Intra-arterial thrombolysis: perform mechanical thrombectomy with stent retrievers over intra- arterial fibrinolysis as first-line therapy. B Show 2 more Laser therapy: do not perform transcranial near-infrared laser therapy for the treatment of AIS. D Ultrasound-enhanced systemic thrombolysis: do not use sonothrombolysis as adjuvant therapy with IV fibrinolysis. D 9. Surgical interventions Decompressive craniectomy (supratentorial infarction): Consider performing decompressive craniectomy in patients with supratentorial infarction and decreased level of consciousness attributed to brain swelling. B Consider performing decompressive craniectomy with dural expansion in patients, either aged 60 years B or > 60 years, deteriorating neurologically within 48 hours from brain swelling associated with unilateral middle cerebral artery infarction despite medical therapy. C Decompressive craniectomy (cerebellar infarction): perform ventriculostomy for the treatment of obstructive hydrocephalus after cerebellar infarction. Consider performing concomitant or subsequent decompressive craniectomy based on factors such as the size of the infarction, https://web.pathway.md/diseases/recwd1RIpW03JSM4H 14/31 6/23/23, 1:57 AM Acute ischemic stroke Pathway neurological condition, degree of brainstem compression, and effectiveness of medical management. B Show 2 more Extracranial-intracranial bypass surgery: Do not perform extracranial-intracranial bypass surgery in patients with stroke or TIA attributable to 50-99% stenosis or occlusion of a major intracranial artery. D Do not perform extracranial-intracranial bypass surgery in patients with a recent (within 120 days) TIA or ischemic stroke ipsilateral to atherosclerotic stenosis or occlusion of the middle cerebral or carotid artery. D 10. Specific circumstances Female patients (lifestyle modifications): Advise a healthy lifestyle consisting of the following for primary stroke prevention in patients with cardiovascular risk factors: regular physical activity moderate alcohol consumption (< 1 drink/day for nonpregnant females) abstention from cigarette smoking diet rich in fruits, vegetables, grains, nuts, and olive oil, and low in saturated fat (such as the DASH diet). B Advise lifestyle interventions focusing on diet and exercise for primary stroke prevention in individuals at high risk for stroke. B Female patients (use of oral contraceptives): recognize that oral contraceptives may be harmful in patients with additional risk factors (such as cigarette smoking, history of thromboembolic events). B Show 3 more Female patients, use of postmenopausal hormone therapy: As per ESO 2022 guidelines, avoid using HRT to reduce the risk of ischemic stroke or mortality from acute stroke in postmenopausal females. D As per ASA/AHA 2014 guidelines: Do not use hormone therapy (conjugated equine estrogen with or without medroxyprogesterone) for primary or secondary prevention of stroke in postmenopausal females. D Do not use selective estrogen receptor modulators, such as raloxifene, tamoxifen, or tibolone, for primary prevention of stroke. D Female patients (secondary prevention): screen female patients with asymptomatic carotid stenosis for other treatable risk factors for stroke and institute appropriate lifestyle changes and medical therapies. B Show 8 more https://web.pathway.md/diseases/recwd1RIpW03JSM4H 15/31 6/23/23, 1:57 AM Acute ischemic stroke Pathway Female patients (patients with migraine with aura): Consider offering treatment to reduce migraine frequency because there is an association between higher migraine frequency and stroke risk, although evidence is lacking that this treatment reduces the risk of first stroke. C Consider advising smoking cessation in patients with migraine with aura because of the increased stroke risk. C Female patients (patients with atrial fibrillation): use risk stratification tools in AF accounting for age- and sex-specific differences in the incidence of stroke. A Show 4 more Female patients (patients with CVT, nonpregnant): obtain a CBC, chemistry panel, PT, and activated PTT in patients with suspected cerebral venous thrombosis. B Show 4 more Female patients (patients with CVT, pregnant): continue LMWH in full anticoagulant doses throughout pregnancy, and LMWH or vitamin K antagonist with a target INR of 2.0-3.0 for 6 weeks postpartum (for a total minimum duration of therapy of 6 months) in patients with cerebral venous thrombosis during pregnancy. B Show 3 more Female patients (stroke during menstruation): Insufficient evidence to recommend IV thrombolysis in female patients with ischemic stroke during menstruation. Consider administering IV alteplase after appropriate assessment of the benefit/risk profile on an individual basis in female patients with AIS during menstruation, otherwise meeting eligibility criteria. E Pregnant patients, IV alteplase: As per ESO 2022 guidelines: Insufficient evidence to recommend IV thrombolysis in pregnant patients with AIS. I Consider administering IV alteplase after appropriate assessment of the benefit/risk profile on an individual basis in pregnant patients with acute disabling ischemic stroke, otherwise meeting eligibility criteria. E As per ASA/AHA 2018 guidelines: Consider administering IV alteplase in pregnant patients with AIS when the anticipated benefits of treating moderate or severe stroke outweigh the anticipated increased risks of uterine bleeding. C Insufficient evidence regarding the safety and efficacy of IV alteplase in the early postpartum period (such as < 14 days after delivery). I Pregnant patients (mechanical thrombectomy): Insufficient evidence to recommend mechanical thrombectomy in pregnant patients with AIS. I Consider performing mechanical thrombectomy after appropriate assessment of the benefit/risk profile on an individual basis in pregnant patients with AIS and large vessel occlusion, otherwise https://web.pathway.md/diseases/recwd1RIpW03JSM4H 16/31 6/23/23, 1:57 AM Acute ischemic stroke Pathway meeting eligibility criteria. Consider preferring mechanical thrombectomy alone, if available, over IV thrombolysis or bridging therapy (IV thrombolysis with mechanical thrombectomy) in pregnant patients with AIS related to large vessel occlusion. E Pregnant patients (anticoagulation therapy): Consider the following options for pregnant women with ischemic stroke or TIA and high-risk thromboembolic conditions such as hypercoagulable state or mechanical heart valves: adjusted dose UFH throughout pregnancy, for example, a subcutaneous dose every 12 hours with monitoring of activated PTT; adjusted-dose LMWH with monitoring of anti-factor Xa throughout pregnancy; or UFH or LMWH until week 13, followed by warfarin until the middle of the third trimester and reinstatement of UFH or LMWH until delivery. C Consider pregnant women with stroke or TIA for treatment with UFH or LMWH throughout the first trimester, followed by low-dose aspirin for the remainder of the pregnancy in the absence of a high-risk thromboembolic condition. C Pregnant patients (prevention of preeclampsia): initiate low-dose aspirin from the 12th week of gestation until delivery in pregnant patients with chronic primary or secondary hypertension or previous pregnancy-related hypertension. A Show 6 more Pregnant patients (lipid-lowering therapy): Advise using a reliable form of contraception in sexually active females of childbearing age treated with statin therapy. B Advise stopping statins 1-2 months before attempting pregnancy in females of childbearing age with hypercholesterolemia, or as soon as the pregnancy is discovered. B Postpartum patients: insufficient evidence to recommend IV thrombolysis in postpartum patients with AIS. I Show 3 more Patients with diabetes mellitus: As per ADA 2023 guidelines, consider offering pioglitazone to lower the risk of stroke or myocardial infarction in patients with a history of stroke and evidence of insulin resistance and prediabetes, balancing the benefits with the increased risk of weight gain, edema, and fracture. B Consider offering lower doses to mitigate the risk of adverse effects. C As per AHA 2021 guidelines, " consider advising lifestyle optimization (healthy diet, regular physical activity, and smoking cessation) to prevent the progression of prediabetes to diabetes in patients with ischemic stroke or TIA and prediabetes. B Show 6 more Patients with renal disease: administer IV alteplase in patients with end-stage renal disease on hemodialysis and normal activated PTT. B Patients with rercent traumatic injury: do not administer IV alteplase in patients with AIS with recent severe head trauma (within 3 months). D Show 2 more https://web.pathway.md/diseases/recwd1RIpW03JSM4H 17/31 6/23/23, 1:57 AM Acute ischemic stroke Pathway Patients with a history of recent surgery: Avoid administering IV alteplase in patients with AIS and a history of intracranial/spinal surgery within the prior 3 months. D Consider administering IV alteplase in carefully selected patients presenting with AIS undergone major surgery in the preceding 14 days, but weigh the potential increased risk of surgical-site hemorrhage against the anticipated benefits of reduced stroke-related neurological deficits. C Patients with a history of recent ischemic stroke: avoid administering IV alteplase in patients presenting with AIS with a prior ischemic stroke within 3 months. D Patients with hyperdense MCA sign: consider administering IV alteplase in patients with a hyperdense middle cerebral artery sign. C Patients with severe hypoattenuation lesions: insufficient evidence to recommend a threshold of hypoattenuation severity or extent affecting treatment response to alteplase. Do not administer IV alteplase in patients with extensive regions of clear hypoattenuation on CT. Recognize that these patients have a poor prognosis despite IV alteplase, and severe hypoattenuation defined as obvious hypodensity represents irreversible injury. I Patients with embolic stroke of undetermined source: do not use direct OACs D or ticagrelor to reduce the risk of secondary stroke in patients with embolic stroke of undetermined source. D Patients with hemorrhagic transformation: consider initiating or continuing antiplatelet or anticoagulation therapy depending on the specific clinical scenario and underlying indication in patients with AIS and hemorrhagic transformation. C Patients with procedural stroke: consider administering IV alteplase for the treatment of AIS complications of cardiac or cerebral angiographic procedures, depending on the usual eligibility criteria. B Patients with drug-associated ischemic stroke: recognize that illicit drug use may be a contributing factor to incident stroke. Consider administering IV alteplase in instances of illicit drug use-associated AIS in patients with no other exclusions. B Patients with cerebral venous sinus thrombosis: Consider anticoagulation for patients with acute cerebral venous sinus thrombosis. C Consider anticoagulation for at least 3 months, followed by antiplatelet therapy in the absence of trial data to define the optimal duration of anticoagulation for acute cerebral venous sinus thrombosis. C Patients with neurological deficits: consider administering IV alteplase in patients with stroke with severe neurological deficits and a high likelihood of morbidity and mortality, to outweigh the anticipated risk of intracerebral hemorrhage secondary to thrombolysis, because of the increased risk of intracerebral hemorrhage in this group of patients. C Patients with disability or impairement: consider administering IV alteplase in patients with preexisting disability (Modified Rankin Score 2), taking into account relevant factors including quality of life, social support, place of residence, need for a caregiver, patients and family preferences, and goals of care. C https://web.pathway.md/diseases/recwd1RIpW03JSM4H 18/31 6/23/23, 1:57 AM Acute ischemic stroke Pathway Show 2 more Patients with inherited thrombophilias: Consider initiating antiplatelet therapy to reduce the risk of recurrent stroke or TIA in patients with ischemic stroke or TIA of unknown source despite thorough diagnostic evaluation, no other thrombotic history, and having any of the following: prothrombin 20210A mutation activated protein C resistance elevated factor VIII levels protein C deficiency protein S deficiency antithrombin III deficiency. C Patients with antiphospholipid syndrome: initiate antiplatelet therapy alone to reduce the risk of recurrent stroke in patients with ischemic stroke or TIA having an isolated antiphospholipid antibody but not fulfilling the criteria for antiphospholipid syndrome. B Show 3 more Patients with hyperhomocysteinemia: Do not initiate folate, vitamin B6, or vitamin B12 supplementation for the prevention of subsequent stroke in patients with ischemic stroke or TIA and hyperhomocysteinemia. D Offer a low-methionine, cysteine-enhanced diet and initiate vitamin B6, vitamin B12, and folate supplementation to reduce plasma homocysteine to population normal levels and thereby reduce the risk of recurrent ischemic stroke in patients with ischemic stroke or TIA and cystathionine -synthase deficiency. B Patients with malignancy: As per AHA 2021 guidelines, consider initiating anticoagulation with direct OACs in preference to warfarin for the prevention of stroke in patients with ischemic stroke or TIA in the setting of AF and cancer. C As per AHA 2018 guidelines, insufficient evidence regarding the safety and efficacy of IV alteplase in patients with current malignancy. I Patients with sickle cell disease (management): consider administering IV alteplase in adult patients with known sickle cell disease presenting with an AIS. C Patients with sickle cell disease (secondary prevention): Administer chronic blood transfusions to reduce Hgb S to < 30% of total Hgb for the prevention of recurrent ischemic stroke in patients with sickle cell disease and prior ischemic stroke or TIA. B Consider initiating hydroxyurea for the prevention of recurrent ischemic stroke in patients with sickle cell disease with prior ischemic stroke or TIA, if transfusion therapy is not available or practical. C Patients with autoimmune vasculitis: initiate immediate oral high-dose corticosteroids to reduce recurrent stroke risk in patients with ischemic stroke or TIA and symptoms attributed to giant cell arteritis. B https://web.pathway.md/diseases/recwd1RIpW03JSM4H 19/31 6/23/23, 1:57 AM Acute ischemic stroke Pathway Show 3 more Patients with infectious vasculitis: Treat the underlying infectious etiology (such as VZV, cerebral vasculitis, neurosyphilis, or bacterial meningitis) to reduce the risk of stroke in patients with ischemic stroke or TIA and infectious vasculitis. B Consider initiating daily aspirin plus combined ART to reduce the risk of recurrent stroke in patients with ischemic stroke or TIA in the context of human immunodeficiency virus vasculopathy. C Patients with Fabry disease: insufficient evidence regarding the role of agalsidase alfa or agalsidase beta in preventing recurrent stroke or TIA in patients with ischemic stroke or TIA and Anderson-Fabry disease. I Patients with carotid artery stenosis: initiate intensive medical therapy with antiplatelet therapy, lipid-lowering therapy, and antihypertensive therapy to reduce the risk of stroke in patients with TIA or stroke and carotid artery stenosis. A Show 11 more Patients with vertebral artery stenosis: Initiate intensive medical therapy (antiplatelet therapy, lipid-lowering, BP control) to reduce stroke risk in patients with recently symptomatic extracranial vertebral artery stenosis. A Insufficient evidence to recommend stenting I or open surgical procedures, including vertebral endarterectomy and vertebral artery transposition, in patients with ischemic stroke or TIA and extracranial vertebral artery stenosis having symptoms despite optimal medical treatment. I Patients with carotid or vertebral artery dissection: As per AHA 2021 guidelines, initiate antithrombotic therapy for at least 3 months to prevent recurrent stroke or TIA in patients with ischemic stroke or TIA after an extracranial carotid or vertebral arterial dissection. B Show 2 more As per AHA 2019 guidelines: Consider initiating either antiplatelet or anticoagulant therapy for 3-6 months in patients with AIS and extracranial carotid or vertebral arterial dissection. C Insufficient evidence to recommend extracranial endovascular therapy (stenting) in patients with AIS and extracranial carotid or extracranial vertebral arterial dissection experiencing definite recurrent cerebral ischemic events despite medical therapy. I Patients with aortic arch atherosclerosis: Initiate intensive lipid management with an LDL-C target of < 70 mg/dL to prevent recurrent stroke in patients with stroke or TIA and evidence of an aortic arch atheroma. B Initiate antiplatelet therapy to prevent recurrent stroke in patients with stroke or TIA and evidence of an aortic arch atheroma. B Patients with aortic arch dissection: do not administer IV alteplase in patients with AIS known or suspected to be associated with aortic arch dissection. D https://web.pathway.md/diseases/recwd1RIpW03JSM4H 20/31 6/23/23, 1:57 AM Acute ischemic stroke Pathway Patients with intracranial aneurysms: consider administering IV alteplase in patients presenting with AIS known to harbor a small or moderate-sized, unruptured, and unsecured intracranial aneurysm. C Show 2 more Patients with intracranial neoplasms: Consider administering IV alteplase in patients with AIS harboring an extra-axial intracranial neoplasm. C Avoid administering IV alteplase in patients with AIS harboring an intra-axial intracranial neoplasm. D Patients with Moyamoya disease: Consider initiating antiplatelet therapy, typically aspirin monotherapy, for the prevention of ischemic stroke or TIA in patients with Moyamoya disease and a history of ischemic stroke or TIA. C Consider performing surgical revascularization with direct or indirect extracranial-intracranial bypass for the prevention of ischemic stroke or TIA in patients with Moyamoya disease and a history of ischemic stroke or TIA. C Patients with small vessel disease: insufficient evidence to support the use of cilostazol for secondary prevention of stroke in patients with ischemic stroke related to small vessel disease. I Patients with carotid web: Initiate antiplatelet therapy to prevent recurrent ischemic stroke or TIA in patients with carotid web in the distribution of ischemic stroke and TIA without other attributable causes of stroke. B Consider performing carotid stenting or carotid endarterectomy to prevent recurrent ischemic stroke in patients with carotid web in the distribution of ischemic stroke refractory to medical management with no other attributable cause of stroke despite comprehensive workup. C Patients with fibromuscular dysplasia: initiate antiplatelet therapy, control BP control, and offer lifestyle modifications for the prevention of future ischemic events in patients with a history of ischemic stroke or TIA and FMD without other attributable causes. B Show 2 more Patients with vertebrobasilar dolichoectasia: consider initiating antiplatelet or anticoagulant therapy for the prevention of recurrent ischemic events in patients with a history of ischemic stroke or TIA and vertebrobasilar dolichoectasia without other attributable causes. C Patients with atrial fibrillation, anticoagulation therapy: As per ASA/AHA 2021 guidelines, initiate oral anticoagulation, such as apixaban, dabigatran, edoxaban, rivaroxaban, or warfarin, to reduce the risk of recurrent stroke in patients with stroke or TIA and nonvalvular AF. A Initiate oral anticoagulation to reduce the risk of recurrent stroke regardless of the pattern of AF, i.e. paroxysmal, persistent, or permanent. B Show 7 more As per ASA/AHA 2019 guidelines: Consider initiating oral anticoagulation between 4-14 days after the onset of neurological symptoms in most patients with AIS and AF. C https://web.pathway.md/diseases/recwd1RIpW03JSM4H 21/31 6/23/23, 1:57 AM Acute ischemic stroke Pathway Insufficient evidence to support adding antiplatelet therapy to OACs for purposes of reducing the risk of ischemic cardiovascular and cerebrovascular events in patients with a history of ischemic stroke, AF, and coronary artery disease. Consider initiating dual antiplatelet/oral anticoagulation in patients with unstable angina and coronary artery stenting. I Patients with atrial fibrillation (LAA closure): consider performing percutaneous closure of the LA appendage with the Watchman device to reduce the risk of recurrent stroke and bleeding in patients with stroke or TIA in the setting of nonvalvular AF having contraindications for lifelong anticoagulation but able to tolerate at least 45 days. C Patients with patent foramen ovale: decide between patent foramen ovale closure and medical management jointly with the patient, a cardiologist, and a neurologist taking into account the probability of a causal role for the patent foramen ovale in patients with a non-lacunar ischemic stroke of undetermined cause and a patent foramen ovale. B Show 3 more Patients with valvular heart disease (antithrombotic therapy): initiate warfarin to reduce the risk of recurrent stroke or TIA in patients with ischemic stroke or TIA and valvular AF (moderate-to- severe mitral stenosis or any mechanical heart valve). B Show 4 more Patients with valvular heart disease (valvular surgery): consider performing early surgery (during initial hospitalization before completion of a full therapeutic course of antibiotics) to reduce the risk of recurrent embolisms, if there is no evidence of ICH or extensive neurological damage, in patients with ischemic stroke or TIA and infective endocarditis presenting with recurrent emboli and persistent vegetations despite appropriate antibiotic therapy. C Show 4 more Patients with myocardial infarction: Consider administering IV alteplase at the dose appropriate for cerebral ischemia, followed by percutaneous coronary angioplasty and stenting if indicated, in patients presenting with concurrent AIS and acute myocardial infarction. C Consider administering IV alteplase in patients presenting with AIS and a history of recent myocardial infarction in the past 3 months, if the recent myocardial infarction was non-STEMI or STEMI involving the right, inferior, C or left anterior myocardium. C Patients with intracardiac thrombi: As per AHA 2021 guidelines, consider obtaining advanced cardiac imaging (such as contrast- enhanced echocardiography or cardiac MRI) to assess for the presence of LV thrombus in patients with stroke or TIA in the setting of acute myocardial infarction. C Show 3 more As per AHA 2018 guidelines: Consider administering IV alteplase in patients with a known LA or ventricular thrombus major AIS likely to produce severe disability. C Insufficient evidence to recommend IV alteplase administration in patients with a known LA or ventricular thrombus presenting with moderate AIS likely to produce mild disability. I https://web.pathway.md/diseases/recwd1RIpW03JSM4H 22/31 6/23/23, 1:57 AM Acute ischemic stroke Pathway Patients with congenital heart disease: Initiate anticoagulation with warfarin to reduce the risk of recurrent stroke or TIA in patients with ischemic stroke or TIA and Fontan palliation. B Consider initiating anticoagulation with warfarin to reduce the risk of recurrent stroke or TIA in patients with cyanotic congenital heart disease and other complex lesions and ischemic stroke or TIA of presumed cardioembolic origin. C Patients with cardiomyopathy: initiate anticoagulation with warfarin for at least 3 months to reduce the risk of recurrent stroke or TIA in patients with ischemic stroke or TIA and LA or LA appendage thrombus in the setting of ischemic, non-ischemic, or restrictive cardiomyopathy and LV dysfunction. B Show 4 more Patients with cardiac tumors: As per AHA 2021 guidelines, consider performing tumor resection to reduce the risk of recurrent stroke in patients with stroke or TIA with a left-sided cardiac tumor. C As per AHA 2018 guidelines: Consider administering IV alteplase in patients with cardiac myxoma and major AIS likely to produce severe disability. C Consider administering IV alteplase in patients with papillary fibroelastoma presenting with major AIS likely to produce severe disability. C Patients with infective endocarditis: do not administer IV alteplase in patients with AIS and symptoms consistent with infective endocarditis because of the increased risk of ICH. D Patients with acute pericarditis: Consider administering IV alteplase in patients with acute pericarditis and major AIS likely to produce severe disability. C Insufficient evidence to recommend administering IV alteplase in patients presenting with acute pericarditis and moderate AIS likely to produce mild disability. I 11. Preventative measures Primary prevention (statin therapy): initiate statins for primary prevention of CVDs in 40-75 years old adults with 1 CVD risk factors (dyslipidemia, diabetes, hypertension, or smoking) and an estimated 10-year CVD risk 10%. B Show 2 more Primary prevention (antiplatelet therapy): insufficient to support the use of antiplatelet therapy to reduce the risk of major adverse cardiovascular events including ischemic stroke in patients with asymptomatic intracranial atherosclerosis. Secondary prevention (antiplatelet therapy): initiate aspirin 325 mg/day over warfarin to reduce the risk of recurrent ischemic stroke and vascular death in patients with stroke or TIA caused by 50-99% stenosis of a major intracranial artery. B https://web.pathway.md/diseases/recwd1RIpW03JSM4H 23/31 6/23/23, 1:57 AM Acute ischemic stroke Pathway Show 4 more Secondary prevention (health system-based interventions): implement voluntary hospital- based or outpatient-focused quality monitoring and improvement programs to improve short-term and long-term adherence to nationally accepted, evidence-based guidelines for secondary stroke prevention in patients with ischemic stroke or TIA. B Show 2 more Secondary prevention (behavioral changes): offer behavior change interventions targeting stroke literacy, lifestyle factors, and medication adherence to reduce cardiovascular events in patients with ischemic stroke or TIA. B Show 5 more 12. Follow-up and surveillance Rehabilitation, approach and timing: As per ASA/AHA 2019 guidelines, provide early rehabilitation in patients hospitalized for stroke in environments with organized, interprofessional stroke care. A Show 3 more As per DoD/VA 2019 guidelines, provide a team-based approach in an organized inpatient unit encompassing comprehensive rehabilitation in order to improve the likelihood of discharge to home after acute stroke. A Show 3 more Rehabilitation, motor therapy: As per ASA/AHA 2019 guidelines, insufficient evidence to support the use of fluoxetine or other SSRIs to enhance motor recovery. I Updated evidence: EFFECTS In adult patients with a clinical diagnosis of ischemic or intracerebral hemorrhage in the previous 2-15 days, fluoxetine was not superior to placebo with respect to physical function as measured by the stroke impact scale score. EFFECTS Trial Collaboration. Lancet Neurol. 2020 Aug. As per DoD/VA 2019 guidelines, offer task-specific practice ("task-oriented practice" or "repetitive task practice") for improving upper- and lower-extremity motor function, gait, posture, and activities of daily living. A Show 17 more Rehabilitation, evaluation for dysphagia: As per ESSD/ESO 2021 guidelines, obtain a formal dysphagia screening test (either water- swallow tests or multiple-consistency tests) as soon as possible after admission to prevent post- stroke pneumonia and decrease the risk of early mortality in all patients with acute stroke. B https://web.pathway.md/diseases/recwd1RIpW03JSM4H 24/31 6/23/23, 1:57 AM Acute ischemic stroke Pathway Show 2 more As per ASA/AHA 2019 guidelines, obtain dysphagia screening before the patient begins eating, drinking, or receiving oral medications to identify patients at increased risk for aspiration. B Consider obtaining dysphagia screening by speech-language pathologists or other trained healthcare providers. B Show 2 more Rehabilitation, dysphagia therapy, nutritional support: As per ESSD/ESO 2021 guidelines, do not administer any food or liquid items, including oral medications, until a dysphagia screening is obtained and swallowing is deemed safe. D Show 2 more As per DoD/VA 2019 guidelines, consider placing a gastrostomy tube to maintain optimal nutrition in patients with dysphagia in the post-acute phase of stroke requiring tube feeding. C Rehabilitation, dysphagia therapy, exercises: As per ESSD/ESO 2021 guidelines, consider offering behavioral swallowing exercises to rehabilitate swallowing function in patients with post-stroke dysphagia. Avoid limiting behavioral interventions to one specific maneuver or training but tailor the treatment to the specific swallowing impairment of the individual patient with post-stroke dysphagia based on a careful assessment of dysphagia. C As per DoD/VA 2019 guidelines, consider offering Shaker exercise or chin tuck against resistance exercises in addition to conventional dysphagia therapy. C Show 2 more Rehabilitation, dysphagia therapy, oral hygiene: As per ESSD/ESO 2021 guidelines, consider implementing oral health care interventions to reduce the risk of pneumonia in patients with stroke. C As per ASA/AHA 2019 guidelines, consider implementing oral hygiene protocols to reduce the risk of pneumonia after stroke. C Rehabilitation (dysphagia therapy, pharmacotherapy): offer pharmacological treatment of post- stroke dysphagia within clinical trial settings. B Show 3 more Rehabilitation, dysphagia therapy, electrical stimulation: As per ESSD/ESO 2021 guidelines, offer neurostimulation techniques in patients with post- stroke dysphagia within clinical trial settings. B Show 2 more As per DoD/VA 2019 guidelines, insufficient evidence to recommend for or against neuromuscular electrical stimulation or pharyngeal electrical stimulation for the treatment of dysphagia. I Rehabilitation (dysphagia therapy, acupuncture): consider offering acupuncture for the rehabilitation of swallowing function in patients with post-stroke dysphagia. C https://web.pathway.md/diseases/recwd1RIpW03JSM4H 25/31 6/23/23, 1:57 AM Acute ischemic stroke Pathway Rehabilitation (cognitive, speech, and sensory therapy): insufficient evidence to recommend for or against the use of any specific cognitive rehabilitation methodology or pharmacotherapy to improve cognitive outcomes. I Show 4 more Rehabilitation, depression and anxiety: As per ASA/AHA 2019 guidelines: Use a structured depression inventory to routinely screen for post-stroke depression. B Initiate antidepressants in the absence of contraindications and closely monitor to verify effectiveness in patients with post-stroke depression. B As per DoD/VA 2019 guidelines, insufficient evidence for or against the universal use of SSRIs or SNRIs for the prevention of post-stroke depression. I Show 6 more Rehabilitation (return to work): Insufficient evidence to recommend for or against any specific assessments or interventions regarding return to work. I Insufficient evidence to recommend for or against using any specific assessments or interventions to facilitate a return to driving. I 13. Quality improvement EMS services: Develop regional systems of stroke care consisting of healthcare facilities providing initial emergency care, including administration of IV alteplase, and centers capable of performing endovascular stroke treatment with comprehensive periprocedural care to which rapid transport can be arranged when appropriate. A Develop triage paradigms and protocols to ensure that patients with a known or suspected stroke are rapidly identified and assessed by use of a validated and standardized tool for stroke screening by emergency medical services leaders, in coordination with local, regional, and state agencies and in consultation with medical authorities and local experts. B Stroke centers/units: certify stroke centers by an independent external body. B Show 6 more Organization of care: develop, adopt, and adhere to care protocols reflecting current care guidelines as established by national and international professional organizations in all hospitals caring for stroke patients within a stroke system of care. B Show 4 more Telemedicine: implement teleradiology systems (approved by the US FDA) for timely review of brain imaging in patients with suspected acute stroke in sites without in-house imaging interpretation expertise. Recognize that teleradiology systems (approved by the US FDA) implemented within a telestroke network are effective in supporting rapid imaging interpretation in time for IV alteplase administration decision making. A https://web.pathway.md/diseases/recwd1RIpW03JSM4H 26/31 6/23/23, 1:57 AM Acute ischemic stroke Pathway Show 5 more Outcome measures: organize a multidisciplinary quality improvement committee in healthcare institutions to review and monitor stroke care quality benchmarks, indicators, evidence-based practices, and outcomes. Consider forming a clinical process improvement team and using a stroke care registry for such quality of care assurances. Consider using a data repository to identify the gaps or disparities in quality stroke care. Consider initiating specific interventions once the gaps have been identified to address these gaps or disparities. B Show 2 more Public health measures: design and implement public education programs focused on stroke systems and the need to seek emergency care in a rapid manner. B Health equity: assess and address social determinants of health (literacy level, language proficiency, medication affordability, food insecurity, housing, and transportation barriers) when managing stroke risk factors to reduce healthcare disparities. B Show 3 more References 1. William J Powers, Alejandro A Rabinstein, Teri Ackerson et al. 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. Stroke. 2019 Dec;50 12):e344-e418. Open 2. Dawn O Kleindorfer, Amytis Towfighi, Seemant Chaturvedi et al. 2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack: A Guideline From the American Heart Association/American Stroke Association. Stroke. 2021 Jul;52 7):e364-e467. Open 3. George Ntaios, Tomasz Dziedzic, Patrik Michel et al. European Stroke Organisation ESO guidelines for the management of temperature in patients with acute ischemic stroke. Int J Stroke. 2015 Aug;10 6 941 9. Open 4. Blanca Fuentes, George Ntaios, Jukka Putaala et al. European Stroke Organisation ESO guidelines on glycaemia management in acute stroke. Eur Stroke J. 2018 Mar;3 1 5 21. Open 5. Rainer Dziewas, Emilia Michou, Michaela Trapl-Grundschober et al. European Stroke Organisation and European Society for Swallowing Disorders guideline for the diagnosis and treatment of post-stroke dysphagia. Eur Stroke J. 2021 Sep;6 3 LXXXIX CXV. Open 6. Furie KL, Kasner SE, Adams RJ et al. Guidelines for the prevention of stroke in patients with stroke or transient ischemic attack: a guideline for healthcare professionals from the american heart association/american stroke association. Stroke. 2011 Jan;42 1 227 76. Open 7. Marios Psychogios, Alex Brehm, Elena L pez-Cancio et al. European Stroke Organisation guidelines on treatment of patients with intracranial atherosclerotic disease. Eur Stroke J. 2022 Sep;7 3 III IV. Open 8. Powers WJ, Rabinstein AA, Ackerson T et al. 2018 Guidelines for the Early Management of Patients With Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke. 2018 Mar;49 3):e46-e110. Open https://web.pathway.md/diseases/recwd1RIpW03JSM4H 27/31 6/23/23, 1:57 AM Acute ischemic stroke Pathway 9. Bushnell C, McCullough LD, Awad IA et al. 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