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For the chapter in the Wells Handbook, please go to Chapter 13. Stroke.


Content Update

August 8, 2019

Endovascular Therapy for Acute Ischemic Stroke, Use Beyond 6 Hours and in Mild Stroke: Endovascular therapy has been shown to have a benefit when used within 6 hours of stroke in patients meeting specific criteria using second generation stent retrievers. The majority of patients receive intravenous (IV) alteplase prior to thrombectomy; however, endovascular therapy may be an option in patients who are not candidates for IV alteplase. The updated 2018 stroke guidelines provide guidance on the use of endovascular therapy beyond 6 hours and in patients with mild stroke. In patients meeting study criteria, functional outcomes were improved with thrombectomy plus standard care with IV alteplase in patients from 6 to 24 hours after symptom onset or patient last known to be well. Endovascular therapy and IV alteplase may have a role in the treatment of patients with mild stroke.

Content Update

Nov. 15, 2018

New Guidelines for Stroke Prevention in Patients with Atrial Fibrillation: In November 2018, the American College of Chest Physicians (ACCP) published updated guidelines for prevention of stroke in patients with atrial fibrillation (AF). The recommendations address antithrombotic selection, patient assessment tools, patient monitoring, management during various clinical situations, and other issues. Based on evidence from randomized clinical trials, the guidelines recommend use of direct oral anticoagulants (DOACs) over warfarin due to a significantly lower risk of stroke, intracranial hemorrhage, or fatal bleeding. Antiplatelet agents are no longer recommended, even in low-risk patients. Several patient assessment tools are recommended to guide patient care decisions in select situations, including the CHADS2-Vasc2 score, the HAS-BLED score, and the SAMe-TT2R2 scoring system. Systematic follow-up, patient education, and monitoring of medication adherence are important for all patients.



  • image Stroke can be either ischemic (87%) or hemorrhagic (13%) and the two types are treated differently.

  • image Transient ischemic attacks (TIAs) require urgent intervention to reduce the risk of stroke, which is known to be highest in the first few days after TIA.

  • image Carotid endarterectomy should be performed in ischemic stroke patients with 70% to 99% stenosis of the ipsilateral carotid artery, provided that it is done in an experienced center.

  • image Carotid stenting is an option for stroke patients eligible for carotid endarterectomy, especially in patients younger than 70 years.

  • image Early reperfusion (less than 4.5 hours from onset) with tissue plasminogen activator (tPA) has been shown to reduce the ultimate disability due to ischemic stroke.

  • image Endovascular thrombectomy with a stent retriever (within 6 hours) improves stroke outcomes in selected patients with proximal large artery occlusion and preservable penumbral tissue.

  • image Antiplatelet therapy is the cornerstone of antithrombotic therapy for the secondary prevention of noncardioembolic ischemic stroke.

  • image Oral anticoagulation is ...

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