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Î Initial treatment with IA fibrinolysis is beneficial for carefully selected
patients with major ischemic strokes of <6 hours' duration caused
by occlusions of the MCA (I-B-R). However, these data derive from
clinical trials that no longer reflect current practice, including use of
fibrinolytic drugs that are not available. A clinically beneficial dose of
IA rtPA is not established, and rtPA does not have FDA approval for IA
use. As a consequence, endovascular therapy with stent retrievers is
recommended over IA fibrinolysis as first-line therapy (I-E).
(Revised from 2013 guideline)
Î IA fibrinolysis initiated within 6 hours of stroke onset in carefully
selected patients who have contraindications to the use of IV rtPA
might be considered, but the consequences are unknown (IIb-C).
(Revised from 2013 guideline)
Î It might be reasonable to favor conscious sedation over general
anesthesia during endovascular therapy for acute ischemic
stroke. However, the ultimate selection of anesthetic technique
during endovascular therapy for acute ischemic stroke should
be individualized based on patient risk factors, tolerance of the
procedure, and other clinical characteristics. Randomized trial data
are needed (IIb-C). (New recommendation from 2013 guideline)
Anticoagulants
Î At present, the usefulness of argatroban or other thrombin inhibitors
for treatment of patients with acute ischemic stroke is not well
established (IIb-B).
Note: These agents should be used in the setting of clinical trials.
Î The usefulness of urgent anticoagulation in patients with severe
stenosis of an internal carotid artery ipsilateral to an ischemic stroke
is not well established (IIb-B).
Î Urgent anticoagulation, with the goal of preventing early recurrent
stroke, halting neurological worsening, or improving outcomes after
acute ischemic stroke, is NOT recommended for treatment of patients
with acute ischemic stroke (III-A).
Î Urgent anticoagulation for the management of noncerebrovascular
conditions is NOT recommended for patients with moderate-to-
severe strokes because of an increased risk of serious intracranial
hemorrhagic complications (III-A).
Î Initiation of anticoagulant therapy within 24 hours of treatment with
IV rtPA is NOT recommended (III-B).
