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Heparin drip6/21/2023 No perfusion imaging (CT-P or MR-P) is required in these patients. Patients ≥18 years should undergo mechanical thrombectomy with a stent retriever if they have minimal prestroke disability, have a causative occlusion of the internal carotid artery or proximal middle cerebral artery, have a National Institutes of Health stroke scale score of ≥6, have a reassuring noncontrast head CT (ASPECT score of ≥6), and if they can be treated within 6 hours of last known normal. For patients who may be candidates for mechanical thrombectomy, an urgent CT angiogram or magnetic resonance (MR) angiogram (to look for large vessel occlusion) is recommended, but this study should not delay treatment with IV tPA if indicated.Centers should attempt to obtain a noncontrast head CT within 20 minutes of arrival in ≥50% of stroke patients who may be candidates for IV tPA or mechanical thrombectomy. An international normalized ratio, partial thromboplastin time, and platelet count do not need to have resulted prior to IV tPA initiation if there is no suspicion for underlying coagulopathy. Prior to initiation of IV tPA in most patients, a noncontrast head computed tomography (CT) and glucose are the only required tests.Centers should attempt to achieve door-to-needle times of <60 minutes in ≥50% of stroke patients treated with IV tPA. IV tPA should be administered to all eligible acute stroke patients within 3 hours of last known normal and to a more selective group of eligible acute stroke patients (based on ECASS III exclusion criteria) within 4.5 hours of last known normal.The benefits of intravenous (IV) tissue plasminogen activator (tPA) are time-dependent, and treatment for eligible patients should be initiated as quickly as possible (even for patients who may also be candidates for mechanical thrombectomy). In addition, in the last 3 months, two trials (DAWN and DEFUSE 3) showed a clear benefit of “extended window” mechanical thrombectomy for certain patients with large vessel occlusion who could be treated out to 16-24 hours. These 2018 guidelines are an update to the 2013 guidelines, which were published prior to the six positive “early window” mechanical thrombectomy trials (MR CLEAN, ESCAPE, EXTEND-IA, REVASCAT, SWIFT PRIME, THRACE) that emerged in 20.The following are key points to remember from the American Heart Association (AHA)/American Stroke Association (ASA) 2018 Guidelines for the Early Management of Patients With Acute Ischemic Stroke: The following Key Points to Remember are not impacted by these changes. Editor’s Note: The American Heart Association and the American Stroke Association released several clarifications, updates, and/or modifications to the 2018 Guidelines for the Early Management of Patients With Acute Ischemic Stroke on April 18, 2018.
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