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Overview
Top Take-Home Messages
1. Mobile stroke units (MSU) enable rapid identification and treatment
of thrombolytic-eligible patients with acute ischemic stroke
(AIS). Recent studies have highlighted the benefit of MSUs over
conventional emergency medical services and, when available,
the guideline now includes recommendations related to the
implementation of MSUs, based on their safety and benefit.
2. Identification of appropriate transport destination for patients with
suspected stroke in the prehospital setting remains challenging.
Previous guidelines recommended transport to the nearest
thrombolytic-capable facility. Given recent evidence, this guideline
endorses consideration of the characteristics of the local system
of care and direct transport to the closest EVT-capable hospital in
the absence of well-functioning systems with rapid interhospital
transfer processes.
3. Intravenous thrombolysis (IVT) is a mainstay of medical
management for patients with AIS. Given numerous international
trials showing noninferiority and the potential advantages of
intravenous tenecteplase compared with alteplase, the new
guidelines endorse the use of either alteplase or tenecteplase in
the 4.5-hour thrombolytic treatment window. Furthermore, we
emphasize rapid thrombolytic treatment in eligible patients with
disabling deficits, regardless of National Institutes of Health Stroke
Scale (NIHSS) score, within the 4.5-hour window without advanced
imaging selection. In addition, the guidelines provide support for
extended window thrombolysis for select patients with stroke of
unknown onset or 4.5–9 hours from onset using advanced imaging
criteria (eg, diffusion weighted imaging-fluid attenuated recovery or
perfusion-based mismatch).
4. For patients with non-disabling (eg, isolated sensory syndrome)
deficits in the 4.5-hour window, trials have failed to demonstrate
benefit of thrombolysis. Dual antiplatelet therapy is preferred and
recommended in this population.
5. New studies have examined the role of adjuvant antithrombotic
therapy, such as argatroban and eptifibatide, concurrently with
IVT. These studies have shown no benefit and, therefore, adjuvant
antithrombotic drugs are not recommended to enhance the
outcomes from thrombolytic therapy.
