril1.25mgIVP

Posttreatment:
Sodiumnitroprusside(0.5mcg/kg/min)

DBP>140mm
Hg Labetalol1020mgIVPandconsiderlabetalol

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infusionat12mg/minornicardipine5mg/hIV
infusionandtitrate

SBP>230mm
Hgor
or

DBP121140
mmHg Nicardipine5mg/h,titrateby2.5mg/hevery5
15min,maximum15mg/hwhendesiredblood
pressurereached,lowerto3mg/hor

SBP180230
mmHgor
DBP105120 Labetalol10mgIVP,mayrepeatanddouble
mmHg every10minuptomaximumdoseof300mg

DBP>140mm
Hg

Sodiumnitroprusside0.5mcg/kg/minmay
reduceapproximately1020%
SBP>220or

Labetalol1020mgIVPover12minmay
DBP121140 repeatanddoubleevery10minuptomaximum
mmHgor doseof150mgornicardipine5mg/hIVinfusion
andtitrate

MAP>130
mmHg or
Noncandidates
forfibrinolysis

SBP<220 Nicardipine5mg/h,titrateby2.5mg/hevery5
mmHgor 15min,maximum15mg/hwhendesiredblood
pressurereached,lowerto3mg/h

DBP105120
mmHgor Antihypertensivetherapyindicatedonlyifacute
myocardialinfarction,aorticdissection,severe
CHF,orhypertensiveencephalopathypresent

MAP<130
mmHg

*Adaptedfrom2005AdvancedCardiacLifeSupport(ACLS)guidelinesand2007
AmericanStrokeAssociationScientificStatement

Abbreviations:SBPsystolicbloodpressureDBPdiastolicbloodpressureIVP
IVpushMAPmeanarterialpressure

Controlofhypotension

Giventheneedtomaintainadequatecerebralbloodflow,severehypotension
shouldbemanagedinstandardfashionwithaggressivefluidresuscitation,asearch
fortheetiologyofhypotension,and,ifnecessary,vasopressorsupport.Evidence
suggeststhatbaselinesystolicbloodpressurebelow100mgHganddiastolicblood
pressurebelow70mmHgcorrelatewithaworseoutcome. [23]

FurtherOutpatientCare

Poststrokeoutpatientcarelargelyfocusesonrehabilitationandpreventionof
recurrentstroke.Rehabilitationplanningandinitiationbeginswithinthefirstdayof
theacutestroke.Recentresearchhasdemonstratedthebenefitsofearlyand
aggressivemobilization. [27]

AdditionalCare
Referraltoaphysicianwithaspecialinterestinstrokeisideal.Strokecareunits

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withspeciallytrainedpersonnelexistandaresaidtoshowimprovedoutcomes
Comorbidmedicalproblemsneedtobeaddressed.Assessmentsofswallow
functionpriortothereinstitutionoforalfeedingisrecommended. [1]Patientsshould
receivedeepvenousthrombosisprophylaxis,althoughthetimingofinstitutionof
thistherapyisunknown.

Medical/LegalPitfalls

Inpatientswithtransientischemicattacks,failuretorecognizethepotentialfornear
termstroke,failuretoperformatimelyassessmentforstrokeriskfactors,and
failuretoinitiateprimaryandsecondarystrokepreventionexposesthepatientto
undueriskofstrokeandexposesclinicianstopotentiallitigation. [3]

ContributorInformationandDisclosures
Author
EdwardCJauch,MD,MS,FAHA,FACEPProfessor,Director,DivisionofEmergencyMedicine,Professor,
DepartmentofNeurosciences,ViceChairofResearch,DepartmentofMedicine,MedicalUniversityofSouth
CarolinaCollegeofMedicineAdjunctProfessor,DepartmentofBioengineering,ClemsonUniversity

EdwardCJauch,MD,MS,FAHA,FACEPisamemberofthefollowingmedicalsocieties:AmericanCollegeof
EmergencyPhysicians,AmericanHeartAssociation,AmericanMedicalAssociation,NationalStrokeAssociation,
SocietyforAcademicEmergencyMedicine,SouthCarolinaMedicalAssociation

Disclosure:Receivedgrant/researchfundsfromGenentechforsitepi.

Coauthor(s)
BrettKissela,MD,MSProfessor,CoDirectoroftheNeurologyResidencyProgram,ViceChairofEducation
andClinicalServices,DepartmentofNeurology,UniversityofCincinnatiCollegeofMedicine

BrettKissela,MD,MSisamemberofthefollowingmedicalsocieties:AmericanAcademyofNeurology,
AmericanHeartAssociation,PhiBetaKappa

Disclosure:ReceivedhonorariafromMedscapeEducationforaneducationalactivityReceivedfeesfor
adjudicationofadverseeventsforclinicaltrial,paymentpereventreviewedfromAbbVieandJanssen.Work
performedasanindependentcontractor.

BrianStettler,MDAssistantProfessor,ProgramDirector,EmergencyMedicineResidencyProgram,Department
ofEmergencyMedicine,andFacultyGreaterCincinnati/NorthernKentuckyStrokeTeam,UniversityofCincinnati

Disclosure:Nothingtodisclose.

ChiefEditor
HelmiLLutsep,MDProfessorandViceChair,DepartmentofNeurology,OregonHealthandScienceUniversity
SchoolofMedicineAssociateDirector,OHSUStrokeCenter

HelmiLLutsep,MDisamemberofthefollowingmedicalsocieties:AmericanAcademyofNeurology,American
StrokeAssociation

Disclosure:MedscapeNeurologyEditorialAdvisoryBoardfor:StrokeAdjudicationCommittee,CREST2.

Acknowledgements
ThomasAKent,MDProfessorandDirectorofStrokeResearchandEducation,DepartmentofNeurology,
BaylorCollegeofMedicineChiefofNeurology,MichaelEDeBakeyVeteransAffairsMedicalCenter

ThomasAKent,MDisamemberofthefollowingmedicalsocieties:AmericanAcademyofNeurology,American
NeurologicalAssociation,NewYorkAcademyofSciences,RoyalSocietyofMedicine,SigmaXi,andStroke
CounciloftheAmericanHeartAssociation

Disclosure:Nothingtodisclose.

HowardSKirshner,MDProfessorofNeurology,PsychiatryandHearingandSpeechSciences,ViceChairman,
DepartmentofNeurology,VanderbiltUniversitySchoolofMedicineDirector,VanderbiltStrokeCenterProgram
Director,StrokeService,VanderbiltStallworthRehabilitationHospitalConsultingStaff,Departmentof
Neurology,NashvilleVeteransAffairsMedicalCenter

HowardSKirshner,MDisamemberofthefollowingmedicalsocieties:AlphaOmegaAlpha,American
AcademyofNeurology,AmericanHeartAssociation,AmericanMedicalAssociation,AmericanNeurological
Association,AmericanSocietyofNeurorehabilitation,NationalStrokeAssociation,PhiBetaKappa,and
TennesseeMedicalAssociation

Disclosure:Nothingtodisclose.

FranciscoTalavera,PharmD,PhDAdjunctAssistantProfessor,UniversityofNebraskaMedicalCenterCollege
ofPharmacyEditorinChief,MedscapeDrugReference

Disclosure:MedscapeSalaryEmployment

Acknowledgments

TheauthorswouldliketothankDr.JenniferFranklinforherassistanceintheupdatingofthisarticle.

References

1.[Guideline]AdamsHPJr,delZoppoG,AlbertsMJ,BhattDL,BrassL,FurlanA,etal.Guidelinesforthe
earlymanagementofadultswithischemicstroke:aguidelinefromtheAmericanHeart
Association/AmericanStrokeAssociationStrokeCouncil,ClinicalCardiologyCouncil,Cardiovascular
http://emedicine.medscape.com/article/1159752overview 6/8
5/17/2016 AcuteManagementofStroke:InitialTreatment,ThrombolyticTherapy,StabilizationofAirwayandBreathing
RadiologyandInterventionCouncil,andtheAtheroscleroticPeripheralVascularDiseaseandQualityof
CareOutcomesinResearchInterdisciplinaryWorkingGroups:theAmericanAcademyofNeurologyaffirms
thevalueofthisguidelineasaneducationaltoolforneurologists.Stroke.2007May.38(5):1655711.
[Medline].

2.BrunoA,KentTA,CoullBM,ShankarRR,SahaC,BeckerKJ,etal.Treatmentofhyperglycemiain
ischemicstroke(THIS):arandomizedpilottrial.Stroke.2008Feb.39(2):3849.[Medline].

3.FurieKL,KasnerSE,AdamsRJ,AlbersGW,BushRL,FaganSC,etal.Guidelinesforthepreventionof
strokeinpatientswithstrokeortransientischemicattack:aguidelineforhealthcareprofessionalsfromthe
americanheartassociation/americanstrokeassociation.Stroke.2011Jan.42(1):22776.[Medline].

4.AdamsH,AdamsR,DelZoppoG,GoldsteinLB.Guidelinesfortheearlymanagementofpatientswith
ischemicstroke:2005guidelinesupdateascientificstatementfromtheStrokeCounciloftheAmerican
HeartAssociation/AmericanStrokeAssociation.Stroke.2005Apr.36(4):91623.[Medline].

5.[Guideline]PowersWJ,DerdeynCP,BillerJ,CoffeyCS,HohBL,JauchEC,etal.2015AmericanHeart
Association/AmericanStrokeAssociationFocusedUpdateofthe2013GuidelinesfortheEarly
ManagementofPatientsWithAcuteIschemicStrokeRegardingEndovascularTreatment:AGuidelinefor
HealthcareProfessionalsFromtheAmericanHeartAssociation/AmericanStrokeAssociation.Stroke.2015
Oct.46(10):302035.[Medline].

6.ObachV,OleagaL,UrraX,MachoJ,AmaroS,CapurroS,etal.MultimodalCTAssistedThrombolysisin
PatientsWithAcuteStroke:ACohortStudy.Stroke.2011Apr.42(4):112931.[Medline].

7.AlbersGW,ThijsVN,WechslerL,KempS,SchlaugG,SkalabrinE,etal.Magneticresonanceimaging
profilespredictclinicalresponsetoearlyreperfusion:thediffusionandperfusionimagingevaluationfor
understandingstrokeevolution(DEFUSE)study.AnnNeurol.2006Nov.60(5):50817.[Medline].

8.HackeW,AlbersG,AlRawiY,etal.Stroke.TheDesmoteplaseinAcuteIschemicStrokeTrial(DIAS):a
phaseIIMRIbased9hourwindowacutestrokethrombolysistrialwithIVdesmoteplase.2005.36:6673.

9.MuchadaM,RubieraM,RodriguezLunaD,PagolaJ,FloresA,KallasJ,etal.BaselineNationalInstitutes
ofHealthstrokescaleadjustedtimewindowforintravenoustissuetypeplasminogenactivatorinacute
ischemicstroke.Stroke.2014Apr.45(4):105963.[Medline].

10.AbilleiraS,CardonaP,RibM,MillnM,ObachV,RoquerJ,etal.Outcomesofacontemporarycohortof
536consecutivepatientswithacuteischemicstroketreatedwithendovasculartherapy.Stroke.2014Apr.
45(4):104652.[Medline].

11.JovinTG,LiebeskindDS,GuptaR,RymerM,RaiA,ZaidatOO,etal.ImagingBasedEndovascular
TherapyforAcuteIschemicStrokeduetoProximalIntracranialAnteriorCirculationOcclusionTreated
Beyond8HoursFromTimeLastSeenWell:RetrospectiveMulticenterAnalysisof237Consecutive
Patients.Stroke.2011Aug.42(8):220611.[Medline].

12.GonzlezRG.Imagingguidedacuteischemicstroketherapy:From"timeisbrain"to"physiologyisbrain".
AJNRAmJNeuroradiol.2006Apr.27(4):72835.[Medline].

13.IngallTJ,O'FallonWM,AsplundK,GoldfrankLR,HertzbergVS,LouisTA,etal.Findingsfromthe
reanalysisoftheNINDStissueplasminogenactivatorforacuteischemicstroketreatmenttrial.Stroke.
2004Oct.35(10):241824.[Medline].

14.SimsJR,RordorfG,SmithEE,KoroshetzWJ,LevMH,BuonannoF,etal.Arterialocclusionrevealedby
CTangiographypredictsNIHstrokescoreandacuteoutcomesafterIVtPAtreatment.AJNRAmJ
Neuroradiol.2005Feb.26(2):24651.[Medline].

15.HackeW,DonnanG,FieschiC,KasteM,vonKummerR,BroderickJP,etal.Associationofoutcomewith
earlystroketreatment:pooledanalysisofATLANTIS,ECASS,andNINDSrtPAstroketrials.Lancet.
2004Mar6.363(9411):76874.[Medline].

16.SaposnikG,FangJ,KapralMK,TuJV,MamdaniM,AustinP,etal.TheiScorepredictseffectivenessof
thrombolytictherapyforacuteischemicstroke.Stroke.2012May.43(5):131522.[Medline].

17.MilhaudD,PoppJ,ThouvenotE,HeroumC,BonafA.Mechanicalventilationinischemicstroke.JStroke
CerebrovascDis.2004JulAug.13(4):1838.[Medline].

18.KriegerD,HackeW.Theintensivecareofthestrokepatient.In:Stroke:Pathophysiology,Diagnosisand
Management.3rded.NewYork,NY:ChurchillLivingstone1998.

19.BrunoA,LevineSR,FrankelMR,BrottTG,LinY,TilleyBC,etal.Admissionglucoselevelandclinical
outcomesintheNINDSrtPAStrokeTrial.Neurology.2002Sep10.59(5):66974.[Medline].

20.BrunoA,BillerJ,AdamsHPJr,ClarkeWR,WoolsonRF,WilliamsLS,etal.Acutebloodglucoseleveland
outcomefromischemicstroke.TrialofORG10172inAcuteStrokeTreatment(TOAST)Investigators.
Neurology.1999Jan15.52(2):2804.[Medline].

21.BairdTA,ParsonsMW,PhanhT,ButcherKS,DesmondPM,TressBM,etal.Persistentpoststroke
hyperglycemiaisindependentlyassociatedwithinfarctexpansionandworseclinicaloutcome.Stroke.2003
Sep.34(9):220814.[Medline].

22.WojnerAlexanderAW,GaramiZ,ChernyshevOY,AlexandrovAV.Headsdown:flatpositioningimproves
bloodflowvelocityinacuteischemicstroke.Neurology.2005Apr26.64(8):13547.[Medline].

23.CastilloJ,LeiraR,GarcaMM,SerenaJ,BlancoM,DvalosA.Bloodpressuredecreaseduringtheacute
phaseofischemicstrokeisassociatedwithbraininjuryandpoorstrokeoutcome.Stroke.2004Feb.
35(2):5206.[Medline].

24.SandsetEC,BathPM,BoysenG,JatuzisD,KrvJ,LdersS,etal.Theangiotensinreceptorblocker
candesartanfortreatmentofacutestroke(SCAST):arandomised,placebocontrolled,doubleblindtrial.
Lancet.2011Feb26.377(9767):74150.[Medline].

http://emedicine.medscape.com/article/1159752overview 7/8
5/17/2016 AcuteManagementofStroke:InitialTreatment,ThrombolyticTherapy,StabilizationofAirwayandBreathing
25.SandsetEC,MurrayGD,BathPM,KjeldsenSE,BergeE.Relationbetweenchangeinbloodpressurein
acutestrokeandriskofearlyadverseeventsandpooroutcome.Stroke.2012Aug.43(8):210814.
[Medline].

26.TheNINDSrtPAStrokeStudyGroup.Tissueplasminogenactivatorforacuteischemicstroke.The
NationalInstituteofNeurologicalDisordersandStrokertPAStrokeStudyGroup.NEnglJMed.1995Dec
14.333(24):15817.[Medline].

27.CummingTB,ThriftAG,CollierJM,ChurilovL,DeweyHM,DonnanGA,etal.Veryearlymobilization
afterstrokefasttracksreturntowalking:furtherresultsfromthephaseIIAVERTrandomizedcontrolled
trial.Stroke.2011Jan.42(1):1538.[Medline].

28.BakerWL,ColbyJA,TongbramV,TalatiR,SilvermanIE,WhiteCM,etal.Neurothrombectomydevices
forthetreatmentofacuteischemicstroke:stateoftheevidence.AnnInternMed.2011Feb15.
154(4):24352.[Medline].

29.DonnanGA,FisherM,MacleodM,DavisSM.Stroke.Lancet.2008May10.371(9624):161223.
[Medline].

30.DerexL,TomsickTA,BrottTG,LewandowskiCA,FrankelMR,ClarkW,etal.Outcomeofstrokepatients
withoutangiographicallyrevealedarterialocclusionwithinfourhoursofsymptomonset.AJNRAmJ
Neuroradiol.2001Apr.22(4):68590.[Medline].

MedscapeReference2011WebMD,LLC

http://emedicine.medscape.com/article/1159752overview 8/8