2018 Guidelines for the Early Management of Patients

Question 1

Brain Imaging

Answer 1

Systems should be established so that brain imaging studies can 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.
I B-NR
New recommendation

Question 2

Only the assessment of blood glucose must precede the initiation of
IV alteplase in all patients.

Answer 2

IV alteplase
treatment should not be delayed while waiting for hematologic or coagulation testing if there is no reason to
suspect an abnormal test.

Question 3

Options to Treat Arterial Hypertension in Patients With AIS Who Are Candidates for Acute Reperfusion Therapy*

Answer 3

Labetalol 10–20 mg IV over 1–2 min, may repeat 1 time; or

Nicardipine 5 mg/h IV, titrate up by 2.5 mg/h every 5–15 min, maximum 15 mg/h; when desired BP reached, adjust to maintain proper BP limits; or

Clevidipine 1–2 mg/h IV, titrate by doubling the dose every 2–5 min until desired BP reached; maximum 21 mg/h
Other agents (eg, hydralazine, enalaprilat) may also be considered
If BP is not maintained ≤185/110 mm Hg, do not administer alteplase

Question 4

Management of BP during and after alteplase or other acute reperfusion therapy to maintain BP ≤180/105 mm Hg:

Answer 4

Monitor BP every 15 min for 2 h from the start of alteplase therapy, then every 30 min for 6 h, and then every hour for 16 h

Question 5

Blood Glucose

Answer 5

Evidence indicates that persistent in-hospital hyperglycemia during
the first 24 hours after AIS is associated with worse outcomes than
normoglycemia and thus, it is reasonable to treat hyperglycemia to
achieve blood glucose levels in a range of 140 to 180 mg/dL and to
closely monitor to prevent hypoglycemia in patients with AIS.

Question 6

IV alteplase

Answer 6

(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 or patient last known well or at baseline state.

is also recommended
for selected patients who can be treated within 3 and 4.5 hours of
ischemic stroke symptom onset or patient last known well.

Question 7

IV alteplase & Heparin

Answer 7

IV alteplase should not be administered to patients who have
received a treatment dose of low-molecular-weight heparin (LMWH)
within the previous 24 hours