Monday, March 5, 2018

Ischemic Stroke Updates (2018 AHA/ASA)

emDocs - March 5, 2018 - Author: Long B - Edited by: Koyfman A
ED Evaluation and Management
  1. "Use of a stroke severity scale (preferably NIHSS) is recommended.
  2. All patients admitted with suspected acute stroke should receive imaging including noncontrast head CT. Although diffusion weighted MRI is more sensitive, routine use in all patients is not recommended as it is not cost effective. If CT is negative and the presentation is unclear, an area of restricted diffusion on MRI may lead to management change.
  3. Imaging should occur within 20 minutes of ED arrival in > 50% of patients who are candidates for tPA and/or mechanical thrombectomy.
  4. There is insufficient evidence to identify a specific amount of acute CT hypoattenuation severity/extent that affects response to tPA. Extent and severity of acute hypoattenuation or early ischemia should not be used to withhold therapy.
  5. The hyperdense MCA sign or loss of gray-white differentiation on CT should not be used to withhold tPA.
  6. Routine MRI for exclusion of cerebral microbleeds before tPA is not recommended.
  7. Using imaging criteria to select patients who woke with stroke symptoms or have unclear time of symptom onset for treatment with tPA is not recommended.
  8. Multimodal CT and MRI (with perfusion imaging) should not delay tPA administration.
  9. For patients meeting criteria for endovascular therapy, noninvasive intracranial vascular imaging is recommended during initial imaging, but this should not delay tPA. Patients who qualify for tPA before vascular imaging should receive tPA before vascular imaging.
  10. For patients who meet criteria for endovascular treatment, CTA is reasonable before obtaining creatinine if there is no history of renal disease and a large vessel occlusion is suspected.
  11. Imaging of the extracranial carotid and vertebral vasculature is reasonable in patients who are candidates for mechanical thrombectomy (evaluate for stenosis, dissection, occlusion).
  12. Additional imaging other than CT and CTA or MRI with MRA such as perfusion studies to select patients for mechanical thrombectomy in < 6 hours is not recommended.
  13. In patients with stroke symptoms within 6-24 hours after last normal with large vessel occlusion in the anterior circulation, CT perfusion, MRI perfusion, DW-MRI is recommended to assist in selecting patients for mechanical thrombectomy (DAWN, DEFUSE 3 trials)..."