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Acute ischemic stroke

AIS is a rapid onset of cerebral function disturbance lasting > 24 hours or leading to death that is caused by occlusion of blood vessels limiting blood supply to the brain.
AIS is caused due to cardioembolism (AF, VHD), arteroembolism (atherosclerotic disease in the extracranial cervical carotid or vertebral artery), lacunar (microatheroma with plaque rupture and microembolism), and embolic stroke of undetermined source. Less common causes include arterial dissection, vasculitis, vasospasm, and hypercoagulable states.
Disease course
The blockage of blood vessels limiting blood supply to a part of brain results in AIS, which causes clinical manifestations of sudden facial droop, arm weakness, slurred speech, dizziness, and visual disturbance. Disease progression may lead to cerebral infarction, paralysis, coma and death.
Prognosis and risk of recurrence
All-cause mortality associated with AIS is 3-fold compared with the age-matched cohort.
Key sources
The following summarized guidelines for the evaluation and management of acute ischemic stroke are prepared by our editorial team based on guidelines from the European Stroke Organisation (ESO 2023; 2022; 2021; 2017; 2016; 2015), the European Society of Hypertension (ESH 2023), the Canadian Cardiovascular Society (CCS/CAIC 2023), the American Diabetes Association (ADA 2023), the U.S. Preventive Services Task Force (USPSTF 2022), the American Heart Association (AHA/ASA 2021; 2019; 2018; 2014), the European Stroke Organisation (ESO/ESSD 2021), the United States Department of Defense (DoD/VA 2019), the European Thyroid Association (ETA 2018), the American College of Preventive Medicine (ACPM/PCNA/ABC/ASPC/ASH/AAPA/AGS/AHA/NMA/ACC/APhA 2018), the American College of Emergency Physicians (ACEP 2015), and the American Heart Association (AHA 2011).


1.Screening and diagnosis

Screening for intracranial atherosclerotic disease: insufficient evidence to recommend routine screening for asymptomatic intracranial atherosclerotic disease in adult stroke-free individuals.
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2.Classification and risk stratification

Severity assessment: assess patients with AIS using a stroke severity rating scale, preferably the NIHSS.

3.Diagnostic investigations

General principles: obtain diagnostic evaluation for gaining insights into the etiology and planning optimal strategies for preventing recurrent stroke, completed or underway within 48 hours of the onset of stroke symptoms, in patients with ischemic stroke or TIA.

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  • Brain CT/MRI (for acute evaluation)

  • Brain CT/MRI (for secondary prevention)

  • CTA/MRA (for acute evaluation)

  • CTA/magnetic resonance angiograph (for acute evaluation)

  • CTA/magnetic resonance angiograph (for secondary prevention)

  • Carotid and vertebral artery imaging

  • Cardiac imaging

  • Laboratory tests

  • ECG

  • Cardiac monitoring

  • Chest radiography

  • Screening for thrombophilic states

  • Screening for dyslipidemia

  • Screening for diabetes mellitus

  • Screening for obstructive sleep apnea

  • Screening for central hypothyroidism

4.Respiratory support

Airway support: provide airway support and ventilatory assistance for the treatment of patients with acute stroke having decreased consciousness or having bulbar dysfunction causing compromise of the airway.

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  • Supplemental oxygen

  • Hyperbaric oxygen therapy

5.Medical management

Prehospital care: as per AHA 2019 guidelines, ensure the use of a stroke assessment tool by first aid providers including emergency medical services dispatch personnel.
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  • Intravenous alteplase (timing)

  • Intravenous alteplase (pre-administration evaluation)

  • Intravenous alteplase (concomitant thrombectomy)

  • Intravenous alteplase (bleeding risk)

  • Intravenous alteplase (complications)

  • Intravenous alteplase (post-administration care)

  • Intravenous tenecteplase

  • Antiplatelet therapy

  • Anticoagulant therapy

  • Management of BP (acute treatment, indications and BP targets)

  • Management of BP (acute treatment, induced hypertension)

  • Management of BP (secondary prevention)

  • Management of glucose levels

  • Management of temperature

  • Management of cerebral edema (general principles)

  • Management of cerebral edema (medical management)

  • Management of cerebral edema (surgical management, supratentorial infarction)

  • Management of cerebral edema (surgical management, cerebellar infarction)

  • Management of seizures

  • Management of dyslipidemia

  • Therapies with no evidence for benefit

  • Palliative care

6.Inpatient care

Thromboprophylaxis, intermittent pneumatic compression, ASA/AHA: offer intermittent pneumatic compression, if not contraindicated, in addition to routine care (aspirin and hydration) to reduce the risk of DVT in immobile patients with stroke.

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  • Thromboprophylaxis (anticoagulation)

  • Thromboprophylaxis (compression stockings)

  • Antibiotic prophylaxis

  • Pressure ulcer prophylaxis

  • Nutritional support

  • Indwelling bladder catheters

7.Nonpharmacologic interventions

Dietary modifications
Consider advising to follow a Mediterranean-type diet, typically with an emphasis on monounsaturated fat, plant-based foods, and fish consumption, with either high extra virgin olive oil or nut supplementation, in preference to a low-fat diet, to reduce the risk of recurrent stroke in patients with stroke and TIA.
Consider advising to reduce the sodium intake by at least 1 g/day sodium (2.5 g/day salt) to reduce the risk of CVD events, including stroke, in patients with stroke or TIA and hypertension.

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  • Physical activity

  • Weight loss

  • Smoking cessation

  • Alcohol consumption

  • Substance use cessation

  • Head positioning

8.Therapeutic procedures

Indications for thrombectomy, 0-6 hours from onset: perform mechanical thrombectomy with a stent retriever in patients meeting all the following criteria:
age ≥ 18 years
pre-stroke mRS score 0-1
causative occlusion of the internal carotid artery or middle cerebral artery segment 1 (M1)
NIHSS score ≥ 6
treatment can be initiated (groin puncture) within 6 hours of symptom onset
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  • Indications for thrombectomy (6-24 hours from onset)

  • Technical considerations for thrombectomy

  • Intracranial angioplasty/stenting

  • Carotid artery revascularization

  • Vertebral artery revascularization

  • Ischemic preconditioning

  • Intra-arterial thrombolysis

  • Laser therapy

  • Ultrasound-enhanced systemic thrombolysis

9.Surgical interventions

Decompressive craniectomy, supratentorial infarction
Consider performing decompressive craniectomy in patients with supratentorial infarction and decreased level of consciousness attributed to brain swelling.
Consider performing decompressive craniectomy with dural expansion in patients, either aged ≤ 60 years
or > 60 years, deteriorating neurologically within 48 hours from brain swelling associated with unilateral middle cerebral artery infarction despite medical therapy.

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  • Decompressive craniectomy (cerebellar infarction)

  • Extracranial-intracranial bypass surgery

10.Specific circumstances

Female patients, lifestyle modifications
Advise a healthy lifestyle consisting of the following for primary stroke prevention in patients with cardiovascular risk factors:
regular physical activity
moderate alcohol consumption (< 1 drink/day for nonpregnant females)
abstention from cigarette smoking
diet rich in fruits, vegetables, grains, nuts, and olive oil, and low in saturated fat (such as the DASH diet)
Advise lifestyle interventions focusing on diet and exercise for primary stroke prevention in individuals at high risk for stroke.

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  • Female patients (use of oral contraceptives)

  • Female patients (use of postmenopausal hormone therapy)

  • Female patients (secondary prevention)

  • Female patients (patients with migraine with aura)

  • Female patients (patients with AF)

  • Female patients (patients with cerebral venous thrombosis, nonpregnant)

  • Female patients (patients with cerebral venous thrombosis, pregnant)

  • Female patients (stroke during menstruation)

  • Pregnant patients (IV alteplase)

  • Pregnant patients (mechanical thrombectomy)

  • Pregnant patients (anticoagulation therapy)

  • Pregnant patients (prevention of preeclampsia)

  • Pregnant patients (lipid-lowering therapy)

  • Postpartum patients

  • Patients with diabetes mellitus

  • Patients with renal disease

  • Patients with recent traumatic injury

  • Patients with a history of recent surgery

  • Patients with a history of recent ischemic stroke

  • Patients with hyperdense MCA sign

  • Patients with severe hypoattenuation lesions

  • Patients with embolic stroke of undetermined source

  • Patients with hemorrhagic transformation

  • Patients with procedural stroke

  • Patients with drug-associated ischemic stroke

  • Patients with cerebral venous sinus thrombosis

  • Patients with neurological deficits

  • Patients with disability or impairment

  • Patients with inherited thrombophilias

  • Patients with antiphospholipid syndrome

  • Patients with hyperhomocysteinemia

  • Patients with malignancy

  • Patients with sickle cell disease (management)

  • Patients with sickle cell disease (secondary prevention)

  • Patients with autoimmune vasculitis

  • Patients with infectious vasculitis

  • Patients with Fabry disease

  • Patients with carotid artery stenosis

  • Patients with vertebral artery stenosis

  • Patients with carotid or vertebral artery dissection

  • Patients with intracranial artery dissection

  • Patients with aortic arch atherosclerosis

  • Patients with aortic arch dissection

  • Patients with intracranial aneurysms

  • Patients with intracranial neoplasms

  • Patients with Moyamoya disease

  • Patients with small vessel disease

  • Patients with carotid web

  • Patients with FMD

  • Patients with vertebrobasilar dolichoectasia

  • Patients with AF (anticoagulation therapy)

  • Patients with AF (LAA closure)

  • Patients with patent foramen ovale

  • Patients with VHD (antithrombotic therapy)

  • Patients with VHD (valvular surgery)

  • Patients with myocardial infarction

  • Patients with intracardiac thrombi

  • Patients with congenital heart disease

  • Patients with cardiomyopathy

  • Patients with cardiac tumors

  • Patients with infective endocarditis

  • Patients with acute pericarditis

11.Preventative measures

Primary prevention, statin therapy: initiate statins for primary prevention of CVDs in 40-75 years old adults with ≥ 1 CVD risk factors (dyslipidemia, diabetes, hypertension, or smoking) and an estimated 10-year CVD risk ≥ 10%.
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  • Primary prevention (antiplatelet therapy)

  • Secondary prevention (antiplatelet therapy)

  • Secondary prevention (health system-based interventions)

  • Secondary prevention (behavioral changes)

12.Follow-up and surveillance

Rehabilitation, approach and timing, ASA/AHA: provide early rehabilitation in patients hospitalized for stroke in environments with organized, interprofessional stroke care.
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  • Rehabilitation (motor therapy)

  • Rehabilitation (evaluation for dysphagia)

  • Rehabilitation (dysphagia therapy, nutritional support)

  • Rehabilitation (dysphagia therapy, exercises)

  • Rehabilitation (dysphagia therapy, oral hygiene)

  • Rehabilitation (dysphagia therapy, pharmacotherapy)

  • Rehabilitation (dysphagia therapy, electrical stimulation)

  • Rehabilitation (dysphagia therapy, acupuncture)

  • Rehabilitation (cognitive, speech, and sensory therapy)

  • Rehabilitation (depression and anxiety)

  • Rehabilitation (return to work)

13.Quality improvement

Emergency medical services
Develop regional systems of stroke care consisting of healthcare facilities providing initial emergency care, including administration of IV alteplase, and centers capable of performing endovascular stroke treatment with comprehensive periprocedural care to which rapid transport can be arranged when appropriate.
Develop triage paradigms and protocols to ensure that patients with a known or suspected stroke are rapidly identified and assessed by use of a validated and standardized tool for stroke screening by emergency medical services leaders, in coordination with local, regional, and state agencies and in consultation with medical authorities and local experts.

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  • Stroke centers/units

  • Organization of care

  • Telemedicine

  • Outcome measures

  • Public health measures

  • Health equity