Guidelines for the early management of patients with ischemic stroke: A scientific statement from the Stroke Council of the American Stroke Association.

In 1994, a panel appointed by the Stroke Council of the American Heart Association authored guidelines for the management of patients with acute ischemic stroke.1 After the approval of the use of intravenous recombinant tissue plasminogen activator (rtPA) for treatment of acute ischemic stroke by the Food and Drug Administration, the guidelines were supplemented by a series of recommendations 2 years later.2 Several promising interventions for the treatment of acute ischemic stroke have subsequently been tested in clinical trials, and other components of acute management have been evaluated since the previous guidelines were published. These new data have prompted the present revision of the prior guideline statement. The goal of these guidelines is to provide updated recommendations that can be used by primary care physicians, emergency medicine physicians, neurologists, and other physicians who provide acute stroke care from admission to an emergency department through the first 24 to 48 hours of hospitalization by addressing the diagnosis and emergent treatment of the acute ischemic stroke in addition to the management of its acute and subacute neurological and medical complications. Several groups have now written statements about management of stroke.3–7 These statements also include recommendations about public educational programs, the organization of stroke resources, and other aspects of patient management. For example, the Brain Attack Coalition published recommendations for organizing stroke services in a community, and the recommendations of the American Heart Association Emergency Cardiovascular Care Committee provide an outline for emergency medical services.6 The current panel elected not to duplicate these recent efforts. Therapies to prevent recurrent stroke, also a component of acute management, are similar to prophylactic medical or surgical therapies used for patients with transient ischemic attacks and other high-risk patients. The reader is referred to relevant recent statements for additional information.8,9 In developing the present guidelines, the panel applied the Rules of Evidence10 and formulation of strength of recommendations used by other American Heart Association (AHA) guidelines panels (Table 1). If the panel concluded that the data support or do not support the use of a particular intervention, appropriate recommendations to use or to not use a specific therapy were made. If data were not definitive, the panel made no specific recommendation. In some cases, supporting evidence based on clinical research is not available for a specific intervention, but nonetheless represents current customary practice. In such circumstances, the panel has provided a recommendation but indicated that the recommendation was based on customary practice. In addition, for assessing the status of brain imaging tests, the panel used the rules of evidence adapted from the quality of evidence ratings for diagnostic tests developed by the American Academy of Neurology Therapeutics and Technology Subcommittee (Table 2).11