Background and Purpose— The purpose of these guidelines is to provide an up-to-date comprehensive set of recommendations in a single document for clinicians caring for adult patients with acute arterial ischemic stroke. The intended audiences are prehospital care providers, physicians, allied health professionals, and hospital administrators. These guidelines supersede the 2013 Acute Ischemic Stroke (AIS) Guidelines and are an update of the 2018 AIS Guidelines. Methods— Members of the writing group were appointed by the American Heart Association (AHA) Stroke Council’s Scientific Statements Oversight Committee, representing various areas of medical expertise. Members were not allowed to participate in discussions or to vote on topics relevant to their relations with industry. An update of the 2013 AIS Guidelines was originally published in January 2018. This guideline was approved by the AHA Science Advisory and Coordinating Committee and the AHA Executive Committee. In April 2018, a revision to these guidelines, deleting some recommendations, was published online by the AHA. The writing group was asked review the original document and revise if appropriate. In June 2018, the writing group submitted a document with minor changes and with inclusion of important newly published randomized controlled trials with >100 participants and clinical outcomes at least 90 days after AIS. The document was sent to 14 peer reviewers. The writing group evaluated the peer reviewers’ comments and revised when appropriate. The current final document was approved by all members of the writing group except when relationships with industry precluded members from voting and by the governing bodies of the AHA. These guidelines use the American College of Cardiology/AHA 2015 Class of Recommendations and Level of Evidence and the new AHA guidelines format. Results— These guidelines detail prehospital care, urgent and emergency evaluation and treatment with intravenous and intra-arterial therapies, and in-hospital management, including secondary prevention measures that are appropriately instituted within the first 2 weeks. The guidelines support the overarching concept of stroke systems of care in both the prehospital and hospital settings. Conclusions— These guidelines provide general recommendations based on the currently available evidence to guide clinicians caring for adult patients with acute arterial ischemic stroke. In many instances, however, only limited data exist demonstrating the urgent need for continued research on treatment of acute ischemic stroke.

Background and Purpose-The purpose of these guidelines is to provide an up-to-date comprehensive set of recommendations for clinicians caring for adult patients with acute arterial ischemic stroke in a single document. The intended audiences are prehospital care providers, physicians, allied health professionals, and hospital administrators. These guidelines supersede the 2013 guidelines and subsequent updates. Methods-Members of the writing group were appointed by the American Heart Association Stroke Council's Scientific Statements Oversight Committee, representing various areas of medical expertise. Strict adherence to the American Heart Association conflict of interest policy was maintained. Members were not allowed to participate in discussions or to vote on topics relevant to their relations with industry. The members of the writing group unanimously approved all recommendations except when relations with industry precluded members voting. Prerelease review of the draft guideline was performed by 4 expert peer reviewers and by the members of the Stroke Council's Scientific Statements Oversight The American Heart Association makes every effort to avoid any actual or potential conflicts of interest that may arise as a result of an outside relationship or a personal, professional, or business interest of a member of the writing panel. Specifically, all members of the writing group are required to complete and submit a Disclosure Questionnaire showing all such relationships that might be perceived as real or potential conflicts of interest. Guidelines for the Early Management of PatientsThis guideline was approved by the American Heart Association Science Advisory and Coordinating Committee on November 29, 2017, and the American Heart Association Executive Committee on December 11, 2017. A copy of the document is available at http://professional.heart.org/statements by using either "Search for Guidelines & Statements" or the "Browse by Topic" area. To purchase additional reprints, call 843-216-2533 or e-mail kelle.ramsay@ wolterskluwer.com. Tables) is available The American Heart Association requests that this document be cited as follows: Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K, Biller J, Brown M, Demaerschalk BM, Hoh B, Jauch EC, Kidwell CS, Leslie-Mazwi TM, Ovbiagele B, Scott PA, Sheth KN, Southerland AM, Summers DV, Tirschwell DL; on behalf of the American Heart Association Stroke Council. 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:eXXXeXXX. doi: 10.1161/STR.0000000000000158. Data Supplement 1 (EvidenceThe expert peer review of AHA-commissioned documents (eg, scientific statements, clinical practice guidelines, systematic reviews) is conducted by the AHA Office of Science Operations. For more on AHA statements and guidelines development, visit http://professional.heart.org/statements. Select the "Guidelines & Statem...

Emergency medical services (EMS) use by stroke patients by calling 911 has been independently associated with earlier emergency department (ED) arrival (onset-to-door time #3 hours), quicker ED evaluation (more patients with door-to-imaging time #25 minutes), and more eligible patients being treated with IV alteplase. However, only w60% of all stroke patients use EMS and is less likely used by men, blacks, and Hispanics. Although EMS prenotification was associated with increased likelihood of alteplase treatment within 3 hours, EDs were notified by EMS in only 67% of transported patients. There is no clear benefit of bypassing the closest IV alteplase-capable hospital to bring the patient to one that offers a higher level of stroke care, including mechanical thrombectomy. In most cases, noncontrast computed tomography to rule out acute intracranial hemorrhage will provide the necessary information to make decisions regarding acute management. Brain imaging studies should be performed within 20 minutes of arrival in the ED in at least 50% of patients who may be candidates for IV alteplase and/or mechanical thrombectomy. Computed tomography angiography is indicated in patients with suspected intracranial large vessel occlusion before obtaining a serum creatinine concentration in patients without a history of renal impairment and treatment with IV alteplase should not be delayed. IV alteplase treatment should not be delayed while waiting for hematologic or coagulation testing if there is no reason to suspect an abnormal test. The only blood test that must be checked before alteplase is serum glucose to be sure high or low levels are not causing symptoms and because hyperglycemia is associated with worse outcomes. IV alteplase (0.9 mg/kg, maximum dose 90 mg over 60 minutes with initial 10% of dose given as bolus over 1 minute) is recommended for selected patients who may be treated within 3 hours of ischemic stroke symptom onset. The benefit is well established for patients with disabling stroke symptoms regardless of age (even >80 years old) and stroke severity. It is generally but not necessarily contraindicated in patients who had major surgery within 14 days. Mechanical thrombectomy with stent retrievers performed via arterial groin punctures should be considered, along with intra-arterial thrombolysis, within 5 to 6 hours of onset of symptoms in patients with causative occlusion of the carotid and intracranial thrombosis. Urgent anticoagulation is not recommended for treatment of patients with acute ischemic stroke. When revascularization is indicated for secondary prevention in patients with minor, nondisabling stroke (mRS score 0-2), it is reasonable to perform carotid endarterectomy or carotid artery stenting between 48 hours and 7 days of the index event rather than delay treatment if there are no contraindications to early revascularization.Conclusion: IV alteplase should be administered within 3 hours of acute ischemic stroke in appropriate patients. Commentary: For those intrepid vascular surgeons who wan...

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