5 Qs on the New Acute Ischemic Stroke Guidelines

Question 1: Which stroke severity rating scale is recommended by the AHA/ASA for emergency evaluation of acute ischemic stroke? 

A. NIHSS
B. RACE
C. LAMS
D. C-STAT

While the Rapid Arterial Occlusion Evaluation (RACE) scale, Los Angeles Motor Scale (LAMS), Cincinnati Stroke Triage Assessment Tool (C-STAT) are all stroke severity scales, the AHA/ASA states that the National Institutes of Health Stroke Scale (NIHSS) is preferred. 

Source: Powers WJ, Rabinstein AA, Ackerson T, et al. 2018 guidelines for the early management of patients with acute ischemic stroke: A guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2018;49:e46-e110.

Question 2. What is the target door-to-needle time in patients treated with IV alteplase for acute ischemic stroke?

A. 20 minutes
B. 30 minutes
C. 60 minutes
D. 90 minutes

According to the AHA/ASA guidelines, the target door-to-needle time in ≥50% of patients treated with IV alteplase for acute ischemic stroke is within 60 minutes. However, the AHA/ASA added a new recommendation stating that a secondary door-to-needle time of within 45 minutes may be reasonable to establish in ≥50% of patients with acute ischemic stroke treated with IV alteplase.

Source: Powers WJ, Rabinstein AA, Ackerson T, et al. 2018 guidelines for the early management of patients with acute ischemic stroke: A guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2018;49:e46-e110.

Question 3. When should aspirin be given in patients with acute ischemic stroke?

A. Immediately 
B. Within 6 hours
C. Within 12 hours
D. Within 24 hours

The AHA/ASA recommends that aspirin should be given to patients with acute ischemic stroke within 24-48 hours of onset. Aspirin is usually delayed until 24 hours later in patients who have received IV alteplase. Aspirin should not be given as a substitute for acute ischemic stroke in patients who are eligible for IV alteplase or mechanical thrombectomy.

Source: Powers WJ, Rabinstein AA, Ackerson T, et al. 2018 guidelines for the early management of patients with acute ischemic stroke: A guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2018;49:e46-e110.

Question 4. In the hospital management of patients with acute ischemic stroke and comorbid conditions that require early treatment of hypertension, the AHA/ASA considers it safe to initially lower blood pressure by what percentage?

A. 10%
B. 15%
C. 20%
D. 25%

For patients with acute ischemic stroke and comorbid conditions that require early treatment of hypertension, the AHA/ASA considers it safe to initially lower blood pressure by 15%. Excessively lowering blood pressure may worsen cerebral ischemia. Comorbid conditions that may require blood pressure management may include acute coronary event, acute heart failure, aortic dissection, post-thrombolysis symptomatic intracerebral hemorrhage, or preeclampsia/eclampsia.

Source: Powers WJ, Rabinstein AA, Ackerson T, et al. 2018 guidelines for the early management of patients with acute ischemic stroke: A guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2018;49:e46-e110.

Question 5. What is the target time for brain imaging upon arrival in the emergency department (ED)?

A. 20 minutes
B. 40 minutes
C. 60 minutes
D. 80 minutes

The AHA/ASA recommends that the target time for brain imaging upon arrival in the ED should be 20 minutes in at least 50% of patients who are possible candidates for IV alteplase or thrombectomy. The benefits of alteplase and thrombectomy are time-dependent. Decreasing the time to brain imaging to rule out intracerebral hemorrhage and identify patients who are eligible for these therapies may speed time to treatment initiation.

For more on this topic, see Guiding Principles in Reducing Stroke Mortality. 

Source: Powers WJ, Rabinstein AA, Ackerson T, et al. 2018 guidelines for the early management of patients with acute ischemic stroke: A guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2018;49:e46-e110.