A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association 2013
Public Stroke Education more extensive care, has considerable appeal.
Recommendations (Unchanged from the previous guideline13) 1. To increase both the number of patients who are 2. Certification of stroke centers by an independent treated and the quality of care, educational external body, such as TJC or state health stroke programs for physicians, hospital department, is recommended (Class I; Level of personnel, and EMS personnel are recommended Evidence B). Additional medical centers should (Class I; Level of Evidence B). (Unchanged from seek such certification. (Revised from the previous the previous guideline13) guideline13) 2. Activation of the 9-1-1 system by patients or 3. Healthcare institutions should organize a other members of the public is strongly multidisciplinary quality improvement recommended (Class I; Level of Evidence B). 9-1- committee to review and monitor stroke care 1 Dispatchers should make stroke a priority quality benchmarks, indicators, evidence-based dispatch, and transport times should be practices, and outcomes (Class I; Level of minimized. (Unchanged from the previous Evidence B). The formation of a clinical process guideline13) improvement team and the establishment of a 3. Prehospital care providers should use stroke care data bank are helpful for such prehospital stroke assessment tools, such as the quality of care assurances. The data repository Los Angeles Prehospital Stroke Screen or can be used to identify the gaps or disparities in Cincinnati Prehospital Stroke Scale (Class I; quality stroke care. Once the gaps have been Level of Evidence B). (Unchanged from the identified, specific interventions can be initiated previous guideline13) to address these gaps or disparities. (New 4. EMS personnel should begin the initial recommendation) management of stroke in the field, as outlined in 4. For patients with suspected stroke, EMS should Table 4 (Class I; Level of Evidence B). bypass hospitals that do not have resources to Development of a stroke protocol to be used by treat stroke and go to the closest facility most EMS personnel is strongly encouraged. capable of treating acute stroke (Class I; Level of (Unchanged from the previous guideline13) Evidence B). (Unchanged from the previous 5. Patients should be transported rapidly to the guideline13) closest available certified PSC or CSC or, if no 5. For sites without in-house imaging interpretation such centers exist, the most appropriate expertise, teleradiology systems approved by the institution that provides emergency stroke care Food and Drug Administration (FDA) or as described in the statement (Class I; Level of equivalent organization are recommended for Evidence A). In some instances, this may involve timely review of brain CT and MRI scans in air medical transport and hospital bypass. patients with suspected acute stroke (Class I; (Revised from the previous guideline13) Level of Evidence B). (New recommendation) 6. EMS personnel should provide prehospital 6. When implemented within a telestroke network, notification to the receiving hospital that a teleradiology systems approved by the FDA (or potential stroke patient is en route so that the equivalent organization) are useful in supporting appropriate hospital resources may be mobilized rapid imaging interpretation in time for before patient arrival (Class I; Level of Evidence fibrinolysis decision making (Class I; Level of B). (Revised from the previous guideline13) Evidence B). (New recommendation) 7. The development of CSCs is recommended Designation of Stroke Centers and Stroke (Class I; Level of Evidence C). (Unchanged from the previous guideline13) Care Quality Improvement Process 8. Implementation of telestroke consultation in Recommendations conjunction with stroke education and training 1. The creation of PSCs is recommended (Class I; for healthcare providers can be useful in Level of Evidence B). The organization of such increasing the use of intravenous rtPA at resources will depend on local resources. The community hospitals without access to adequate stroke system design of regional ASRHs and onsite stroke expertise (Class IIa; Level of PSCs that provide emergency care and that are Evidence B). (New recommendation) closely associated with a CSC, which provides 9. The creation of ASRHs can be useful (Class IIa; emergency management. (Unchanged from the Level of Evidence C). As with PSCs, the previous guideline13) organization of such resources will depend on 2. Either NECT or MRI is recommended before local resources. The stroke system design of intravenous rtPA administration to exclude ICH regional ASRHs and PSCs that provide (absolute contraindication) and to determine emergency care and that are closely associated whether CT hypodensity or MRI hyperintensity with a CSC, which provides more extensive care, of ischemia is present (Class I; Level of Evidence has considerable appeal. (New recommendation) A). (Revised from the 2009 imaging scientific statement9) Emergency Evaluation and Diagnosis of 3. Intravenous fibrinolytic therapy is recommended Acute Ischemic Stroke in the setting of early ischemic changes (other Recommendations than frank hypodensity) on CT, regardless of 1. An organized protocol for the emergency their extent (Class I; Level of Evidence A). (Revised from the 2009 imaging scientific evaluation of patients with suspected stroke is statement9) recommended (Class I; Level of Evidence B). The goal is to complete an evaluation and to begin 4. A noninvasive intracranial vascular study is fibrinolytic treatment within 60 minutes of the strongly recommended during the initial imaging patient’s arrival in an ED. Designation of an evaluation of the acute stroke patient if either acute stroke team that includes physicians, intra-arterial fibrinolysis or mechanical nurses, and laboratory/radiology personnel is thrombectomy is contemplated for management encouraged. Patients with stroke should have a but should not delay intravenous rtPA if careful clinical assessment, including indicated (Class I; Level of Evidence A). (Revised neurological examination. (Unchanged from the from the 2009 imaging scientific statement9) previous guideline) 5. In intravenous fibrinolysis candidates, the brain 2. The use of a stroke rating scale, preferably the imaging study should be interpreted within 45 NIHSS, is recommended (Class I; Level of minutes of patient arrival in the ED by a Evidence B). (Unchanged from the previous physician with expertise in reading CT and MRI guideline13) studies of the brain parenchyma (Class I; Level 3. A limited number of hematologic, coagulation, of Evidence C). (Revised from the previous and biochemistry tests are recommended during guideline13) the initial emergency evaluation, and only the 6. CT perfusion and MRI perfusion and diffusion assessment of blood glucose must precede the imaging, including measures of infarct core and initiation of intravenous rtPA (Table 8) (Class I; penumbra, may be considered for the selection of Level of Evidence B). (Revised from the previous patients for acute reperfusion therapy beyond guideline13) the time windows for intravenous fibrinolysis. 4. Baseline electrocardiogram assessment is These techniques provide additional information recommended in patients presenting with acute that may improve diagnosis, mechanism, and ischemic stroke but should not delay initiation of severity of ischemic stroke and allow more intravenous rtPA (Class I; Level of Evidence B). informed clinical decision making (Class IIb; (Revised from the previous guideline13) Level of Evidence B). (Revised from the 2009 imaging scientific statement9) 5. Baseline troponin assessment is recommended in patients presenting with acute ischemic stroke 7. Frank hypodensity on NECT may increase the but should not delay initiation of intravenous risk of hemorrhage with fibrinolysis and should rtPA (Class I; Level of Evidence C). (Revised from be considered in treatment decisions. If frank the previous guideline13) hypodensity involves more than one third of the 6. The usefulness of chest radiographs in the MCA territory, intravenous rtPA treatment hyperacute stroke setting in the absence of should be withheld (Class III; Level of Evidence evidence of acute pulmonary, cardiac, or A). (Revised from the 2009 imaging scientific pulmonary vascular disease is unclear. If statement9) obtained, they should not unnecessarily delay administration of fibrinolysis (Class IIb; Level of Recommendations for Patients With Cerebral Evidence B). (Revised from the previous Ischemic Symptoms That Have Resolved guideline13) 1. Noninvasive imaging of the cervical vessels should be performed routinely as part of the evaluation of patients with suspected TIAs (Class Early Diagnosis: Brain and Vascular I; Level of Evidence A). (Unchanged from the 2009 Imaging TIA scientific statement6) Recommendations for Patients With Acute Cerebral 2. Noninvasive imaging by means of CTA or MRA Ischemic Symptoms That Have Not Yet Resolved of the intracranial vasculature is recommended 1. Emergency imaging of the brain is recommended to exclude the presence of proximal intracranial before initiating any specific therapy to treat stenosis and/or occlusion (Class I; Level of acute ischemic stroke (Class I; Level of Evidence Evidence A) and should be obtained when A). In most instances, NECT will provide the knowledge of intracranial stenoocclusive disease necessary information to make decisions about will alter management. Reliable diagnosis of the recanalize occluded vessels, including intra- presence and degree of intracranial stenosis arterial fibrinolysis (Class I; Level of Evidence requires the performance of catheter C). (Unchanged from the previous guideline13) angiography to confirm abnormalities detected 7. In patients with markedly elevated blood with noninvasive testing. (Revised from the 2009 pressure who do not receive fibrinolysis, a TIA scientific statement6) reasonable goal is to lower blood pressure by 3. Patients with transient ischemic neurological 15% during the first 24 hours after onset of symptoms should undergo neuroimaging stroke. The level of blood pressure that would evaluation within 24 hours of symptom onset or mandate such treatment is not known, but as soon as possible in patients with delayed consensus exists that medications should be presentations. MRI, including DWI, is the withheld unless the systolic blood pressure is preferred brain diagnostic imaging modality. If >220 mm Hg or the diastolic blood pressure is MRI is not available, head CT should be >120 mm Hg (Class I; Level of Evidence C). performed (Class I; Level of Evidence B). (Revised from the previous guideline13) (Unchanged from the 2009 TIA scientific 8. Hypovolemia should be corrected with statement6) intravenous normal saline, and cardiac arrhythmias that might be reducing cardiac General Supportive Care and Treatment of output should be corrected (Class I; Level of Acute Complications Evidence C). (Revised from the previous Recommendations guideline13) 1. Cardiac monitoring is recommended to screen 9. Hypoglycemia (blood glucose <60 mg/dL) should for atrial fibrillation and other potentially be treated in patients with acute ischemic stroke serious cardiac arrhythmias that would (Class I; Level of Evidence C). The goal is to necessitate emergency cardiac interventions. achieve normoglycemia. (Revised from the Cardiac monitoring should be performed for at previous guideline13) least the first 24 hours (Class I; Level of Evidence 10. Evidence from one clinical trial indicates that B). (Revised from the previous guideline13) initiation of antihypertensive therapy within 24 2. Patients who have elevated blood pressure and hours of stroke is relatively safe. Restarting are otherwise eligible for treatment with antihypertensive medications is reasonable after intravenous rtPA should have their blood the first 24 hours for patients who have pressure carefully lowered (Table 9) so that their preexisting hypertension and are neurologically systolic blood pressure is <185 mm Hg and their stable unless a specific contraindication to diastolic blood pressure is <110 mm Hg (Class I; restarting treatment is known (Class IIa; Level of Level of Evidence B) before fibrinolytic therapy is Evidence B). (Revised from the previous initiated. If medications are given to lower blood guideline13) pressure, the clinician should be sure that the 11. No data are available to guide selection of blood pressure is stabilized at the lower level medications for the lowering of blood pressure in before beginning treatment with intravenous the setting of acute ischemic stroke. The rtPA and maintained below 180/105 mm Hg for antihypertensive medications and doses included in Table 9 are reasonable choices based on at least the first 24 hours after intravenous rtPA treatment. (Unchanged from the previous general consensus (Class IIa; Level of Evidence guideline13) C). (Revised from the previous guideline13) 3. Airway support and ventilatory assistance are 12. Evidence indicates that persistent in-hospital recommended for the treatment of patients with hyperglycemia during the first 24 hours after acute stroke who have decreased consciousness stroke is associated with worse outcomes than or who have bulbar dysfunction that causes normoglycemia, and thus, it is reasonable to treat compromise of the airway (Class I; Level of hyperglycemia to achieve blood glucose levels in Evidence C). (Unchanged from the previous a range of 140 to 180 mg/dL and to closely guideline13) monitor to prevent hypoglycemia in patients with 4. Supplemental oxygen should be provided to acute ischemic stroke (Class IIa; Level of maintain oxygen saturation >94% (Class I; Level Evidence C). (Revised from the previous of Evidence C). (Revised from the previous guideline13) guideline13) 13. The management of arterial hypertension in 5. Sources of hyperthermia (temperature >38°C) patients not undergoing reperfusion strategies should be identified and treated, and antipyretic remains challenging. Data to guide medications should be administered to lower recommendations for treatment are inconclusive temperature in hyperthermic patients with or conflicting. Many patients have spontaneous stroke (Class I; Level of Evidence C). (Unchanged declines in blood pressure during the first 24 from the previous guideline13) hours after onset of stroke. Until more definitive 6. Until other data become available, consensus data are available, the benefit of treating arterial exists that the previously described blood hypertension in the setting of acute ischemic pressure recommendations should be followed in stroke is not well established (Class IIb; Level of patients undergoing other acute interventions to Evidence C). Patients who have malignant hypertension or other medical indications for secondary to stroke and not a postictal aggressive treatment of blood pressure should be phenomenon (Class IIa; Level of Evidence C). treated accordingly. (Revised from the previous (Unchanged from the previous guideline13) guideline13) 7. The effectiveness of sonothrombolysis for 14. Supplemental oxygen is not recommended in treatment of patients with acute stroke is not nonhypoxic patients with acute ischemic stroke well established (Class IIb; Level of Evidence B). (Class III; Level of Evidence B). (Unchanged from (New recommendation) the previous guideline13) 8. The usefulness of intravenous administration of tenecteplase, reteplase, desmoteplase, urokinase, Intravenous Fibrinolysis or other fibrinolytic agents and the intravenous Recommendations administration of ancrod or other 1. Intravenous rtPA (0.9 mg/kg, maximum dose 90 defibrinogenating agents is not well established, mg) is recommended for selected patients who and they should only be used in the setting of a may be treated within 3 hours of onset of clinical trial (Class IIb; Level of Evidence B). ischemic stroke (Class I; Level of Evidence A). (Revised from the previous guideline13) Physicians should review the criteria outlined in 9. The effectiveness of intravenous treatment with Tables 10 and11 (which are modeled on those rtPA is not well established (Class IIb; Level of used in the NINDS Trial) to determine the Evidence C) and requires further study for eligibility of the patient. A recommended patients who can be treated in the time period of regimen for observation and treatment of 3 to 4.5 hours after stroke but have 1 or more of patients who receive intravenous rtPA is the following exclusion criteria: (1) patients >80 described in Table 12. (Unchanged from the years old, (2) those taking oral anticoagulants, previous guideline13) even with INR ≤1.7, (3) those with a baseline 2. In patients eligible for intravenous rtPA, benefit NIHSS score >25, or (4) those with a history of of therapy is time dependent, and treatment both stroke and diabetes mellitus. (Revised from should be initiated as quickly as possible. The the 2009 intravenous rtPA Science Advisory14) door-to-needle time (time of bolus 10. Use of intravenous fibrinolysis in patients with administration) should be within 60 minutes conditions of mild stroke deficits, rapidly from hospital arrival (Class I; Level of Evidence improving stroke symptoms, major surgery in A). (New recommendation) the preceding 3 months, and recent myocardial 3. Intravenous rtPA (0.9 mg/kg, maximum dose 90 infarction may be considered, and potential mg) is recommended for administration to increased risk should be weighed against the eligible patients who can be treated in the time anticipated benefits (Class IIb; Level of Evidence period of 3 to 4.5 hours after stroke onset (Class C). These circumstances require further study. I; Level of Evidence B). The eligibility criteria (New recommendation) for treatment in this time period are similar to 11. The intravenous administration of streptokinase those for people treated at earlier time periods for treatment of stroke is not recommended within 3 hours, with the following additional (Class III; Level of Evidence A). (Revised from the exclusion criteria: patients >80 years old, those previous guideline13) taking oral anticoagulants regardless of INR, 12. The use of intravenous rtPA in patients taking those with a baseline NIHSS score >25, those direct thrombin inhibitors or direct factor Xa with imaging evidence of ischemic injury inhibitors may be harmful and is not involving more than one third of the MCA recommended unless sensitive laboratory tests territory, or those with a history of both stroke such as aPTT, INR, platelet count, and ECT, and diabetes mellitus. (Revised from the 2009 TT, or appropriate direct factor Xa activity intravenous rtPA Science Advisory14) assays are normal, or the patient has not 4. Intravenous rtPA is reasonable in patients received a dose of these agents for >2 days whose blood pressure can be lowered safely (to (assuming normal renal metabolizing function). below 185/110 mm Hg) with antihypertensive Similar consideration should be given to patients agents, with the physician assessing the stability being considered for intra-arterial rtPA (Class of the blood pressure before starting intravenous III; Level of Evidence C). (New recommendation) rtPA (Class I; Level of Evidence B). (Unchanged Further study is required. from the previous guideline13) 5. In patients undergoing fibrinolytic therapy, Endovascular Interventions physicians should be aware of and prepared to Recommendations emergently treat potential side effects, including 1. Patients eligible for intravenous rtPA should bleeding complications and angioedema that receive intravenous rtPA even if intra-arterial may cause partial airway obstruction (Class I; treatments are being considered (Class I; Level of Level of Evidence B). (Revised from the previous Evidence A).(Unchanged from the previous guideline13) guideline13) 6. Intravenous rtPA is reasonable in patients with 2. Intra-arterial fibrinolysis is beneficial for a seizure at the time of onset of stroke if evidence treatment of carefully selected patients with suggests that residual impairments are major ischemic strokes of <6 hours’ duration caused by occlusions of the MCA who are not 10. The usefulness of emergent intracranial otherwise candidates for intravenous rtPA (Class angioplasty and/or stenting is not well I; Level of Evidence B). The optimal dose of established. These procedures should be used in intra-arterial rtPA is not well established, and the setting of clinical trials (Class IIb; Level of rtPA does not have FDA approval for intra- Evidence C). (New recommendation) arterial use. (Revised from the previous 11. The usefulness of emergent angioplasty and/or guideline13) stenting of the extracranial carotid or vertebral 3. As with intravenous fibrinolytic therapy, arteries in unselected patients is not well reduced time from symptom onset to reperfusion established (Class IIb; Level of Evidence C). Use with intraarterial therapies is highly correlated of these techniques may be considered in certain with better clinical outcomes, and all efforts must circumstances, such as in the treatment of acute be undertaken to minimize delays to definitive ischemic stroke resulting from cervical therapy (Class I; Level of Evidence B). (New atherosclerosis or dissection (Class IIb; Level of recommendation) Evidence C). Additional randomized trial data 4. Intra-arterial treatment requires the patient to are needed. (New recommendation) be at an experienced stroke center with rapid access to cerebral angiography and qualified Anticoagulants interventionalists. An emphasis on expeditious Recommendations assessment and treatment should be made. 1. At present, the usefulness of argatroban or other Facilities are encouraged to define criteria that thrombin inhibitors for treatment of patients can be used to credential individuals can perform with acute ischemic stroke is not well established intra-arterial revascularization procedures. (Class IIb; Level of Evidence B). These agents Outcomes on all patients should be tracked should be used in the setting of clinical trials. (Class I; Level of Evidence C). (Revised from the (New recommendation) previous guideline13) 2. The usefulness of urgent anticoagulation in 5. When mechanical thrombectomy is pursued, patients with severe stenosis of an internal stent retrievers such as Solitaire FR and Trevo carotid artery ipsilateral to an ischemic stroke is are generally preferred to coil retrievers such as not well established (Class IIb; Level of Evidence Merci (Class I; Level of Evidence A). The relative B). (New recommendation) effectiveness of the Penumbra System versus 3. Urgent anticoagulation, with the goal of stent retrievers is not yet characterized. (New preventing early recurrent stroke, halting recommendation) neurological worsening, or improving outcomes 6. The Merci, Penumbra System, Solitaire FR, and after acute ischemic stroke, is not recommended Trevo thrombectomy devices can be useful in for treatment of patients with acute ischemic achieving recanalization alone or in combination stroke (Class III; Level of Evidence A). with pharmacological fibrinolysis in carefully (Unchanged from the previous guideline13) selected patients (Class IIa; Level of Evidence B). 4. Urgent anticoagulation for the management of Their ability to improve patient outcomes has not noncerebrovascular conditions is not yet been established. These devices should recommended for patients with moderate-to- continue to be studied in randomized controlled severe strokes because of an increased risk of trials to determine the efficacy of such serious intracranial hemorrhagic complications treatments in improving patient outcomes. (Class III; Level of Evidence A). (Unchanged from (Revised from the previous guideline13) the previous guideline13) 7. Intra-arterial fibrinolysis or mechanical 5. Initiation of anticoagulant therapy within 24 thrombectomy is reasonable in patients who have hours of with intravenous rtPA is not contraindications to the use of intravenous recommended Class III; Level of Evidence B). fibrinolysis (ClassIIa; Level of Evidence C). (Unchanged from the previous guideline13) (Revised from the previous guideline13) 8. Rescue intra-arterial fibrinolysis or mechanical Antiplatelet Agents thrombectomy may be reasonable approaches to Recommendations recanalization in patients with large-artery 1. Oral administration of aspirin (initial dose is 325 occlusion who have not responded to intravenous mg) within 24 to 48 hours after stroke onset is fibrinolysis. Additional randomized trial data are recommended for treatment of most patients needed (Class IIb; Level of Evidence B). (New (Class I; Level of Evidence A). (Unchanged from recommendation) the previous guideline13) 9. The usefulness of mechanical thrombectomy 2. The usefulness of clopidogrel for the treatment of devices other than the Merci retriever, the acute ischemic stroke is not well established Penumbra System, Solitaire FR, and Trevo is not (Class IIb; Level of Evidence C). Further research well established (Class IIb; Level of Evidence C). testing the usefulness of the emergency These devices should be used in the setting of administration of clopidogrel in the treatment of clinical trials. (Revised from the previous patients with acute stroke is required. (Revised guideline13) from the previous guideline13) 3. The efficacy of intravenous tirofiban and Neuroprotective Agents eptifibatide is not well established, and these Recommendations agents should be used only in the setting of 1. Among patients already taking statins at the time clinical trials (Class IIb; Level of Evidence C). of onset of ischemic stroke, continuation of statin (New recommendation) therapy during the acute period is reasonable 4. Aspirin is not recommended as a substitute for (Class IIa; Level of Evidence B). (New other acute interventions for treatment of stroke, recommendation) including intravenous rtPA (Class III; Level of 2. The utility of induced hypothermia for the Evidence B). (Unchanged from the previous treatment of patients with ischemic stroke is not guideline13) well established, and further trials are 5. The administration of other intravenous recommended (Class IIb; Level of Evidence B). antiplatelet agents that inhibit the glycoprotein (Revised from the previous guideline13) IIb/IIIa receptor is not recommended (Class III; 3. At present, transcranial near-infrared laser Level of Evidence B). (Revised from the previous therapy is not well established for the treatment guideline13) Further research testing the of acute ischemic stroke (Class IIb; Level of usefulness of emergency administration of these Evidence B), and further trials are medications as a treatment option in patients recommended. (New recommendation) with acute ischemic stroke is required. 4. At present, no pharmacological agents with 6. The administration of aspirin (or other putative neuroprotective actions have antiplatelet agents) as an adjunctive therapy demonstrated efficacy in improving outcomes within 24 hours of intravenous fibrinolysis is not after ischemic stroke, and therefore, other recommended (Class III; Level of Evidence C). neuroprotective agents are not recommended (Revised from the previous guideline13) (Class III; Level of Evidence A). (Revised from the previous guideline13) Volume Expansion, Vasodilators, and 5. Data on the utility of hyperbaric oxygen are Induced Hypertension inconclusive, and some data imply that the Recommendations intervention may be harmful. Thus, with the 1. In exceptional cases with systemic hypotension exception of stroke secondary to air producing neurological sequelae, a physician embolization, this intervention is not may prescribe vasopressors to improve cerebral recommended for treatment of patients with blood flow. If drug-induced hypertension is used, acute ischemic stroke (Class III; Level of close neurological and cardiac monitoring is Evidence B). (Unchanged from the previous recommended (Class I; Level of Evidence C). guideline13) (Revised from the previous guideline13) 2. The administration of high-dose albumin is not Surgical Interventions well established as a treatment for most patients Recommendations with acute ischemic stroke until further 1. The usefulness of emergent or urgent CEA when definitive evidence regarding efficacy becomes clinical indicators or brain imaging suggests a available (Class IIb; Level of Evidence B). (New small infarct core with large territory at risk (eg, recommendation) penumbra), compromised by inadequate flow 3. At present, use of devices to augment cerebral from a critical carotid stenosis or occlusion, or in blood flow for the treatment of patients with the case of acute neurological deficit after CEA, acute ischemic stroke is not well established in which acute thrombosis of the surgical site is (Class IIb; Level of Evidence B). These devices suspected, is not well established (Class IIb; Level should be used in the setting of clinical trials. of Evidence B). (New recommendation) (New recommendation) 2. In patients with unstable neurological status 4. The usefulness of drug-induced hypertension in (either stroke-in-evolution or crescendo TIA), the patients with acute ischemic stroke is not well efficacy of emergent or urgent CEA is not well established (Class IIb; Level of Evidence B). established (Class IIb; Level of Evidence B). (New (Revised from the previous guideline13) Induced recommendation) hypertension should be performed in the setting of clinical trials. Admission to the Hospital and General 5. Hemodilution by volume expansion is not Acute Treatment (After Hospitalization) recommended for treatment of patients with Recommendations acute ischemic stroke (Class III; Level of 1. The use of comprehensive specialized stroke care Evidence A). (Revised from the previous (stroke units) that incorporates rehabilitation is guideline13) recommended (Class I; Level of Evidence A). 6. The administration of vasodilatory agents, such (Unchanged from the previous guideline13) as pentoxifylline, is not recommended for 2. Patients with suspected pneumonia or UTIs treatment of patients with acute ischemic stroke should be treated with appropriate antibiotics (Class III; Level of Evidence A). (Unchanged from (Class I; Level of Evidence A). (Revised from the the previous guideline13) previous guideline) 3. Subcutaneous administration of anticoagulants is Treatment of Acute Neurological recommended for treatment of immobilized Complications patients to prevent DVT (Class I; Level of Recommendations Evidence A). (Unchanged from the previous 1. Patients with major infarctions are at high risk guideline13) for complicating brain edema and increased ICP. 4. The use of standardized stroke care order sets is Measures to lessen the risk of edema and close recommended to improve general management monitoring of the patient for signs of (Class I; Level of Evidence B). (Unchanged from neurological worsening during the first days the previous guideline13) after stroke are recommended (Class I; Level of 5. Assessment of swallowing before the patient Evidence A). Early transfer of patients at risk for begins eating, drinking, or receiving oral malignant brain edema to an institution with medications is recommended (Class I; Level of neurosurgical expertise should be considered. Evidence B). (Unchanged from the previous (Revised from the previous guideline13) guideline13) 2. Decompressive surgical evacuation of a space- 6. Patients who cannot take solid food and liquids occupying cerebellar infarction is effective in orally should receive NG, nasoduodenal, or PEG preventing and treating herniation and brain tube feedings to maintain hydration and stem compression (Class I; Level of Evidence B). nutrition while undergoing efforts to restore (Revised from the previous guideline13) swallowing (Class I; Level of Evidence B). 3. Decompressive surgery for malignant edema of (Revised from the previous guideline13) the cerebral hemisphere is effective and 7. Early mobilization of less severely affected potentially lifesaving (Class I; Level of Evidence patients and measures to prevent subacute B). Advanced patient age and patient/family complications of stroke are recommended (Class valuations of achievable outcome states may I; Level of Evidence C). (Unchanged from the affect decisions regarding surgery. (Revised from previous guideline13) the previous guideline13) 8. Treatment of concomitant medical diseases is 4. Recurrent seizures after stroke should be treated recommended (Class I; Level of Evidence C). in a manner similar to other acute neurological (Unchanged from the previous guideline13) conditions, and antiepileptic agents should be 9. Early institution of interventions to prevent selected by specific patient characteristics (Class recurrent stroke is recommended (Class I; Level I; Level of Evidence B). (Unchanged from the of Evidence C). (Unchanged from the previous previous guideline13) guideline13) 5. Placement of a ventricular drain is useful in 10. The use of aspirin is reasonable for treatment of patients with acute hydrocephalus secondary to patients who cannot receive anticoagulants for ischemic stroke (Class I; Level of Evidence C). DVT prophylaxis (Class IIa; Level of Evidence (Revised from the previous guideline13) A). (Revised from the previous guideline13) 6. Although aggressive medical measures have been 11. In selecting between NG and PEG tube routes of recommended for treatment of deteriorating feeding in patients who cannot take solid food or patients with malignant brain edema after large liquids orally, it is reasonable to prefer NG tube cerebral infarction, the usefulness of these feeding until 2 to 3 weeks after stroke onset measures is not well established (Class IIb; Level (Class IIa; Level of Evidence B). (Revised from the of Evidence C). (Revised from the previous previous guideline13) guideline13) 12. The use of intermittent external compression 7. Because of lack of evidence of efficacy and the devices is reasonable for treatment of patients potential to increase the risk of infectious who cannot receive anticoagulants (Class IIa; complications, corticosteroids (in conventional or Level of Evidence B). (Revised from the previous large doses) are not recommended for treatment guideline13) of cerebral edema and increased ICP 13. Routine use of nutritional supplements has not complicating ischemic stroke (Class III; Level of been shown to be beneficial (Class III; Level of Evidence A). (Unchanged from the previous Evidence B). (Revised from the previous guideline13) guideline13) 8. Prophylactic use of anticonvulsants is not 14. Routine use of prophylactic antibiotics has not recommended (Class III; Level of Evidence C). been shown to be beneficial (Class III; Level of (Unchanged from the previous guideline13) Evidence B). (Revised from the previous guideline13) 15. Routine placement of indwelling bladder catheters is not recommended because of the associated risk of catheter-associated UTIs (Class III; Level of Evidence C). (Unchanged from the previous guideline13)