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Stroke 2014:
Update on Guidelines
Florida Osteopathic Medical Association
15th Annual Cardiovascular & Medicine Symposium May 15, 2014
Kenneth Hentschel, DO, PhD, FAANEM
St. Vincent’s Spine & Brain Institute
Disclosures
• I have no financial relationships that impact
on this activity
Background
• A panel of experts from the AHA and the ASA
convened and published guidelines for acute
stroke care in 2007
• Updates were published in 2009 & 2013
• The most recent guidelines were published
5/1/14, the scope continues to expand
Goals/Objectives
• To decrease the morbidity and mortality of
your patients with ischemic stroke
• To improve secondary prevention of
TIA/stroke in your patients
Method
• Several guidelines from the AHA/ASA
on the topic of stroke were reviewed
and summarized here as a high yield
points for the primary provider
Overview
– Prehospital stroke management
– Evaluation & treatment of Acute stroke in
the emergency department
– Evaluation & treatment of stroke/TIA in the
hospitalized patient
– Endovascular & Surgical interventions
– Risk factor management
– Special populations
– Potential complications
Prehospital Stroke Management
• Patients should be transported to the nearest
certified primary or comprehensive stroke
center
– Bypass closer, nonstroke centers
• EMS providers should alert the hospital that
they are en route with a possible acute stroke
patient so that the stroke alert team may be
mobilized
Emergency Evaluation
• An organized stroke alert protocol is
recommended for use in acute stroke
• Use of the NIH stroke scale is recommended
for uniformity
Emergency Evaluation
• Only a limited number of tests are required
prior to TPA administration
– CT head without contrast
– Serum glucose
– PT/INR, PTT
• Baseline troponin & EKG are recommended,
but should not delay TPA administration
Emergency Evaluation
• CT Head without contrast
required prior to TPA to exclude:
– Intracranial hemorrhage
(contraindication)
– Greater than 1/3 MCA territory
hypodensity (relative
contraindication/precaution)
– Should be read within 45min of
patient arrival
Brain & Vascular Imaging
• CT or MRI perfusion/diffusion imaging may
identify patients with an ischemic penumbra
at risk, who could be candidates for TPA even
if outside of the time window
– Possibly available at comprehensive stroke
centers
General Supportive Care
• Antihypertensive meds should be held for the
first 24h unless >220/120
– Patients not receiving TPA
– In general, resume antihypertensive meds in the
stable stroke patient after 24h (otherwise they may
be missed or poorly controlled when patient is
dispositioned)
• In patients with markedly high BP, lower BP
15% in the first 24h
– Eg. SBP 220, goal SBP 187
General Supportive Care
• Airway support & ventilatory assistance may
be required in patients with decreased level
of consciousness or bulbar dysfunction
• Oxygen:
– Supplemental O2 to maintain saturation >94%
– Not required if not hypoxic
General Supportive Care
• Cardiac monitoring recommended to screen
for arrhythmias
• Sources of hyperthermia (>38oC) should be
identified and treated
• Prophylactic antiepileptic medications are not
recommended in acute stroke
IV Fibrinolysis/TPA
• IV TPA (0.9 mg/kg, not to exceed 90mg) for
acute stroke onset <3 h
– Door to needle time should be <60min
• Inclusion criteria
– Acute ischemic stroke with measurable deficit
– Age >18 y
– Onset of symptoms <3 hours
acute stroke; <3 h
IV Fibrinolysis/TPA
• IV TPA exclusion criteria
– Significant head trauma or stroke in prior 3 months
– Symptoms suggest Subarachnoid hemorrhage
– Arterial puncture at noncompressible site in last 7d
– History of previous Intracranial hemorrhage
– Intracranial neoplasm, AVM or aneurysm
– Recent intracranial or intraspinal surgery
– Uncontrolled BP (>185/110)
– Active internal bleeding
acute stroke; <3 h
IV Fibrinolysis/TPA
• IV TPA exclusion criteria
– Platelet count <100k
– Coagulopathy
• Any elevation of aPTT (heparin)
• INR >1.7 or PT >15 (warfarin)
• Use of direct thrombin inhibitor in last 48h
• Use of direct factor Xa inhibitor in last 48h
– Blood glucose level <50 mg/dl
– Large volume infarction on CT head >1/3 cerebral
hemisphere
acute stroke; <3 h
IV Fibrinolysis/TPA
• IV TPA relative exclusion criteria
– Only minor or rapidly improving stroke symptoms
(new)
– Pregnancy
– Seizure at onset
– Major surgery or serious trauma within the last 2
weeks
– GI/GU hemorrhage within last 3 weeks
– Acute MI within last 3 months
acute stroke; <3 h
TPA Blood Pressure Management
• Lower BP to <185/110 before TPA therapy
– Labetolol 10-20 mg iv, may repeat once
– Nicardipine 5 mg/h iv
• titrate up 2.5 mg/h q5-15min
• NTE 15 mg/h
• After TPA keep BP <180/105 for 24h
– Monitor BP q15min x 2h, then
– Monitor BP q30min x 6h, then
– Monitor BP q60min thereafter
acute stroke; <3 h
Endovascular Interventions
• Intra arterial (IA) fibrinolysis may benefit
selected patients with acute strokes <6h
– May be performed with or without IV TPA
– Performed at comprehensive stroke centers
– Usually for Large proximal vessel occlusions
acute stroke (<6 h)
Endovascular Interventions
• Mechanical thrombectomy systems
– Large proximal vessel occlusion
– Comprehensive stroke centers
– Stent retrievers preferred over coil retrievers
acute stroke (<6 h)
Anticoagulants
• Urgent anticoagulation to prevent recurrent
stroke, or halt neurological deterioration, after
acute noncardioembolic ischemic stroke is
not recommended
Anticoagulants
• Urgent anticoagulation for the treatment of
systemic disorders (e.g. pulmonary
embolism) in the context of moderate to
severe acute ischemic stroke is not
recommended
• Anticoagulants should not be started within
24 h of IV TPA administration
Antiplatelet Agents
• Glycoprotein IIb/IIIa receptor antagonists are
not recommended for the treatment of acute
stroke
• No antiplatelet agents should be administered
for 24h from IV TPA therapy
Neuroprotective Agents
• No pharmacological agents have shown
neuroprotection
• Utility of hyperbaric oxygen treatment in acute
stroke is not well established, except for
cases of air embolization
Vasodilators & Hypotension
• The use of vasodilators in acute stroke is not
recommended
• Consider vasopressors for symptomatic
hypotension in acute stroke
Hospital Admission & Treatment
• The use of standardized stroke order sets is
recommended
• Immobile patients should be treated with SC
heparin for DVT prophylaxis
– Use aspirin & intermittent external compression
devices if heparin contraindicated
• UTIs and pneumonia should be treated
– Prophylactic antibiotics not helpful
– Routine bladder catheters not recommended
Hospital Admission & Treatment
• Swallow assessment is
recommended prior to any oral intake
• Nutrition/hydration by NG or PEG
recommended in patients with
dysphagia
– May use NG for first 2-3 weeks post
stroke
• Nutritional supplements have not
been shown to be helpful in acute
stroke
Blood Pressure Management
• Hold BP meds for first 24h unless there is
specific superseding factor (ie. TPA, acute MI
or malignant HTN) to prevent extension of
stroke in evolution
– Resume antihypertensive medication when the
patient is stable and “beyond the first several
days”
• Pursue a BP goal of <140/90 or <130/90 after
lacunar stroke
Dyslipidemia Management
• The new ACC/AHA guideline (2013) moved
away from reliance on cholesterol
measurements and became more focused
upon the individual & their risk factors
– All TIA/stroke patients would fall into the highest
risk category for which intensive lipid lowering is
recommended
Glucose Management
• After TIA/stroke, all patients should be
screened for diabetes
– Consider fasting glucose, HbgA1c, or GTT. Test
choice & timing guided by clinical judgment
• For diabetics pursue goal HgbA1c <7%, or
lowest attainable
Glucose Management
• Pursue euglycemia
– Hypoglycemia (<60mg/dl) should be avoided,
treated
– Hyperglycemia should be treated toward goal
range (140-180 mg/dl)
Antiplatelet Agents
• For patients with non-cardioembolic
stroke/TIA, antiplatelet agent (monotherapy)
is recommended over anticoagulation
– Aspirin 50-325 mg QD
– Aspirin/dipyridamole ER 25/200 mg BID
– Clopidogrel 75mg QD
• Antiplatelet therapy should commence within
24-48 h of TIA/stroke
Antiplatelet Agents
• For patients with acute stroke/TIA, not treated
with TPA, the combination of ASA and
clopidogrel may be reasonable
– Start within 24h after minor stroke/TIA
– Continue for up to 90d
– Combination therapy at 2-3y shows increased
hemorrhagic risk
Antiplatelet Agents
• In patients with recurrent TIA/stroke despite
appropriate antiplatelet therapy, there is no
evidence that increased (aspirin) dose or
changing antiplatelet therapies offers
additional benefit
– Aspirin resistance is uncommon
– Clopidogrel resistance is even more uncommon
Atrial Fibrillation
• In cryptogenic TIA/stroke, it’s reasonable to
perform prolonged (30d) rhythm monitoring
for AF within 6 months of the event
Atrial Fibrillation
• Warfarin, Apixaban, or Dabigatran is indicated
for the prevention of recurrent stroke in
patients with nonvalvular AF, whether
paroxysmal or permanent
– Rivaroxaban may also be a reasonable agent
– Selection of agent should be personalized by the
clinician
– Warfarin: target INR 2.5, range 2-3
Atrial Fibrillation
• When using anticoagulation (AC) for the
prevention of recurrent stroke in patients with
nonvalvular AF, its usually reasonable to start
AC within 2 weeks of the event
• If there is high hemorrhagic risk, the above
AC may be delayed
– Large infarction
– Hemorrhagic transformation
– Uncontrolled accelerated HTN
Atrial Fibrillation
• A combination of AC and antiplatelet agent
are not routinely recommended, but may be
reasonable in some clinical settings
– Stent, ACS, CAD
• For patients who are unable to have AC,
antiplatelet therapy is recommended
– Aspirin 325mg QD or Clopidogrel 75 mg QD
– Sometimes both may be reasonable
Acute MI & Thrombus
• For patients with stroke/TIA & acute
myocardial infarction or LA or LV thrombus,
the recommended treatment is AC for at least
3 months
– If warfarin: INR 2.5, range 2-3
• Similarly, treat with AC in the setting of acute
anterior STEMI without mural thrombus, but
with anterior/apical akinesis/dyskinesis
Cardiomyopathy
• For patients with stroke/TIA, who also
have LV assist device (LVAD), AC is
reasonable
– Provided there is no active GI bleed or
coagulopathy
• For patients with stroke/TIA, in sinus
rhythm, with cardiomyopathy (EF
<35%), without thrombus, the efficacy
of AC is uncertain
Native Cardiac Valvular Disease
• For patients with stroke/TIA, who also have
rheumatic mitral valve disease, either with or
without AF, long term AC is recommended
– If warfarin: INR 2.5, range 2-3
• For patients with stroke/TIA, and aortic or
non-rheumatic mitral valvular disease or mitral
valve prolapse, without AF, antiplatelet
therapy is recommended
Prosthetic Heart Valves
• For patients with stroke/TIA, who
have mechanical heart valves,
long term AC is recommended
– If mitral: INR 3, range 2.5-3.5
– If aortic: INR 2.5, range 2-3
– If considered low risk for
hemorrhage, addition of aspirin (75-
100 mg) QD recommended
Prosthetic Heart Valves
• For patients with mechanical heart valves who
have stroke/TIA despite AC, it’s reasonable to
intensify therapy
– Increase aspirin dose to 325 mg QD, or
– Increase target INR, depending upon hemorrhage
risk
Prosthetic Heart Valves
• For patients with stroke/TIA, who have
bioprosthetic heart valves, antiplatelet therapy
is recommended
• For patients with bioprosthetic heart valves
who have stroke/TIA despite antiplatelet
therapy, addition of AC may be considered
– If warfarin: INR target 2.5, range 2-3
Aortic Arch Atheroma
• For patients with stroke/TIA and evidence of
aortic arch atheroma, antiplatelet therapy is
recommended
– Intensive statin therapy also indicated
– Surgical endarterectomy of aortic arch plaque is
not recommended
Arterial Dissection
• For patients with stroke/TIA and evidence of
extracranial carotid or vertebral dissection,
antiplatelet or AC therapy for 3-6 months is
recommended
– If recurrent symptoms despite therapy, consider
endovascular treatment (stent)
– If recurrent symptoms despite endovascular
treatment (stent), consider surgical options
Patent Foramen Ovale
• For patients with stroke/TIA and evidence of
PFO, it is unclear if AC is equivalent or
superior to antiplatelet therapy
– If PFO & source of venous embolism identified,
then AC recommended & PFO closure may be
reasonable
– If PFO & source of venous embolism identified,
but AC contraindicated, recommend IVC filter
– If PFO, but no source of embolism, data do not
support PFO closure
Antiphospholipid Antibody
• For patients with stroke/TIA, routine
screening for antiphospholipid Ab is not
recommended without other manifestations of
antiphospholipid syndrome (APS)
• For patients with stroke/TIA, and positive
antiphospholipid Ab, antiplatelet therapy is
recommended
• For patients with stroke/TIA, and signs of
APS, AC therapy may be considered
depending upon hemorrhagic risk
Sickle Cell Disease
• For patients with stroke/TIA and Sickle cell
disease (SCD), chronic blood transfusions to
decrease Hbg S to <30% of total Hgb is
recommended
– Consider Hydroxyurea treatment if TF unavailable
– For adults, general treatments, RF management
also applies
Central Venous Sinus Thrombosis
• For patients with acute CVST, treatment with
AC is recommended
– May be reasonable even in some patients with
CVST and evidence of intracranial hemorrhage
• If CVST and thrombophilia, consider AC for 3
months or more, followed by antiplatelet
therapy
Pregnancy
• For high risk condition that would require AC,
in the pregnant patient, the following therapy
could be reasonable:
– LMWH BID throughout pregnancy, dose adjusted
to anti-Xa activity 4h after injection
– UFH SQ BID throughout pregnancy, dose
adjusted to aPTT
• Discontinue therapy >24 h before induction of
labor or c-sxn
Pregnancy
• For low risk condition that would require
antiplatelet therapy, in the first trimester
pregnant patient, the following could be
reasonable:
– LMWH BID through first trimester (dose adjusted)
– UFH BID through first trimester (dose adjusted)
– No treatment
• After the first trimester, it may be reasonable
to use aspirin 50-150 mg QD
Nursing Mothers
• It is reasonable to treat nursing mothers
requiring aspirin or AC (LMWH, UFH or
warfarin) therapy
– Negligible secretion into breast milk
Brain & Vascular Imaging
• Patients with transient neurologic symptoms
should have MRI/CT head within 24h of
symptom onset
– MRI is preferred study over CT
Brain & Vascular Imaging
• MRA neck or carotid US should be performed
in all patients hospitalized for evaluation of
TIA/stroke
• MRA head or CTA head may be performed
when the data could alter the management
plan
Extracranial Carotid Disease
• For patients with TIA/stroke within 6 months &
severe (70-99%) ipsi ICA stenosis, carotid
endarterectomy (CEA) is recommended, if
perioperative M&M <6%
• For patients with TIA/stroke with moderate
(50-69%) ipsi ICA stenosis, CEA may be
indicated depending upon patient-specific
factors (and perioperative M&M <6%)
Extracranial Carotid Disease
• For patients with TIA/stroke and mild (<50%)
ICA stenosis, no CEA or stenting is
recommended
• When revascularization is indicated, it’s
reasonable to perform the surgery <2 weeks
from the event
• In patients with recent (<6 months)
TIA/stroke, EC/IC bypass surgery is not
recommended
Extracranial Carotid Disease
• Optimal medical therapy is recommended for
all patients with carotid artery stenosis after
TIA/stroke
– Antiplatelet, statin & RF modification
• Following CEA/stenting, long term carotid
Doppler imaging in asymptomatic patients is
not indicated
Extracranial Vertebral Disease
• Optimize vascular health with emphasis on
antiplatelet, statin, BP control and lifestyle
modifications recommended for all patients
with symptomatic vertebral artery stenosis
• Endovascular vertebral stents may be
considered when patients have vertebral
TIA/stroke despite medical management
• Open surgical procedures may be
considered if medical therapy & stents fail
• For patients with TIA/stroke due to stenosis of
a major intracranial artery, aspirin 325mg/d is
preferred over warfarin
• For patients with subacute stroke (<30d), due
to intracranial stenosis of a major artery, the
addition of clopidogrel 75mg/d (to ASA
325mg/d) may be reasonable
• For TIA/stroke due to intracranial
atherosclerosis, pursue goal BP <140/90 and
high intensity statin therapy
Intracranial
Atherosclerosis
Intracranial Atherosclerosis
• For TIA/stroke due to intracranial
atherosclerosis, use antiplatelet, pursue goal
BP <140/90 and high intensity statin therapy
• For TIA/stroke due to stenosis (50-99%) of a
major intracranial artery, neither
angioplasty/stent nor EC/IC bypass are
recommended because the periprocedural
risk is greater than the lower rate of stroke
with medical management
Nutrition
• Patients with stroke/TIA and signs
of malnutrition should have dietary
consultation
• Following stroke/TIA patients
should limit their sodium intake to
<2.4g/day
Nutrition
• Patients may consider a
Mediterranean diet
– Emphasizes vegetables, fruits,
whole grains, low fat dairy,
poultry, fish legumes olive oil
and nuts
– Minimizes sweets and red meats
• In hyperhomocysteinemia,
supplementing B6, B12 &
folate does not reduce
recurrent event risk
Cigarette Smoking
• Strongly advise all smokers following
stroke/TIA to quit
• Its reasonable to advise post stroke/TIA
patients to even avoid secondhand smoke
• Educate & offer smoking cessation aides
Alcohol Consumption
• Heavy drinking is associated with increased
stroke risk. Advise heavy drinkers to wean
and discontinue heavy alcohol intake
• Light-Moderate drinking may be reasonable,
although non-drinkers should not start
– Heavy: regularly consuming >2 drinks/d for males
& >1 drink/d for females
– Moderate: regularly consuming 1-2 drinks/d for
males & 1 drink/d for females
Sleep Apnea
• Screen for sleep apnea in all patients post
stroke/TIA. It is more commonly present than
not
– May treat with auto titration CPAP
– Treatment of OSA is associated with fewer post
stroke complications and better outcomes
Rehabilitation
• Stroke centers should incorporate
rehabilitation and early mobilization
• Following stroke/TIA, for capable patients,
moderate to intense physical activity (3-4/wk
for 40min) is recommended
– Moderate: brisk walk, stationary bike
– Vigorous: jogging
Malignant Brain Edema
• Large ischemic strokes can be complicated by
(cytotoxic) edema
– Peaks around 72h
– Transfer to Comprehensive Stroke Center
– Corticosteroids are not recommended
– Elevate HOB 20-30 degrees
– Mannitol 0.25-0.5g/kg iv, over 20 min, q6h
• NTE 2g/kg
– Hypervent to goal PCO2 30-35mm Hg produces short
duration decreased ICP
– Decompressive hemicraniectomy
Decompressive Surgery
• Large proximal vessel occlusions (ICA, M1CA)
with malignant edema may be considered for
decompressive hemicraniectomy
– Candidates are younger (<65y)
– Candidates have (R) hemisphere lesions
– Mortality 50-70% despite interventions
• Cerebellar infarctions which may provoke
herniation or obstructive hydrocephaly
– Suboccipital decompression or ventriculostomy
Hemorrhagic Transformation
• Possible complication of ischemic stroke from
bleeding into infarcted area
• Usually develops in first 24h following stroke
• More common in larger strokes, older
patients and after cardioembolic mechanism
• No standardized treatment; varies case by
case
Anticoagulation After ICH
• For patients requiring AC who have had
hemorrhagic transformation, depending upon
the clinical scenario, AC may sometimes be
continued
• AC is not recommended in patients with lobar
hemorrhage suspected of having cerebral
amyloid angiopathy
– May consider antiplatelet therapy
Anticoagulation After ICH
• For patients requiring AC after
Intraparenchymal or subarachnoid or
subdural hemorrhages, the optimal timing of
resuming AC is unclear
– Most wait 1-4 weeks
– Recheck CT head without contrast for acute blood
and evolution of hematoma
– Some use antiplatelet agent before later resuming
AC
Conclusions
• The goal of the guidelines is to limit mortality
& morbidity of stroke
• The guidelines support an concept of
multidisciplinary stroke care
• The guidelines emphasize early treatment
• Specific interventions are outlined to optimize
cerebral resuscitation
References
• Guidelines for the Early Management of Patients With Acute
Ischemic Stroke: A Guideline for Healthcare Professionals From
the American heart Association/American Stroke Association.
EC Jauch et al. Stroke. 2013;44.
http://stroke.ahajournals.org/content/early/2013/01/31/STR.0b013e318284056a
• Guidelines for the Prevention of Stroke in Patients With Stroke
and Transient Ischemic Attack: A Guideline for Healthcare
Professionals From the American heart Association/American
Stroke Association. WN Kernan et al. Stroke. 2014: 45.
Thank
You
Kenneth Hentschel, DO, PhD, FAANEM
St Vincent’s Spine & Brain Institute
Southside Campus
Office phone: 308-7959
