Top Things to Know: 2019 Update to the 2018 Guidelines for the Early Management of Acute Ischemic Stroke

Published: October 30, 2019

  1. Each year, about 795,000 persons experience stroke; about 690,000 are new acute ischemic strokes (AIS) and about 140,000 deaths can be attributed to stroke per year.
  2. This guideline updates the 2018 AIS guideline with content based on recent clinical trials and clarifies previous recommendations.
  3. The guideline is a comprehensive one, addressing AIS management from acute symptoms onset in the prehospital phase through two weeks post-acute stroke.
  4. Prehospital procedures need to be developed to identify and rapidly triage and transport IV fibrinolytic ineligible patients with a high likelihood of large vessel occlusion and potentially eligible for thrombectomy to the nearest healthcare facility that can perform these procedures.
  5. Stroke systems of care should be developed to assure that fibrinolytic eligible patients and mechanical thrombectomy eligible patients receive treatment as fast as possible.
  6. Dysphagia screening is effective in discovering patients at potentially high risk of aspiration.
  7. Intravenous (IV) aspirin should not be given within 90 minutes after the start of IV alteplase.
  8. Patients with non-cardioembolic ischemic stroke, treatment with triple antiplatelet therapy (aspirin, clopidogrel and dipyridamole) for secondary prevention should not be administered.
  9. Standard IV alteplase dosing (0.9mg/kg over an hour, with a 10% bolus over one minute) can be beneficial in patients who wake-up (within 4.5 hours) with AIS symptoms, or in patients who have an unclear time of onset of (>4.5 hours) of stroke symptoms from last known well time and who have a DWI lesion smaller than one-third of the middle cerebral artery (MCA) territory and no visible signal change on fluid-attenuated inversion recovery (FLAIR)imaging.
  10. Tenecteplase (TNK) may be considered instead of IV alteplase for patients who are eligible to undergo mechanical thrombectomy.
  11. Smoking recommendations with a high level of evidence are discussed in this guideline. High intensity interventions target smoking cessation and nicotine replacement.
  12. Comprehensive recommendations from the 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Cholesterol Guidelines are included in this guideline for management of hyperlipidemia in stroke patients.
  13. This guideline includes comprehensive recommendations on brain imaging for both acute imaging and in-hospital evaluation.
  14. Effective treatment for AIS must be instituted urgently and measures to prevent recurrent stroke should be started as soon as possible while in hospital.


Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K, Biller J, Brown M, Demaerschalk BM, Hoh B, Jauch EC, Kidwell CS, Leslie-Mazwi TM, Ovbiagele B, Scott PA, Sheth KN, Southerland AM, Summers DV, Tirschwell DL; on behalf of the American Heart Association Stroke Council. 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 [published online ahead of print October 30, 2019]. Stroke. doi: 10.1161/STR.0000000000000211.