Guidelines for Acute Ischemic Stroke Treatment
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Guidelines for Acute Ischemic Stroke Treatment Shuwei Qiu1 • Yun Xu1,2,3,4
Received: 2 February 2020 / Accepted: 18 March 2020 Ó Shanghai Institutes for Biological Sciences, CAS 2020
Acute ischemic stroke (AIS) is one of the serious diseases endangering human health worldwide; it usually leads to serious handicap with a high risk of recurrence and death. Despite the global burden of stroke, great advances are still being made. Since the publication of the 2013 guidelines for the early management of AIS patients, new high-quality evidence has resulted in prominent changes in the evidence-based treatment of AIS, such as image assessment, treatment beyond the time-window, new thrombolytic drugs, thrombolysis for strokes with an unknown onset time, and dual antiplatelet therapy for minor strokes. Especially in 2015, publication of the results of five clinical trials on mechanical thrombectomy contributed to the focused update of the 2013 guidelines for the early management of patients with AIS regarding endovascular treatment. Five years later, the publication of the DAWN and DEFUSE 3 results focusing on AIS beyond 6 h from onset demonstrated a significant benefit of mechanical thrombectomy for selected stroke patients 6 h–24 h from onset. Consequently, the American Heart Association/ American Stroke Association (AHA/ASA) issued new
& Yun Xu [email protected] 1
Department of Neurology, Drum Tower Hospital, Medical School and The State Key Laboratory of Pharmaceutical Biotechnology, Institute of Brain Science, Nanjing University, Nanjing 210008, China
2
Jiangsu Key Laboratory for Molecular Medicine, Medical School of Nanjing University, Nanjing 210008, China
3
Jiangsu Province Stroke Center for Diagnosis and Therapy, Nanjing 210008, China
4
Nanjing Medical Center for Neurology, Nanjing 210008, China
guidelines to supersede the 2013 guidelines in January 2018 [1], of which certain chapters were unfortunately deleted due to controversy. Here, we highlight some of the new recommendations and comment on imaging evaluation, intravenous (IV) thrombolysis, mechanical thrombectomy, and antiplatelet treatment from the AHA/ASA and the China 2018–2019 AIS guidelines [2, 3].
Precision Thrombolysis and Thrombectomy under Multimodal Imaging Guidance The benefit of IV alteplase is time-dependent, and earlier treatment within the therapeutic window leads to a greater benefit. Studies have shown that median or mean door-toimaging times of B20 min can be achieved in a variety of different hospital settings. As a result, the 2018 guidelines recommended that ‘‘brain imaging studies can be performed within 20 minutes of arrival in the emergency department (ED) in at least 50% of patients who may be candidates for IV alteplase and/or mechanical thrombectomy’’. However, the absence of detailed screening information in the DAWN and DEFUSE 3 trials limits estimation of the true impact of time on prognosis in the population beyond the 6-h time window, leading to the deletion of
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