Guidelines for the management of patients with acute ischemic stroke

This guideline article was authored by The Stroke Council of the AHA/ASA (the American Stroke Association and the American Heart Association). It provides an overview of the recommended management of patients with ischemic stroke according to the latest published medical data.

An ischemic stroke occurs when the blood supply to part of the brain is interrupted or severely reduced (by a blocked or narrowed artery), depriving brain tissue of oxygen (referred to as ischemia). Within minutes, brain cells begin to die. That is why early intervention to open the blocked artery and restore blood supply is critical. 

Despite recent advances in the treatment of ischemic strokes and the decline in stroke mortality, the incidence of stroke is increasing and ischemic stroke remains a leading cause of adult death and disability. To reduce these trends, the AHA/ASA regularly releases updated guidelines – based on the most recent medical research – for the optimal management of acute strokes.

The present article reviews recently published data, covering both known and new treatment options, and provides updated guidelines for the management of patients with acute ischemic stroke .

Current recommendations for the management of acute ischemic stroke include:

A. Early diagnosis and treatment

• Early recognition and treatment of patients with stroke is critical in order to save brain function. Imaging of the brain by a CT or MRI scan should be initiated within 25 minutes, and interpreted by an expert within 45 minutes of the patient's arrival at the hospital.
• Fibrinolytic therapy (clot-dissolving drugs injected into the vein; fibrinolysis) should be given within 60 minutes of the patient’s arrival at the hospital. Patients who have high blood pressure should have their blood pressure carefully lowered and maintained below 185/110 mmHg before the drug is given.
• Patients should be admitted into a specialized stroke center within 3 hours of their arrival at the hospital. These special care units address the complications of stroke, and manage the early stages of rehabilitation.
• At the stroke center, patients should receive supportive care (breathing support, fever reduction) and be monitored for any deterioration, while blood pressure and blood sugar levels should be stabilized. 

B. Secondary prevention (prevention of further strokes)

• To prevent additional strokes, anti-platelet drugs (prevent new clot formation via platelet cell inhibition) such as aspirin, should be initiated within 24 to 48 hours after the onset of the stroke.

C. Recovery and rehabilitation

• Patients' capability of swallowing should be assessed before the administration of anything orally (i.e. food, drugs). Patients who cannot take solid foods and liquids should receive a feeding tube to maintain nutrition during rehabilitation.
• If patients are bedridden, anticoagulants (drugs that inhibit the coagulation system) should be administered to prevent blood clots in the veins of the limbs. Otherwise, early mobilization (mild physical activity such as assisted walking) is recommended.

Therapies under investigation:

• New techniques for invasive treatment of an ischemic stroke are currently undergoing clinical trials. These include intra-arterial fibrinolysis (local, instead of whole-body administration of clot-dissolving drugs), mechanical clot removal (known as thrombectomy), and stenting (removal of the clot and insertion a small mesh tube to hold the blocked artery open). The combination of fibrinolytic drugs and thrombectomy appears to have the highest rate of success in patients with occlusions in large arteries, without raising the risk of bleeding within the brain. 
• Neuroprotection consist of therapies aimed at salvaging brain cells affected by the stroke. These are given right after the diagnosis of an ischemic stroke to reduce brain damage. Neuroprotective strategies include induced hypothermia (reducing the body temperature), hyperbaric oxygen (using a decompression chamber that provides high-pressure oxygen), and transcranial near-infra-red laser therapy (the laser stimulates injured brain cells to increase their energy stores, thus protecting them from the lack of oxygen). To this end, there is insufficient evidence to support the clinical use of any of these therapies.