Background and Purpose—The authors present an overview of the current evidence and management recommendations for evaluation and treatment of adults with acute ischemic stroke. The intended audienc...

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Guidelines for the Early Management of Patients With Acute Ischemic Stroke A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association

March 5, 2019 e1 WRITING GROUP MEMBERS Emelia J. Benjamin, MD, ScM, FAHA, Chair Paul Muntner, PhD, MHS, FAHA, Vice Chair Alvaro Alonso, MD, PhD, FAHA Marcio S. Bittencourt, MD, PhD, MPH Clifton W. Callaway, MD, FAHA April P. Carson, PhD, MSPH, FAHA Alanna M. Chamberlain, PhD Alexander R. Chang, MD, MS Susan Cheng, MD, MMSc, MPH, FAHA Sandeep R. Das, MD, MPH, MBA, FAHA Francesca N. Delling, MD, MPH Luc Djousse, MD, ScD, MPH Mitchell S.V. Elkind, MD, MS, FAHA Jane F. Ferguson, PhD, FAHA Myriam Fornage, PhD, FAHA Lori Chaffin Jordan, MD, PhD, FAHA Sadiya S. Khan, MD, MSc Brett M. Kissela, MD, MS Kristen L. Knutson, PhD Tak W. Kwan, MD, FAHA Daniel T. Lackland, DrPH, FAHA Tené T. Lewis, PhD Judith H. Lichtman, PhD, MPH, FAHA Chris T. Longenecker, MD Matthew Shane Loop, PhD Pamela L. Lutsey, PhD, MPH, FAHA Seth S. Martin, MD, MHS, FAHA Kunihiro Matsushita, MD, PhD, FAHA Andrew E. Moran, MD, MPH, FAHA Michael E. Mussolino, PhD, FAHA Martin O’Flaherty, MD, MSc, PhD Ambarish Pandey, MD, MSCS Amanda M. Perak, MD, MS Wayne D. Rosamond, PhD, MS, FAHA Gregory A. Roth, MD, MPH, FAHA Uchechukwu K.A. Sampson, MD, MBA, MPH, FAHA Gary M. Satou, MD, FAHA Emily B. Schroeder, MD, PhD, FAHA Svati H. Shah, MD, MHS, FAHA Nicole L. Spartano, PhD Andrew Stokes, PhD David L. Tirschwell, MD, MS, MSc, FAHA Connie W. Tsao, MD, MPH, Vice Chair Elect Mintu P. Turakhia, MD, MAS, FAHA Lisa B. VanWagner, MD, MSc, FAST John T. Wilkins, MD, MS, FAHA Sally S. Wong, PhD, RD, CDN, FAHA Salim S. Virani, MD, PhD, FAHA, Chair Elect On behalf of the American Heart Association Council on Epidemiology and Prevention Statistics Committee and Stroke Statistics Subcommittee

Heart Disease and Stroke Statistics—2019 Update: A Report From the American Heart Association

Background Intravenous thrombolysis with alteplase is the only approved treatment for acute ischemic stroke, but its efficacy and safety when administered more than 3 hours after the onset of symptoms have not been established. We tested the efficacy and safety of alteplase administered between 3 and 4.5 hours after the onset of a stroke. Methods After exclusion of patients with a brain hemorrhage or major infarction, as detected on a computed tomographic scan, we randomly assigned patients with acute ischemic stroke in a 1:1 double-blind fashion to receive treatment with intravenous alteplase (0.9 mg per kilogram of body weight) or placebo. The primary end point was disability at 90 days, dichotomized as a favorable outcome (a score of 0 or 1 on the modified Rankin scale, which has a range of 0 to 6, with 0 indicating no symptoms at all and 6 indicating death) or an unfavorable outcome (a score of 2 to 6 on the modified Rankin scale). The secondary end point was a global outcome analysis of four neurologic and disability scores combined. Safety end points included death, symptomatic intracranial hemorrhage, and other serious adverse events. Results We enrolled a total of 821 patients in the study and randomly assigned 418 to the alteplase group and 403 to the placebo group. The median time for the administration of alteplase was 3 hours 59 minutes. More patients had a favorable outcome with alte plase than with placebo (52.4% vs. 45.2%; odds ratio, 1.34; 95% confidence interval [CI], 1.02 to 1.76; P = 0.04). In the global analysis, the outcome was also improved with alteplase as compared with placebo (odds ratio, 1.28; 95% CI, 1.00 to 1.65; P<0.05). The incidence of intracranial hemorrhage was higher with alteplase than with placebo (for any intracranial hemorrhage, 27.0% vs. 17.6%; P = 0.001; for symptomatic intracranial hemorrhage, 2.4% vs. 0.2%; P = 0.008). Mortality did not differ significant ly between the alteplase and placebo groups (7.7% and 8.4%, respectively; P = 0.68). There was no significant difference in the rate of other serious adverse events. Conclusions As compared with placebo, intravenous alteplase administered between 3 and 4.5 hours after the onset of symptoms significantly improved clinical outcomes in patients with acute ischemic stroke; alteplase was more frequently associated with symptomatic intracranial hemorrhage. (ClinicalTrials.gov number, NCT00153036.)

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Thrombolysis with Alteplase 3 to 4.5 Hours After Acute Ischemic Stroke

The Task Force for the management of atrial fibrillation of the European Society of Cardiology (ESC)  

Developed with the special contribution of the European Heart Rhythm Association (EHRA) of the ESC  

Endorsed by the European Stroke Organisation (ESO)

/pdf/2016-esc-guidelines-for-the-management-of-atrial-ba0601yb9m.pdf

2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS

Each chapter listed in the Table of Contents (see next page) is a hyperlink to that chapter. The reader clicks the chapter name to access that chapter.

Each chapter listed here is a hyperlink. Click on the chapter name to be taken to that chapter. 

Each year, the American Heart Association (AHA), in conjunction with the Centers for Disease Control and Prevention, the National Institutes of Health, and other government agencies, brings together in a single document the most up-to-date statistics related to heart disease, stroke, and the cardiovascular risk factors listed in the AHA’s My Life Check - Life’s Simple 7 (Figure1), which include core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure [BP], and glucose control) that contribute to cardiovascular health. The Statistical Update represents …

Heart Disease and Stroke Statistics-2018 Update: A Report From the American Heart Association.

Even 10 years after the approval of thrombolysis this life-saving and disability reducing therapy is still underused. important reasons for that are very strict inclusion criteria such as the early and narrow time-window, fear of bleeding complications and doubts regarding the effectivity. An intensive and constant effort is required to educate the public that stroke is a treatable emergency. In addition to the medical reasons, economic considerations in a context of decreasing resources emphasize the importance of effective stroke treatment. The results of numerous recent studies such as the European register SITS-MOST help to strengthen the confidence in thrombolysis. In addition the development and advancement of new imaging tools such as multiparametric MRI and advanced CT-techniques will improve patient selection and may enable us to extend the time-window for treatment. Intraarterial thrombolysis,,,bridging" methods and new devices for intravascular intervention are the subjects of intensive ongoing research. Even though no randomized trials are available intraarterial thrombolysis is the treatment of choice for acute basilar occlusion, but if this intervention is not available an intravenous approach may be an equal alternative.

Thrombolyse bei ischamischem Schlaganfall : Ein Update

P-27 Vagus nerve cross-sectional area decreases in progressive idiopathic Parkinson’s syndrome

Intensive heart rhythm monitoring to decrease ischemic stroke and systemic embolism - the Find-AF 2 study - Rationale and design.

Background: Prior to the conduct of the Head Position in Stroke Trial (HeadPoST), an international survey (n = 128) revealed equipoise for selection of head position in acute ischemic stroke. Objectives: We aimed to determine whether equipoise exists for head position in spontaneous hyperacute intracerebral hemorrhage (ICH) patients following HeadPoST. Design: This is an international, web-distributed survey focused on head positioning in hyperacute ICH patients. Methods: A survey was constructed to examine clinicians’ beliefs and practices associated with head positioning of hyperacute ICH patients. Survey items were developed with content experts, piloted, and then refined before distributing through stroke listservs, social media, and purposive snowball sampling. Data were analyzed using descriptive statistics and χ2 test. Results: We received 181 responses representing 13 countries on four continents: 38% advanced practice providers, 32% bedside nurses, and 30% physicians; overall, participants had median 7 [interquartile range (IQR) = 3–12] years stroke experience with a median of 100 (IQR = 37.5–200) ICH admissions managed annually. Participants disagreed that HeadPoST provided ‘definitive evidence’ for head position in ICH and agreed that their ‘written admission orders include 30-degree head positioning’, with 54% citing hospital policies for this head position in hyperacute ICH. Participants were unsure whether head positioning alone could influence ICH longitudinal outcomes. Use of serial proximal clinical and technology measures during the head positioning intervention were identified by 82% as the most appropriate endpoints for future ICH head positioning trials. Conclusion: Interdisciplinary providers remain unconvinced by HeadPoST results that head position does not matter in hyperacute ICH. Future trials examining the proximal effects of head positioning on clinical stability in hyperacute ICH are warranted.

International beliefs and head positioning practices in patients with spontaneous hyperacute intracerebral hemorrhage

In the personal opinion of this comment's author, we have a serious problem and lack of data if we withhold intravenous thrombolysis (IVT) and/or endovascular therapy (EVT) from any patient that fulfills the criteria for these treatments based on all the randomized trials that finally led to US Federal Drug Administration and European Medicines Agency (FDA/EMA) labelling and guideline recommendation of these therapies. The gain we experienced is the broad application of IVT to all acute stroke patients aged 16 years or older within 4.5 h based on a noncontrast computed tomography (CT) regardless of age, National Institutes of Health Stroke Scale (NIHSS) score, and with only few strict contraindications. The same holds true for such patients up to 6 h with a proximal vessel occlusion shown on computed tomography angiography (CTA) for EVT and most recently for basilar artery occlusion. A metanalysis of IVT trials did not show any significant difference in the proportional effect of IVT on outcomes stratified by NIHSS severity, by point estimates the “milder” and the more severe patients fared better [1]. Not dwelling on settings with heroically long time windows and selection criteria with advanced imaging and notsoadvanced artificial intelligence applications, and with respect to the article by Schwarz and colleagues in this issue of EJoN [2], I refer here to the standard 4.5– 6 h known time window patient with a clinically “mild stroke”. Present guidelines are mostly inconclusive or inconsistent also when compared to each other. The European Stroke Organisation (ESO) guideline, for instance, differentiates the indication for IVT based on the prematurely stopped small PRISMS trial [3] definition of nondisabling and disabling minor stroke criteria (semantically nonsense) and does not recommend treatment in patients with symptoms such as isolated mild aphasia, mild cortical hand, hemimotor loss, or ataxia [4]. All the latter are in many a patient's and stroke physician's view disabling symptoms that one would rather see ameliorated by a given treatment, with twice as high odds for recovery suggested by some authors [5]. On top of this, just imagine that this “mild” stroke is caused by a proximal vessel occlusion in the ICA/MCAM1 territory, a situation where we have now overwhelming data in general in favor of combined IVT/EVT whenever possible. For the specific “mild stroke” population discussed here there are far fewer data from small observational trials. To my clinical mind, this warrants the standard approach until proven otherwise as is also expert consensus in the current ESO guideline [6]. Regarding EVT or IVT/EVT in “mild” strokes, the expert consensus in the 2019 ESO guideline recommends recruitment into trials or otherwise treatment. Even for socalled nondisabling minor stroke (whatever that may be), the vote was 5 of 11 experts in favor of IVT/EVT [6]. Ghil Schwarz and colleagues present a Safe Implementation of Treatment in StrokeInternational Stroke Thrombolysis Registry (SITSISTR)derived, propensity scorematched analysis of patients with a “mild stroke” (i.e., patients with NIHSS scores ≤5 points treated with IVT/EVT vs IVT alone) [2]. Out of more than 1000 patients, 312 patients were matched per group. The result in brief was a twice higher rate of poor outcomes, numerically more symptomatic

https://onlinelibrary.wiley.com/doi/pdfdirect/10.1111/ene.15747

Peter D. Schellinger

Papers

Thrombolyse bei ischamischem Schlaganfall : Ein Update

P-27 Vagus nerve cross-sectional area decreases in progressive idiopathic Parkinson’s syndrome

Intensive heart rhythm monitoring to decrease ischemic stroke and systemic embolism - the Find-AF 2 study - Rationale and design.

International beliefs and head positioning practices in patients with spontaneous hyperacute intracerebral hemorrhage

Contraintuitive fallacy in a big‐risk‐no‐gain stroke scenario? Please verify!