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ischemic%20stroke
ISCHEMIC STROKE
Ischemic stroke occurs when a blood vessel supplying the brain is obstructed.
Consider stroke in any patient presenting with sudden focal neurological deficit or any alteration in level of consciousness.
Rapid evaluation is essential for sure of time-sensitive treatments.
Determine if patient's symptoms are due to stroke and exclude stroke mimics (eg migraine, hypertensive encephalopathy, hypoglycemia, seizures or post-ictal paresis); identify other conditions requiring immediate intervention and determine the potential causes of stroke.

Ischemic Stroke References

  1. Jellinger PS, Smith DA, Mehta AE, et al; AACE Task Force for Management of Dyslipidemia and Prevention of Atherosclerosis. American Association of Clinical Endocrinologists' guidelines for management of dyslipidemia and prevention of atherosclerosis. Endocr Pract. 2012 Mar;18(Suppl 1):1-78. https://www.ncbi.nlm.nih.gov. Accessed 4 Sep 2013. PMID: 22522068
  2. Adams HP, del Zoppo G, Alberts MJ, et al. Guidelines for the early management of adults with ischemic stroke. A guideline from the American Heart Association/American Stroke Association Stroke Council, Clinical Cardiology Council, Cardiovascular Radiology and Intervention Council, and the Atherosclerotic Peripheral Vascular Disease and Quality of Care Outcomes in Research Interdisciplinary Working Groups. Stroke. 2007 May;38(5):1655-1711. http://stroke.ahajournals.org. Accessed 16 May 2011. PMID: 17431204
  3. Adams HP. Secondary prevention of atherothrombotic events after ischemic stroke. Mayo Clin Proc. 2009;84(1):43-51. doi: 10.1016/S0025-6196(11)60807-0. PMID: 19121254
  4. Adams RJ, Albers G, et al. Update to the AHA/ASA Recommendations for the prevention of stroke in patients with stroke and transient ischemic attack. Stroke. 2008 May;39(5):1647-1652. PMID: 18322260
  5. Alberts MJ, Ovbiagele B. Current strategies for ischemic stroke prevention: role of multimodal combination therapies. J Neurol. 2007 Oct;254(10):1414-1426. PMID: 17934879
  6. Albers GW, Amarenco P, Easton JD, et al. Antithrombotic and thrombolytic therapy for ischemic stroke: American College of Chest Physicians evidence-based clinical practice guidelines (8th Edition). Chest. 2008 Jun;133(Suppl 6):630S-669S. PMID: 18574275
  7. Andre C, Bacellar AL, Bezerra DD, et al; Executive committee from the Brazilian Stroke Society and the Scientific Department in Cerebrovascular Diseases of the Brazilian Academy of Neurology. Guidelines for acute ischemic stroke treatment: part II: stroke treatment. Arq Neuropsiquiatr. 2012 Nov;70(11):885-893. PMID: 23175203
  8. Alexandrov AV, Wojner AW, Grotta JC. CLOTBUST: design of a randomized trial of ultrasound-enhanced thrombolysis for acute ischemic stroke [abstract]. J Neuroimaging. 2004 Apr;14(2):108-112. PMID: 15095554
  9. Antithrombotic Trialists' Collaboration. Collaborative meta-analysis of randomised trials of antiplatelet therapy for prevention of death, myocardial infarction, and stroke in high risk patients. BMJ. 2002 Jan;324(7329):71-86. PMID: 11786451
  10. Biller J. Antiplatelet therapy in ischemic stroke: variability in clinical trials and its impact on choosing the appropriate therapy. J Neurol Sci. 2009 Sep;284:1-9. PMID: 19380153
  11. Connolly SJ, Ezekowitz MD, Yusuf S, et al. Dabigatran versus warfarin in patients with atrial fibrillation. N Engl J Med. 2009 Sep;361(12):1139-1151. PMID: 19717844
  12. Camm AJ, Lip GY, De Caterina R, et al; ESC Committee for Practice Guidelines (CPG). 2012 focused update of the ESC Guidelines for the management of atrial fibrillation: an update of the 2010 ESC Guidelines for the management of atrial fibrillation. Developed with the special contribution of the European Heart Rhythm Association. Eur Heart J. 2012;33(21):2719-2747. http://www.escardio.org. Accessed 15 Jun 2016. PMID: 22922413
  13. Coull BM, Williams LS, Goldstein LB, et al. Anticoagulants and antiplatelet agents in acute ischemic stroke: report of the Joint Stroke Guideline Development Committee of the American Academy of Neurology and the American Stroke Association (a division of the American Heart Association). Stroke. 2002 Jul;33(7):1934-1942. PMID: 12105379
  14. Del Zoppo GJ, Saver JL, Jauch EC, et al. Expansion of the time window for treatment of acute ischemic stroke with intravenous tissue plasminogen activator: a science advisory from the American Heart Association/American Stroke Association. Stroke. 2009 Aug;40(8):2945-2948. PMID: 19478221
  15. Furie KL, Goldstein LB, Albers GW, et al; American Heart Association Stroke Council; Council on Quality of Care and Outcomes Research; Council on Cardiovascular Nursing; Council on Clinical Cardiology; Council on Peripheral Vascular Disease. Oral antithrombotic agents for the prevention of stroke in nonvalvular atrial fibrillation: a science advisory for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2012 Dec;43(12):3442-3453. http://stroke.ahajournals.org/content/43/12/3442. Accessed 19 Nov 2012. PMID: 22858728
  16. Furie KL, Kasner SE, Adams RJ, et al. Guidelines for the prevention of stroke in patients with stroke or transient ischemic attack. A guideline for healthcare professionals from the American Heart Association/American Stroke Association. May 16, 2011. Stroke. 2011;42:227-276. http://stroke.ahajournals.org. Accessed 16 May 2011
  17. Huang Y, Cheng Y, Wu J, et al. Cilostazol as an alternative to aspirin after ischaemic stroke: a randomised, double-blind, pilot study. Lancet Neurol. 2008 Jun;7(6):494-499. doi: 10.1016/S1474-4422(08)70094-2. PMID: 18456558
  18. Guyatt GH, Akl EA, Crowther M, et al. Executive summary: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2012 Feb;141(Suppl 2):7S-47S. http://www.chestnet.org. Accessed 09 Mar 2012. PMID: 22315257
  19. Jauch EC, Saver JL, Adams HP Jr, et al; American Heart Association Stroke Council; Council on Cardiovascular Nursing; Council on Peripheral Vascular Disease; Council on Clinical Cardiology. 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. 2013 Mar;44(3):870-947. http://stroke.ahajournals.org. Accessed 24 Apr 2013. PMID: 23370205
  20. Jianu DC, Muresanu DF, Bajenaru O, et al. Cerebrolysin adjuvant treatment in Broca's aphasics following first acute ischemic stroke of the left middle cerebral artery. J Med Life. 2010 Jul;3(3):297-307. Accessed 29 Mar 2011. PMID: 20945821
  21. Ladurner G, Kalvach P, Moessler H. Neuroprotective treatment with cerebrolysin in patients with acute stroke: a randomised controlled trial. J Neural Transm. 2005 Mar;112(3):415-428. http://www.ncbi.nlm.nih.gov. Accessed 23 Mar 2011. PMID: 15583955
  22. Lindsay P, Bayley M, McDonald A, et al. Toward a more effective approach to stroke: Canadian Best Practice Recommendations for Stroke Care. CMAJ. 2008 May;178(1):1418-1425. PMID: 18490636
  23. Lee WH, Chu CY, Hsu PC, et al. Comparison of antiplatelet and antithrombotic therapy for secondary prevention of ischemic stroke in patients with peripheral artery disease: population-based follow-up study in Taiwan. Circ J. 2012;77(4):1046-1052. http://jstage.jst.go.jp. Accessed 18 Feb 2013. PMID: 23269006
  24. Maegdefessel L, Spin JM, Azuma J, et al. New options with dabigatran etexilate in anticoagulant therapy. Vasc Health Risk Manag. 2010 May;6:339-349. http://www.ncbi.nlm.nih.gov. Accessed 09 Mar 2012. PMID: 20531953
  25. Ng PW, Huang CY, et al. Consensus statement on ischaemic stroke care in Hong Kong. Hong Kong Med J. 2004 Apr;10(2):124-129. PMID: 15075433
  26. Paciaroni M, Bogousslavsky J. Primary and secondary prevention of ischemic stroke. Eur Neurol. 2010;63(5):267-278. doi: 10.1159/000285183. PMID: 20357456
  27. Sherman DG. Stroke prevention in atrial fibrillation: pharmacological rate versus rhythm control. Stroke. 2007 Feb;38(Suppl 2):615-617. http://stroke.ahajournals.org. PMID: 17261701
  28. Shulga O, Bornstein N. Antiplatelets in secondary stroke prevention. Feb 28, 2011. Front Neurol. 2011;2(36). http://www.ncbi.nlm.nih.gov. Accessed 19 Oct 2012. PMID: PMC3131527
  29. The American Heart Association. 2005 International Consensus on cardiopulmonary resuscitation (CPR) and emergency cardiovascular care (ECC) science with treatment recommendations. Part 9: stroke. Circulation. 2005;112:III-110-III-104
  30. Summers D, Leonard A, Wentworth D, et al. Comprehensive overview of nursing and interdisciplinary care of the acute ischemic stroke patient: a scientific statement from the American Heart Association. Stroke. 2009 Aug;40(8):2911-2944. PMID: 19478222
  31. Van der Worpp HB, van Gijn J. Acute ischemic stroke. N Engl J Med. 2007 Aug;357(6):572-579. PMID: 17687132
  32. Wann LS, Curtis AB, Ellenbogen KA, et al. 2011 ACCF/AHA/HRS focused update on the management of patients with atrial fibrillation (update on dabigatran): a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. J Am Coll Cardiol. 2011 Mar;57(11):1330-1337. doi: 10.1016/j.jacc.2011.01.010. PMID: 21324629
  33. Zhang C. Cerebrolysin enhances neurogenesis in the ischemic brain and improves functional outcome after stroke. J Neurosci Res. 2010 Nov;88(15):3275-3281. http://www.ncbi.nlm.nih.gov. Accessed 23 Mar 2011. PMID: 20857512
  34. Yew KS, Cheng E. Acute stroke diagnosis. Am Fam Physician. 2009 Jul;80(1):33-40. PMID: 19621844
  35. Biller J, Schneck M. Vascular diseases of the nervous system: ischemic cerebrovascular disease. In: Bradley W, Daroff R, Fenichel G, et al. Bradley: Neurology I Clinical practice. 5th. Philadelphia: Butterworth Heinemann Elsevier; 2008. http://www.mdconsult.com
  36. The Stroke Society of the Philippines. Guidelines for the prevention, treatment and rehabilitation of stroke. 5th ed. Quezon City; 2010:10-111
  37. MedWormhttp://www.medworm.com/rss/index.php/Cardiology/7/http://www.medworm.com/rss/medicalfeeds/specialities/Cardiology.xml
  38. MedWormhttp://www.medworm.com/rss/index.php/Neurology/25/http://www.medworm.com/rss/medicalfeeds/specialities/Neurology.xml
  39. Katzan IL. Antiplatelets in secondary stroke prevention. Cleveland Clinic. http://www.clevelandclinicmeded.com. Jan 2009. Accessed 19 Nov 2012.
  40. Cucchiarra BL, Messe SR. Antiplatelet therapy for secondary prevention of stroke. UpToDate. http://www.uptodate.com. 26 Sep 2012. Accessed 19 Nov 2012.
  41. National Stroke Foundation. Clinical guidelines for stroke management 2010. http://strokefoundation.com.au. Sep 2010. Accessed 16 May 2011.
  42. Ministry of Health Singapore. Clinical practice guidelines. Stroke and transient ischaemic attacks: assessment, investigation, immediate management and secondary prevention. MOH (Singapore). http://www.moh.gov.sg. Jul 2009. Accessed 16 May 2011.
  43. Ministry of Health Malaysia. Clinical practice guidelines: management of stroke. http://www.acadmed.org.my. 2006.
  44. Anderson D, Larson D, Bluhm J, et al. Institute for Clinical Systems Improvement. Diagnosis and initial treatment of ischemic stroke. https://www.icsi.org. Jul 2012. Accessed 20 Feb 2013.
  45. National Institute for Health and Care Excellence. Dabigatran etexilate for the prevention of stroke and systemic embolism in atrial fibrillation. NICE. http://publications.nice.org.uk. 2012. Accessed 29 Mar 2012.
  46. European Stroke Organization. Guidelines for management of ischaemic stroke and transient ischaemic attack. http://www.eso-stroke.org. Mar 2008. Accessed 15 Dec 2009.
  47. Scottish Intercollegiate Guidelines Network. Management of patients with stroke: rehabilitation, prevention and management of complications, and discharge planning. SIGN. http://www.sign.ac.uk. Jun 2010. Accessed 26 May 2011.
  48. National Collaborating Centre for Chronic Conditions (UK). Stroke: Diagnosis and initial management of acute stroke and transient ischaemic attack (TIA). http://publications.nice.org.uk. 2008.
  49. Berglund L, Brunzell JD, Goldberg AC, et al. Evaluation and treatment of hypertriglyceridemia: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2012 Sep;97(9):2969-2989. doi: 10.1210/jc.2011-3213. Accessed 04 Sep 2013. PMID: 22962670
  50. Culebras A, Messé SR, Chaturvedi S, et al. Summary of evidence-based guideline update: prevention of stroke in nonvalvular atrial fibrillation: report of the Guideline Development Subcommittee of the American Academy of Neurology. Neurology. 2014 Feb;82(8):716-724. doi: 10.1212/WNL. 0000000000000145. Accessed 27 Mar 2014. PMID: 24566225
  51. Kernan WN, Ovbiagale B, Black HR, et al. Guidelines for the prevention of stroke in patients with stroke and transient ischemic attack: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2014 Jul;45(7):2160-2236. http://stroke.ahajournals.org. Accessed 23 Feb 2015. PMID: 24788967
  52. Powers WJ, Derdeyn CP, Biller J, et al. 2015 AHA/ASA focused updated of the 2013 guidelines for the early management of patients with acute ischemic stroke regarding endovascular treatment: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2015 Jun;Pii. doi: 10.1161/STR.0000000000000074. Accessed 11 Sep 2015. PMID: 26123479
  53. Wang Y, Wang Y, Zhao X, et al. Clopidogrel with aspirin in acute minor stroke or transient ischemic attack. N Eng J Med. 2013 Jul;369(1):11-19. doi: 10.1056/NEJMoa1215340. Accessed 22 Sep 2015. PMID: 23803136
  54. Lane DA, Lip GY. Use of the CHA2DS2-VASc and HAS-BLED scores to aid decision making for thromboprophylaxis in nonvalvular atrial fibrillation. Circulation. 2012 Aug;126(7):860-865. doi: 10.1161/CIRCULATIONAHA.111.060061. Accessed 22 Sep 2015. PMID: 22891166
  55. Heidbuchel H, Verhamme P, Alings M, et al. Updated European Heart Rhythm Association practical guide on the use of non-vitamin K antagonist anticoagulants in patients with non-valvular atrial fibrillation. Europace. 2015 Oct;17(10):1467-1507. doi: 10.1093/europace/euv309. PMID: 26324838
  56. Demaerschalk BM, Kleindorfer DO, Adeoye OM, et al; American Heart Association Stroke Council and Council on Epidemiology and Prevention. Scientific rationale for the inclusion and exclusion criteria for intravenous alteplase in acute ischemic stroke: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2016 Feb;47(2):581-641. doi: 10.1161/STR.0000000000000086. PMID: 26696642
  57. Dennis M, Caso V, Kappelle LJ, Pavlovic A, Sandercock P; for the European Stroke Organization. European Stroke Organization (ESO) guidelines for prophylaxis for venous thromboembolism in immobile patients with acute ischaemic stroke. European Stroke Journal. 2016;1(1):6-19. http://www.eso-stroke.org. Accessed 27 Jun 2016
  58. Meschia JF, Bushnell C, Boden-Albala B, et al; American Heart Association Stroke Council; Council on Cardiovascular and Stroke Nursing; Council on Clinical Cardiology; Council on Functional Genomics and Translational Biology; Council on Hypertension. Guidelines for the primary prevention of stroke: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2014 Dec;45(12):3754-3832. http://stroke.ahajournals.org. Accessed 27 Jun 2016. PMID: 25355838
  59. Winstein CJ, Stein J, Arena R, et al; American Heart Association Stroke Council, Council on Cardiovascular and Stroke Nursing, Council on Clinical Cardiology, and Council on Quality of Care and Outcomes Research. Guidelines for adult stroke rehabilitation and recovery: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2016 Jun;47(6):e98-e169. doi: 10.1161/STR.0000000000000098. PMID: 27145936
  60. Xu AD, Wang YJ, Wang DZ; Chinese Stroke Therapy Expert Panel for Intravenous Recombinant Tissue Plasminogen Activator. Consensus statement on the use of intravenous recombinant tissue plasminogen activator to treat acute ischemic stroke by the Chinese Stroke Therapy Expert Panel. CNS Neurosci Ther. 2013 Aug;19(8):543-548. doi: 10.1111/cns.12126. Accessed 27 Jun 2016. PMID: 23710819
  61. The Stroke Society of the Philippines. SSP handbook of stroke: guidelines for the prevention, treatment and rehabilitation of stroke. 6th ed. Quezon City, Philippines: The Stroke Society of the Philippines; 2014:11-121.
  62. Kirchhof P, Benussi S, Kotecha D, et al. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur Heart J. 2016 Oct;37(38):2893-2962. doi: 10.1093/eurheartj/ehw210. Accessed 27 Jan 2017. PMID: 27567408
  63. Smith EE, Saposnik G, Biessels GJ, et al; American Heart Association Stroke Council; Council on Cardiovascular Radiology and Intervention; Council on Functional Genomics and Translational Biology; and Council on Hypertension. Prevention of stroke in patients with silent cerebrovascular disease: a scientific statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2017 Feb;48(2):e44-e71. doi: 10.1161/STR.0000000000000116. PMID: 27980126
  64. Fugate JE, Rabinstein AA. Absolute and relative contraindications to IV rt-PA for acute ischemic stroke. Neurohospitalist. 2015 Jul;5(3):110-121. doi: 10.1177/1941874415578532. PMID: 26288669
  65. Minematsu K, Toyoda K, Hirano T, et al. Guidelines for the intravenous application of recombinant tissue-type plasminogen activator (alteplase), the second edition, October 2012:a guideline from the Japan Stroke Society. J Stroke Cerebrovasc Dis. 2013 Jul;22(5):571-600. doi: 10.1016/j.jstrokecerebrovasdis.2013.04.001. PMID: 23727456
  66. Pexman JH, Barber PA, Hill MD, et al. Use of the Alberta Stroke Program Early CT Score (ASPECTS) for assessing CT scans in patients with acute stroke. AJNR Am J Neuroradiol. 2001 Sep;22(8):1534-1542. http://www.ajnr.org. Accessed 5 May 2017. PMID: 11559501
  67. Saccor RL, Kasner SE, Broderick JP, et al. An updated definition of stroke for the 21st century: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2013 Jul;44(7):2064-2089. doi: 10.1161/STR.0b013e318296aeca. PMID: 23652265
  68. Crocco TJ, Meurer WJ. Stroke. In: Walls RM, Hockberger RS, Gausche-Hill M, eds. Rosen's Emergency Medicine: Concepts and Clinical Practice. 9th ed. Philadelphia, PA: Elsevier; 2018. :1241-1255.
  69. Lau G, Pendlebury S, Rothwell P. The clinical features and differential diagnosis of acute stroke. Transient Ischemic Attack and Stroke: Diagnosis, Investigation and Treatment. Cambridge: Cambridge University Press; 2018. Accessed 02 Oct 2018:139-158.
  70. Marks MP, Heit JJ, Lansberg MG, et al. Endovascular treatment in the DEFUSE 3 study. Stroke. 2018 Jul 9;49:2000-2003. doi: 10.1161/STROKEAHA.118.022147. PMID: 29986935
  71. Baerlocher MO, Asch M, Myers A. Five things to know about…metformin and intravenous contrast. CMAJ. 2013 Jan;185(1):E78. doi: 10.1503/cmaj.090550. PMID: 23048079
  72. Yee AH, Rabinstein AA. Neurologic presentations of acid-base imbalance, electrolyte abnormalities, and endocrine emergencies. Neurol Clin. 2010 Feb;28(1):1-16. doi: 10.1016/j.ncl.2009.09.002. PMID: 19932372
  73. Ortel TL. Chapter 42 - Antithrombotic therapy. In: McPherson RA, Pincus MR. Henry's Clinical Diagnosis and Management by Laboratory Methods. 23rd edition; 2017. http://dx.doi.org/10.1016/B978-0-323-29568-0.00042-5. :842-853.e2.
  74. Powers WJ, Rabinstein AA, Ackerson T, et al; 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 Mar;49(3):e46-e110. doi: 10.1161/STR.0000000000000158. PMID: 29367334
  75. Powers WJ, Rabinstein AA, Ackerson T, et al. Guidelines for the early management of patients with acute ischemic stroke: 2019 update to the 2018 guidelines for the early management of acute ischemic stroke: A guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2019 Dec;50(12):e344-e418. doi: 10.1161/STR.0000000000000211. PMID: 31662037
  76. Phipps MS, Cronin CA. Management of acute ischemic stroke. BMJ. 2020 Feb 13;368:l6983. doi: 10.1136/bmj.l6983. PMID: 32054610
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