COVID-19-associated stroke: Difference between revisions

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Revision as of 16:51, 12 July 2020

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Parul Pahal, M.B.B.S [2], Moises Romo M.D.

Synonyms and keywords: COVID-19, SARS-CoV-2, stroke, CT scan, cerebrovascular disease, TPA, alteplase

Overview

Cerebral hemorrhage or ischemia disrupts cerebral perfusion and can lead to an acute neurologic condition, stroke. It is one of the neurological complications of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, and is reported in critically ill Coronavirus Disease 2019 (COVID-19). COVID-19, is a pandemic, caused by a novel coronavirus, SARS-CoV-2. This rapidly spreading acute illness is commonly marked by symptoms like fever, cough, and shortness of breath, that can progress to severe respiratory complications and death. However, various non-pulmonary features are reported as the COVID-19 understanding is unfolding with the spike of cases and continuously rising number of cases globally. Stroke is one of the complication more commonly seen in severe COVID-19 patients, and was first reported in a retrospective study published in February 2020. The incidence is higher in younger men with no pre-existing neurological condition. The prognosis of COVID-19 patients presenting with stroke is very poor, based on the reported cases and studies published so far.

Historical Perspective

Neurological symptoms in Coronavirus disease 2019 (COVID-19) patients were first reported in February 2020 in a retrospective case series study by Mao L. et al. in hospitalized COVID-19 patients in Wuhan, China. Ling Mao from Tongji Medical College in Wuhan, and his group reviewed the data retrospectively from January 16, 2020, to February 19, 2020. One third of the 214 hospitalized laboratory- confirmed COVID-19 patients included in this study reported at least one neurologic symptom. The symptoms range from non-specific symptoms like headache, myalgia, fatigue, to more specific symptoms like seizure, coma, and acute cerebrovascular disease. However, incidence of acute cerebrovascular disease or stroke was higher in severe cases of COVID-19.^[1]

Classification

There is no specific classification established for 'Stroke in COVID-19 patients'. It is same as the general classification of stroke.

Stroke can be classified into

Ischemic stroke: This can be due to
- Thrombosis (Large vessel or Small vessel thrombosis)
- Embolism
- Systemic hypoperfusion

Hemorrhagic stroke: This can be due to

Pathophysiology

The most common type of stroke in patients with COVID-19 is ischemic.^[2]

The exact pathophysiology of 'stroke in COVID-19' is not fully understood. However, it is thought that stroke in COVID-19 could be due to one of the following pathophysiologies-

Sepsis induced coagulopathy in COVID-19 patients is thought to be contributing to microthromobosis. This is supported by elevation of D-dimer and C-reactive protein, which are hypercoagulability and inflammatory markers, in COVID-19 positive patients.
The angiotensin-converting enzyme II (ACEII) receptors are also present on the vascular endothelial cells and neural cells in the brain . These receptors expressed in the brain are responsible for sympathoadrenal system regulation, and vascular autoregulation^[3]. When the virus binds to these receptors, this vascular autoregulation is hampered and can lead to elevated blood pressure, eventually leading to rupture of the cerebral vessels and intracranial hemorrhage^[4]. It does so by altering the balance of renin-angiotensin system which likely triggers endothelium dysfunction, organ damage, which eventually results in stroke^[5].
Viral Neurotropism and Neuroinvasion is another possible pathogenic mechanism for cerebrovascular accidents in COVID-19 patients. The coronaviruses usually cause mild respiratory illness, but the beta coronavirues are known to have a role in nervous system involvement^[6]. The Novel coronavirus “severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)” is a beta coronavirus, similar to severe acute respiratory syndrome coronavirus (SARS-CoV) and Middle East respiratory syndrome coronavirus (MERS-CoV)^[7]. It,therefore, has infection mechanism and potential to invade the nervous system, similar to SARS-Cov and MERS-Cov^[8]. The detection of virus in the cells of the brain on autopsy^[9] (neural and capillary endothelial cells), and viral presence in the cerebrospinal fluid of the encephalitis patient infected with SARS-Cov-2^[10] supports the neuro-invasiveness of the virus. The two possible routes are retrograde axonal transport (via nasal cavity) or hematogenous spread (via blood brain barrier endothelial cells)^[9]. Once the virus reaches the brain, it attaches with the ACE II receptors.
Direct entry into brain tissues from cribriform plate to brain^[11]. This is one of the proposed mechanism as COVID-19 positive patients also presented with anosmia and hyposmia which possibly occurs due to viral effect on olfactory bulb, which is in close proximity to cribriform plate^[1]

Further investigations should be done to better understand the mechanism of Stroke in patients with COVID-19.

Causes

Coronavirus disease 2019 (COVID-19) associated stroke is caused by SARS-CoV-2.

Differentiating COVID-19-associated stroke from other Diseases

Stroke associated with COVID-19 should be differentiated from other diseases that can have similar presentation as stroke. These include-

Other COVID-19 associated neurological complications: Encephalitis, Encephalopathy, Meningitis, Seizure, Guillain-Barre syndrome, polyneuritis cranialis
Neurologic in non-COVID patients: Transient Ischemic Attack, Encephalitis, Brain abscess, Hemiplegic Migraine, Seizures, Postictal paralysis, Cerebral venous sinus thrombosis, Cerebral neoplasm, Cerebral Infections (Meningitis, Encephalitis, Brain Abscess, Progressive multifocal leukoencephalopathy)
Traumatic: Epidural hematoma, Subdural hematoma, Traumatic brain Injury
Toxic and/or Metabolic: Hypoglycemia, Hyponatremia, Drug intoxication
Syncope
Lyme's disease
Ear and Nose diseases: Benign Paroxysmal Positional Vertigo, Vestibular Neuronitis, Meniere's Disease
Psychiatric: Malingering, Conversion disorder
Paraneoplastic syndromes
Autoimmune disorders: Multiple Sclerosis, Acute inflammatory demyelinating polyradiculoneuropathy(Guillain-Barre syndrome)

Stroke in COVID-19 positive patients vs. Stroke in non-COVID-19 patients:

A retrospective cohort study (15th March,2020 to 19th April,2020) conducted by Yaghi et. al. in hospitalized patients in New York Healthcare systems compared stroke characteristics in patients with and without COVID-19^[12]. This study included 3,556 COVID-19 positive patients, out of which 32 patients were diagnosed with ischemic stroke based on imaging. These COVID-19 positive stroke patients were then compared with 46 hospitalized stroke patients without COVID-19. Based on findings of this study-

- Younger patient population (average age-63 years) as compared to relatively older patient population (average age-70 years) in non-COVID-19 patients.
- Severe stroke (National Institutes of Health Stroke Scale- average score 19) as compared to non-COVID patients with lesser average score (8) seen on National Institutes of Health Stroke Scale
- Higher D-dimer levels which point towards severe blood clotting (10,000 in this study). Relatively lower D-dimer levels (525 in this study) were seen in non-COVID patients.
- Mostly Cryptogenic stroke seen in COVID-19 patients.
- Increased mortality seen in COVID-19 patients.
- Most of COVID-19 patients did not have any history of prior stroke (only 3.1% reported stroke history) as opposed to non-COVID patient group in which prior history of stroke was reported in 13%.
- Non-COVID patients were more likely to have higher blood pressure levels.

Further studies are going on to understand the clinical characteristics specific to stroke in COVID-19 patients. It has been observed that the findings vary in different countries possibly due to racial/ethnicity variations. Since strokes have been reported in critically ill COVID-19 patients, hence, it is difficult to diagnose stroke in intubated and sedated COVID-19 patients.

Stroke in COVID-19 positive patients vs. Stroke in Influenza patients:

Out of 1916 COVID-19 patients (Emergency Department visits or were hospitalized with COVID-19) in retrospective cohort study which included patients from two academic hospitals in New York, 31 patients (1.6%) with median age 69 years, experienced acute ischemic stroke. The majority of these patients were men (58%). 8 patients (26%] had initial presentation as stroke while 23 had stroke over the course of the disease after testing positive for COVID-19.

Based on this study, the COVID-19 patients have much higher incidence of stroke when compared to influenza patients.^[13]

Epidemiology and Demographics

The incidence of stroke in COVID-19 varies significantly depending on the study population.

The prevalence of COVID-19-associated stroke varies in different studies

Prevalence of stroke in patients with COVID-19
Date of publication	Country	Author	Number of patients	Severe infection	Neurological symptoms	Acute Cerebrovascular disease	Ischemic/Hemorrhagic Stroke
April 10, 2020	Wuhan, China	Mao et al.^[1]	214	88 patients (41.1%), Mean age-58.2 years	78 patients (36.4%)	5 among severe [5.7%] infection group vs 1 [0.8%]) in non-severe group	Ischemic-4, Hemorrhagic-1
May 29, 2020	Wuhan, China	Qin et al.^[14] (Retrospective cohort study)	1875	461 severe on admission		50 patients ie. 15 among severe and 35 among mild on admission (Median age-70 years), 30 males and 20 females	Ischemic-90%, Hemorrhagic-10%
May 20, 2020	New York	Yaghi et al.^[12] (Retrospective cohort study)	3556		Stroke at the time of admission-14/32 (43.8%), eventually developed stroke during hospitalization-18 (56.2%)	32 patients (0.9%)	Ischemic stroke- 32
April 28, 2020	New York city	Oxley et al.^[15]	5				Large vessel stroke-5, Mean age-<50 years
July 12, 2020	New York	Valderrama et al.	1 (52-year old male)				Ischemic stroke

The incidence of stroke in hospitalized COVID-19 patients is reported to be 0.9–2%^[16].majority of them being ischemic subtype. The mortality in COVID-19 positive stroke patients is reported to be 39%^[1].

The ischemic stroke prevalence in COVID-19 patients is 1.6%.^[16]

A New York study published in May reported that the proportion of these strokes seem to be higher in younger men.^[12] Most of these strokes are large vessel ischemic strokes and are catastrophic.

In a retrospective observational case series of six stroke patients in a hospital in Italy, with lab confirmed COVID-19, the median age reported was 69 years. Ischemic stroke subtype was seen in 4 patients(67%) as compared to hemorrhagic which was only seen in 2 patients (33%). Vascular risk factors were seen in 5/6 patients, which included diabetes mellitus, arterial hypertension

In a single center retrospective study conducted in Wuhan by Qin C. et al. which included 1875 laboratory-confirmed COVID-19 patients from january 27th, 2020, to March 5th, 2020, 50 patients had history of stroke. The median age of this study group was 63 years, with stroke patients relatively older(70 years) when compared to non-stroke patients (62 years).^[14]

Stroke is one of the neurological manifestations in patients with severe infection. There is limited information on COVID-19 patients with stroke who survived.

Risk Factors

Stroke in COVID-19 infected patients is seen in relatively young patients as compared to with non COVID-19 patients.

COVID-19 associated stroke in severe patients. This includes older population with comorbidities like diabetes, hypertension, etc. However, due to disparities in the stroke prevalence in different studies, no clear association has been established.

Screening

There is insufficient evidence to recommend routine screening for stroke in COVID-19 patients. However, if the patient presents with stroke, COVID-19 screening should be done.

Natural History, Complications, and Prognosis

Prognosis is generally poor for COVID-19 patients with stroke. A study reported a high proportion of these patients were admitted to the Intensive Care Unit(ICU) and required mechanical ventilation. The mortality of COVID-19 patients with stroke was much higher when compared to COVID-19 patients with no history of stroke^[14].

Cerebral hemorrhage or ischemia disrupts cerebral perfusion and can lead to an acute neurologic condition, stroke. It is one of the neurological complications of SARS-Cov-2 infection, and is seen in critically ill COVID-19 patients. 5% of hospitalized COVID-19 patients with severe illness had acute stroke, with majority of patients with Ischemic stroke. The severe and critically ill patients when compared to moderate cases, had increased hypercoagulability and inflammatory markers. These patients are at higher risk for stroke. The better outcomes in critically ill patients who received prophylactic thrombolytic therapy points towards a possibility of hypercoagulability associated with COVID-19.^[1]

Diagnosis

Diagnosis of stroke associated to COVID-19 is based on history of symptoms development, physical examination, imaging findings, plus a positive COVID-19 test.
There are no standard established criteria for the evaluation of stroke associated to COVID-19.
General management protocols for COVID-19-associated stroke should be established so that brain imaging can be realized as prompt as possible in patients who may be candidates for IV fibrinolysis or mechanical thrombectomy or both.^[17]

Diagnostic Study of Choice

Non-contrast CT Scan of the brain (within 20 minutes of arrival in emergency department).^[18]
MRI to detect smaller lesions, if required, once the hemorrhagic stroke is excluded by non-contrast CT Scan with certainty.^[19]
In a patient who presents with neurological symptoms, RT-PCR for SARS-CoV-2 should be done as well.

History and Symptoms

The majority of patients with COVID-19-associated stroke initially presented with respiratory symptoms (e.g. cough, shortness of breath etc) and constitutional features. These patients developed cerebrovascular signs and symptoms later in the course of disease.
A few studies reported cases which presented with neurological symptoms suggestive of stroke. Most of these patients had underlying history of chronic diseases such as diabetes mellitus, atrial fibrillation, etc.

Patient no.	Onset of neurologic symptoms	Age and Gender	Neurologic Signs & Symptoms
1	On Admission	73-year old, Male	Respiratory distress, fever, and altered mental status ^[20]
2	On Admission	83-year old, Female	Fever, slurring of speech, facial droop, and reduced oral intake ^[20]
3	On Admission	80-year old female	Left sided weakness, altered mental status, one week history of frequent falls ^[20]
4	On Admission	88-year old, Female	An 15 minute episode of weakness and numbness of right arm and word finding difficulty ^[20]
5	On Admission	58-year old, Male	Dense Right-sided weakness and acute onset aphasia ^[21]

Physical Examination

The use of stroke scales such as the National Institutes of Health Stroke Scale (NIHSS) (Table 1) helps to measure the degree of neurological impairment, ease communication, may help select patients candidates for fibrinolytic or mechanical therapy, permits the evaluation of changing clinical status, and identifies those patients at higher risk for complications (eg. intracerebral hemorrhage).^[22]
The pre-stroke Modified Rankin Score (mRS) is an estimated score used to assess the patient’s pre-stroke level of function. An estimated mRS should be abstracted from current medical record documentation about the patient’s ability to perform activities of daily living prior to the hospitalization for the acute ischemic stroke event.^[23]
Alberta stroke program early CT score (ASPECTS) is a 10 point quantitative score used to asses early ischemic changes in patients suspected of having acute large vessel anterior circulation occlusion.^[24]

National Institutes of Health Stroke Scale (NIHSS)
Tested item	Title	Response and score
1A	Level of consciousness	0—Alert
		1—Drowsy
		2—Obtunded
		3—Coma/unresponsive
1B	Orientation questions (2)	0—Answers both correctly
		1—Answers 1 correctly
		2—Answers neither correctly
2	Gaze	0—Normal horizontal movements
		1—Partial gaze palsy
		2—Complete gaze palsy
3	Visual fields	0—No visual field defect
		1—Partial hemianopia
		2—Complete hemianopia
		3—Bilateral hemianopia
4	Facial movement	0—Normal
		1—Minor facial weakness
		2—Partial facial weakness
		3—Complete unilateral palsy
5	Motor function (arm) a. Left b. Right	0—No drift
		1—Drift before 10 s
		2—Falls before 10 s
		3—No effort against gravity
		4—No movement
6	Motor function (leg) a. Left b. Right	0—No drift
		1—Drift before 5 s
		2—Falls before 5 s
		3—No effort against gravity
		4—No movement
7	Limb ataxia	0—No ataxia
		1—Ataxia in 1 limb
		2—Ataxia in 2 limbs
8	Sensory	0—No sensory loss
		1—Mild sensory loss
		2—Severe sensory loss
9	Language	0—Norma
		1—Mild aphasia
		2—Severe aphasia
		3—Mute or global aphasia
10	Articulation of words	0—Norma
		1—Mild dysarthria
		2—Severe dysarthria
11	Extinction or inattention	0—Absent
		1—Mild loss (1 sensory modality lost)
		2—Severe loss (2 modalities lost)
Table 1. Adapted from Lyden et al., 1994^[25] American Heart Association, Inc.

Alberta stroke program early CT score (ASPECTS)
Area affected		Score
Subganglionic Nuclei:	M1 - Frontal operculum	1
	M2 - Anterior temporal lobe	1
	M3 - Posterior temporal lobe	1
Supraganglionic Nuclei:	M4 - Anterior MCA	1
	M5 - Lateral MCA	1
	M6 - Posterior MCA	1
Basal Ganglia:	C - Caudate	1
	L - Lentiform Nucleus	1
	I - Insula	1
	IC - Internal Capsule	1
Table 2. Adapted from The University of Calgary ASPECT score in Accute stroke, 2020^[24]

*Pre-Stroke Modified Rankin Score (mRS)*
Score	Item tested
0	The patient had no residual symptoms.
1	The patient had no significant disability; able to carry out all activities.
2	The patient had slight disability; unable to carry out all activities but able to look after self without daily help.
3	The patient had moderate disability; requiring some external help but able to walk without the assistance of another individual.
4	The patient had moderately severe disability; unable to walk or attend to bodily functions without assistance of another individual.
5	The patient had severe disability; bedridden, incontinent, requires continuous care.
6	Unable to determine (UTD) from the medical record documentation.
Table 3. Adapted from Specifications Manual for Joint Commission National Quality Measures, 2018^[23]

Laboratory Findings

Serum glucose assessment is the only lab study that should proceed IV alteplase initiation, this should be over 50 mg/dL for its administration.^[17]
Coagulation studies and complete blood count should be delayed until after IV alteplase initiation unless there is suspicion for a coagulopathy disorder.^[17]
Troponin should be assessed in patients presenting with ischemic stroke.^[17]
In adults who are 20 years of age or older and not on lipid-lowering therapy, measurement of either a fasting or a nonfasting plasma lipid profile is effective in estimating atherosclerotic cardiovascular disease (ASCVD) risk and documenting baseline low-density lipoprotein cholesterol (LDL-C). 4 to 12 weeks after statin initiation or dose adjustment and every 3 to 12 months thereafter based on need to assess adherence or safety.^[17]*
In patients older than 75 years of age with clinical ASCVD, it is reasonable to initiate moderate or high-intensity statin therapy after evaluation of the potential for ASCVD risk reduction, adverse effects, and drug interactions.*

Ultrasound

Echocardiography may be necessary in patients with ischemic stroke to identify and prevent secondary causes of stroke.
Carotid ultrasound should be performed in all patients with ischemic stroke.

X-ray

There is no evidence of usefulness of chest x-ray in the acute setting of stroke.^[17]

CT scan

Non-contrasted CT scan of the head should should always be performed before initiating IV alteplase.^[17]
Once hemorragic stroke is excluded, CT scan with contrast should be realized in patients with no history of renal disease without measuring creatinine concentration, taking into account that both COVID-19 infection and stroke increase the risk for renal impairment per se.^[2]^[26]
CT angiography of the brain may be needed in patients to make a decision for mechanical thrombectomy.^[2]^[27]^[28]
CT angiography's contrast can increase the risk of acute kidney injury in patients with COVID-19 infection.^[2]
CT perfusion should be done in patients who present within 24 hours of the initiation of symptoms.^[2]
Concurrent CT scan of the head and chest may be ordered at the same time in patients with COVID-19 infection.^[2]^[29]
CT angiography of the extracranial carotid and vertebral arteries, in addition to the intracranial circulation,is recommended in patients who are potential candidates for mechanical thrombectomy.^[17]^[30]

MRI

MRI of the head before IV alteplase administration to exclude microbleeds is not recommended.^[17]
Multimodal MRI of the head should be done in patients who present within 24 hours of the initiation of symptoms.^[2]
In patients who wake up with clinical symptoms of stroke of unknown onset (more than 3 hours?), an MRI with diffusion-positive FLAIR may be useful for selecting those who can benefit from IV alteplase administration.^[17]

Electrocardiogram

Baseline electrocardiographic assessment is recommended in patients presenting with ischemic stroke.^[17]

Treatment

Medical therapy

The reported cases of treatment for COVID-19-associated stroke have followed the same pattern as regular stroke with few changes. The following recommendations are mainly based on the current guidelines of management for stroke of the AHA 2019.
The use of thrombolysis via ultrasound waves concomitant to IV fibrinolysis is not recommended.^[31]
IV alteplase is always preferred over mechanical thrombectomy when there are no contraindications.^[32]
The usefulness of anticoagulants such as thrombin inhibitors (dabigatran) and factor Xa inhibitors (rivaroxaban, apixaban, edoxaban) is not well established in the acute setting of stroke.^[33]
In patients who are 75 years of age or younger with clinical ASCVD, high-intensity statin therapy should be initiated or continued with the aim of achieving a 50% or greater reduction in LDL-C levels.*
A clinician-patient risk discussion is recommended before initiation of statin therapy to review net clinical benefit, weighing the potential for ASCVD risk reduction against the potential for statin-associated side effects, statin-drug interactions, and safety, while emphasizing that side effects can be addressed successfully.*
Among patients already taking statins at the time of onset of ischemic stroke, continuation of statin therapy during the acute period is reasonable.*
For patients with ischemic stroke who qualify for statin treatment, in-hospital initiation of statin therapy is reasonable.^[34]*

Alteplase

The dose of IV alteplase is 0.9 mg/kg (maximum dose 90 mg) over 60 min, with 10% of the dose given as a bolus over 1 min.^[17]
Hyperglycemia should be treated during the first 24 hours after ischemic stroke, to achieve values of 140 to 180 mg/dL.^[17]
IV alteplase should be initiated as soon as possible, having been demonstrated better outcomes the sooner is administered.^[17]
IV alteplase may cause bleeding and angioedema.^[17]
IV alteplase (0.9 mg/kg, maximum dose 90 mg over 60 minutes with initial 10% of dose given as bolus over 1 minute) is recommended for selected patients who can be treated within 3-4.5 hours of ischemic stroke symptom onset or patient last known well or at baseline state.^[35]^[17]^[36]
Glycoprotein IIb/IIIa inhibitors (tirofiban, apiximab, eptifibatide) should not be coadministered with IV alteplase.^[17]^[37]
IV alteplase may be used in patients under warfarin if the INR is lower than 1.7.^[17]
IV alteplase should not be administered to patients who have received a full dose of low-molecular-weight heparin within the previous 24 hours (including prophylactic doses).^[17]^[38]
Blood pressure should be sustained lower than 180/105 mmHg the first 24 hours after IV alteplase administration. Intensive lowering has been shown to be safe.^[17]^[39]
In case of intracranial bleeding due to alteplase administration, alteplase should be suspended, blood draws should be taken (CBC, coagulation studies), tranexamic acid should be administered (1000 mg IV infused over 10 min), and a subsecuent non-contratested CT scan of the head taken.^[40]
The use of IV alteplase should be used cautiously in patients who undergone a major surgery in the past 2 weeks.^[17]
IV alteplase In ischemis stroke is contraindicated in patients with a severe head trauma or subarachnoid hemorrage in the preceding 3 months.^[17]

Tenecteplase

The dose of tenecteplase is a single IV bolus of 0.25-mg/kg (maximum 25 mg).^[41]
Tenecteplase may be useful in patients with minor neurological impairment.^[42]

Antiplatelet therapy

The dose of aspirin is usually between 160-300mg daily.^[43]
Administration of aspirin is recommended in patients with AIS within 24 to 48 hours after onset. For those treated with IV alteplase, aspirin administration is generally delayed until 24 hours later.^[44]
IV aspirin administration within 90 minutes after the start of IV alteplase is associated with symptomatic intracranial hemorrhage, for which co administration is discouraged but benefits should be assessed in each individual case.^[17]^[45]
Dual antiplatelet therapy with aspirin and clopidogrel (75 mg/d, with a loading dose of 600mg) may be started within 24 hours after symptom onset and continued for 21 days in patients with no cardioembolic ischemic stroke.^[46]
Aspirin should not substitute IV alteplase or mechanical thrombectomy in patients eligible for these therapies.

Surgery

Mechanical thrombectomy may be useful in selected patients with up to 24 hours of initiation of stroke.^[17]^[47]
In patients who undergo mechanical thrombectomy,blood pressure should be maintained below 180/105 mmHg during and for 24 hours after the procedure.^[17]
Mechanical thrombectomy with stent retrievers is recommended over intra arterial fibrinolysis as first-line therapy.^[17]
The usefulness of emergency carotid endarterectomy, carotid angioplasty and stenting in the absence of an intracranial clot is not well established.^[17]

Mechanical thrombectomy with a stent retriever

Patients should receive mechanical thrombectomy with a stent retriever if they meet all the following criteria:^[48]
1. Prestroke mRS score of 0 to 1
2. Causative occlusion of the internal carotid artery or MCA segment 1 (M1)
3. Age ≥18 years
4. NIHSS score of ≥6
5. ASPECTS of ≥6; and
6. Treatment can be initiated within 6 hours of symptom onset

Aspiration thrombectomy

Aspiration thrombectomy has not been shown to be inferior to stent retriever.^[49]

Direct aspiration thrombectomy as first-pass mechanical thrombectomy is recommended as noninferior to stent retriever for patients who meet all the following criteria:^[49]
1. Prestroke mRS score of 0 to 1;
2. Causative occlusion of the internal carotid artery or M1;
3. Age ≥18 years;
4. NIHSS score of ≥6;
5. ASPECTS ≥6; and
6. Treatment initiation within 6 hours of symptom onset.

Intra arterial fibrinolysis

Intra-arterial fibrinolysis may be initiated within 6 hours of stroke onset in selected patients in whom IV alteplase is contraindicated.

Other aspects of management

Volume expansors are not recommended in ischemic stroke.^[17]^[50]
The best head positioning after stroke is not well established.^[17]^[51]

Supplemental oxygen and mechanical ventilation support should be provided when necessary to maintain oxygen saturation higher than 93%.^[17]^[52]

Sources of hyperthermia (>38°C) should be identified and treated with antipyretics in patients with stroke.^[17]^[53]
Hypoglycemia (<60 mg/dL) should be treated in the acute setting in patients with ischemic stroke.^[17]
Blood pressure ≥220/120 in patients who did not receive TPA should be treated within the first 48 to 72 hours after the onset of ischemic stroke.^[54]
Enteral feeding should be started within 7 days of admission after an acute stroke when there is no contraindications.^[55]
Psychological screening is always recommended to exclude poststroke depression.^[56]
Early rehabilitation in patients with stroke is adviced.^[17]

Primary Prevention

Smoking cessation should be highly encouraged in patients who suffered from stroke, behavioral interventions and nicotine replacement may be necessary.

Secondary Prevention

There are no established measures for the secondary prevention of COVID-19 associated stroke.

References

↑ ^1.0 ^1.1 ^1.2 ^1.3 ^1.4 Mao, Ling; Jin, Huijuan; Wang, Mengdie; Hu, Yu; Chen, Shengcai; He, Quanwei; Chang, Jiang; Hong, Candong; Zhou, Yifan; Wang, David; Miao, Xiaoping; Li, Yanan; Hu, Bo (2020). "Neurologic Manifestations of Hospitalized Patients With Coronavirus Disease 2019 in Wuhan, China". JAMA Neurology. 77 (6): 683. doi:10.1001/jamaneurol.2020.1127. ISSN 2168-6149.
↑ ^2.0 ^2.1 ^2.2 ^2.3 ^2.4 ^2.5 ^2.6 Qureshi, Adnan I; Abd-Allah, Foad; Al-Senani, Fahmi; Aytac, Emrah; Borhani-Haghighi, Afshin; Ciccone, Alfonso; Gomez, Camilo R; Gurkas, Erdem; Hsu, Chung Y; Jani, Vishal; Jiao, Liqun; Kobayashi, Adam; Lee, Jun; Liaqat, Jahanzeb; Mazighi, Mikael; Parthasarathy, Rajsrinivas; Steiner, Thorsten; Suri, M Fareed K; Toyoda, Kazunori; Ribo, Marc; Gongora-Rivera, Fernando; Oliveira-Filho, Jamary; Uzun, Guven; Wang, Yongjun (2020). "Management of acute ischemic stroke in patients with COVID-19 infection: Report of an international panel". International Journal of Stroke. 15 (5): 540–554. doi:10.1177/1747493020923234. ISSN 1747-4930.
↑ Saavedra, Juan M. (2005). "Brain Angiotensin II: New Developments, Unanswered Questions and Therapeutic Opportunities". Cellular and Molecular Neurobiology. 25 (3–4): 485–512. doi:10.1007/s10571-005-4011-5. ISSN 0272-4340.
↑ Sharifi-Razavi, A.; Karimi, N.; Rouhani, N. (2020). "COVID-19 and intracerebral haemorrhage: causative or coincidental?". New Microbes and New Infections. 35: 100669. doi:10.1016/j.nmni.2020.100669. ISSN 2052-2975.
↑ Hess, David C.; Eldahshan, Wael; Rutkowski, Elizabeth (2020). "COVID-19-Related Stroke". Translational Stroke Research. 11 (3): 322–325. doi:10.1007/s12975-020-00818-9. ISSN 1868-4483.
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↑ Yu, Fei; Du, Lanying; Ojcius, David M.; Pan, Chungen; Jiang, Shibo (2020). "Measures for diagnosing and treating infections by a novel coronavirus responsible for a pneumonia outbreak originating in Wuhan, China". Microbes and Infection. 22 (2): 74–79. doi:10.1016/j.micinf.2020.01.003. ISSN 1286-4579.
↑ Li, Yan‐Chao; Bai, Wan‐Zhu; Hashikawa, Tsutomu (2020). "The neuroinvasive potential of SARS‐CoV2 may play a role in the respiratory failure of COVID‐19 patients". Journal of Medical Virology. 92 (6): 552–555. doi:10.1002/jmv.25728. ISSN 0146-6615.
↑ ^9.0 ^9.1 Paniz‐Mondolfi, Alberto; Bryce, Clare; Grimes, Zachary; Gordon, Ronald E.; Reidy, Jason; Lednicky, John; Sordillo, Emilia Mia; Fowkes, Mary (2020). "Central nervous system involvement by severe acute respiratory syndrome coronavirus‐2 (SARS‐CoV‐2)". Journal of Medical Virology. 92 (7): 699–702. doi:10.1002/jmv.25915. ISSN 0146-6615.
↑ Moriguchi, Takeshi; Harii, Norikazu; Goto, Junko; Harada, Daiki; Sugawara, Hisanori; Takamino, Junichi; Ueno, Masateru; Sakata, Hiroki; Kondo, Kengo; Myose, Natsuhiko; Nakao, Atsuhito; Takeda, Masayuki; Haro, Hirotaka; Inoue, Osamu; Suzuki-Inoue, Katsue; Kubokawa, Kayo; Ogihara, Shinji; Sasaki, Tomoyuki; Kinouchi, Hiroyuki; Kojin, Hiroyuki; Ito, Masami; Onishi, Hiroshi; Shimizu, Tatsuya; Sasaki, Yu; Enomoto, Nobuyuki; Ishihara, Hiroshi; Furuya, Shiomi; Yamamoto, Tomoko; Shimada, Shinji (2020). "A first case of meningitis/encephalitis associated with SARS-Coronavirus-2". International Journal of Infectious Diseases. 94: 55–58. doi:10.1016/j.ijid.2020.03.062. ISSN 1201-9712.
↑ Baig, Abdul Mannan; Khaleeq, Areeba; Ali, Usman; Syeda, Hira (2020). "Evidence of the COVID-19 Virus Targeting the CNS: Tissue Distribution, Host–Virus Interaction, and Proposed Neurotropic Mechanisms". ACS Chemical Neuroscience. 11 (7): 995–998. doi:10.1021/acschemneuro.0c00122. ISSN 1948-7193.
↑ ^12.0 ^12.1 ^12.2 Yaghi, Shadi; Ishida, Koto; Torres, Jose; Mac Grory, Brian; Raz, Eytan; Humbert, Kelley; Henninger, Nils; Trivedi, Tushar; Lillemoe, Kaitlyn; Alam, Shazia; Sanger, Matthew; Kim, Sun; Scher, Erica; Dehkharghani, Seena; Wachs, Michael; Tanweer, Omar; Volpicelli, Frank; Bosworth, Brian; Lord, Aaron; Frontera, Jennifer (2020). "SARS-CoV-2 and Stroke in a New York Healthcare System". Stroke. 51 (7): 2002–2011. doi:10.1161/STROKEAHA.120.030335. ISSN 0039-2499.
↑ Merkler, Alexander E.; Parikh, Neal S.; Mir, Saad; Gupta, Ajay; Kamel, Hooman; Lin, Eaton; Lantos, Joshua; Schenck, Edward J.; Goyal, Parag; Bruce, Samuel S.; Kahan, Joshua; Lansdale, Kelsey N.; LeMoss, Natalie M.; Murthy, Santosh B.; Stieg, Philip E.; Fink, Matthew E.; Iadecola, Costantino; Segal, Alan Z.; Cusick, Marika; Campion, Thomas R.; Diaz, Ivan; Zhang, Cenai; Navi, Babak B. (2020). "Risk of Ischemic Stroke in Patients With Coronavirus Disease 2019 (COVID-19) vs Patients With Influenza". JAMA Neurology. doi:10.1001/jamaneurol.2020.2730. ISSN 2168-6149.
↑ ^14.0 ^14.1 ^14.2 Qin, Chuan; Zhou, Luoqi; Hu, Ziwei; Yang, Sheng; Zhang, Shuoqi; Chen, Man; Yu, Haihan; Tian, Dai-Shi; Wang, Wei (2020). "Clinical Characteristics and Outcomes of COVID-19 Patients With a History of Stroke in Wuhan, China". Stroke. 51 (7): 2219–2223. doi:10.1161/STROKEAHA.120.030365. ISSN 0039-2499.
↑ Oxley, Thomas J.; Mocco, J.; Majidi, Shahram; Kellner, Christopher P.; Shoirah, Hazem; Singh, I. Paul; De Leacy, Reade A.; Shigematsu, Tomoyoshi; Ladner, Travis R.; Yaeger, Kurt A.; Skliut, Maryna; Weinberger, Jesse; Dangayach, Neha S.; Bederson, Joshua B.; Tuhrim, Stanley; Fifi, Johanna T. (2020). "Large-Vessel Stroke as a Presenting Feature of Covid-19 in the Young". New England Journal of Medicine. 382 (20): e60. doi:10.1056/NEJMc2009787. ISSN 0028-4793.
↑ ^16.0 ^16.1 Tsivgoulis, Georgios; Katsanos, Aristeidis H.; Ornello, Raffaele; Sacco, Simona (2020). "Ischemic Stroke Epidemiology During the COVID-19 Pandemic". Stroke. 51 (7): 1924–1926. doi:10.1161/STROKEAHA.120.030791. ISSN 0039-2499.
↑ ^17.00 ^17.01 ^17.02 ^17.03 ^17.04 ^17.05 ^17.06 ^17.07 ^17.08 ^17.09 ^17.10 ^17.11 ^17.12 ^17.13 ^17.14 ^17.15 ^17.16 ^17.17 ^17.18 ^17.19 ^17.20 ^17.21 ^17.22 ^17.23 ^17.24 ^17.25 ^17.26 ^17.27 ^17.28 ^17.29 ^17.30 ^17.31 ^17.32 Powers, William J.; Rabinstein, Alejandro A.; Ackerson, Teri; Adeoye, Opeolu M.; Bambakidis, Nicholas C.; Becker, Kyra; Biller, José; Brown, Michael; Demaerschalk, Bart M.; Hoh, Brian; Jauch, Edward C.; Kidwell, Chelsea S.; Leslie-Mazwi, Thabele M.; Ovbiagele, Bruce; Scott, Phillip A.; Sheth, Kevin N.; Southerland, Andrew M.; Summers, Deborah V.; Tirschwell, David L. (2019). "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. 50 (12). doi:10.1161/STR.0000000000000211. ISSN 0039-2499.
↑ Yew KS, Cheng EM (April 2015). "Diagnosis of acute stroke". Am Fam Physician. 91 (8): 528–36. PMID 25884860.
↑ Bouchez, Laurie; Sztajzel, Roman; Vargas, Maria Isabel; Machi, Paolo; Kulcsar, Zsolt; Poletti, Pierre-Alexandre; Pereira, Vitor Mendes; Lövblad, Karl-Olof (2017). "CT imaging selection in acute stroke". European Journal of Radiology. 96: 153–161. doi:10.1016/j.ejrad.2016.10.026. ISSN 0720-048X.
↑ ^20.0 ^20.1 ^20.2 ^20.3 Avula, Akshay; Nalleballe, Krishna; Narula, Naureen; Sapozhnikov, Steven; Dandu, Vasuki; Toom, Sudhamshi; Glaser, Allison; Elsayegh, Dany (2020). "COVID-19 presenting as stroke". Brain, Behavior, and Immunity. 87: 115–119. doi:10.1016/j.bbi.2020.04.077. ISSN 0889-1591.
↑ Zandi, Michael S; Manji, Hadi; Jäger, Hans Rolf; Hoskote, Chandrashekar; Werring, David J; Vincent, Angela; Howard, Robin; Spillane, Jennifer; Lunn, Michael P; Thom, Maria; Houlihan, Catherine; Carletti, Francesco; Farmer, Simon F; Longley, Nicky; Checkley, Anna; Simister, Robert; Perry, Richard J; Chandratheva, Arvind; Schott, Jonathan M; Silber, Eli; Sreedharan, Jemeen; Attwell, David; Yoong, Michael; Davies, Nicholas W S; Carswell, Christopher; Everitt, Alex D; Miller, Thomas D; Hotton, Gary; Foulkes, Alexander J M; Trip, S Anand; Yong, Wisdom; Keddie, Stephen; Levee, Viva; Mehta, Puja R; Lim, Soon Tjin; McLoughlin, Benjamin; McNamara, Patricia; Morrow, Jasper; Christofi, Gerry; Price, Gary; Tuzlali, Hatice; Boyd, Elena; Chinthapalli, Krishna; Geraldes, Ruth; Khoo, Anthony; Vivekanandam, Vinojini; Zambreanu, Laura; Raftopoulos, Rhian E; Kumar, Guru; Jayaseelan, Dipa L; Bharucha, Tehmina; Wiethoff, Sarah; Nortley, Ross; Benjamin, Laura; Brown, Rachel L; Paterson, Ross W (2020). "The emerging spectrum of COVID-19 neurology: clinical, radiological and laboratory findings". Brain. doi:10.1093/brain/awaa240. ISSN 0006-8950.
↑ Adams, H. P.; Davis, P. H.; Leira, E. C.; Chang, K.-C.; Bendixen, B. H.; Clarke, W. R.; Woolson, R. F.; Hansen, M. D. (1999). "Baseline NIH Stroke Scale score strongly predicts outcome after stroke: A report of the Trial of Org 10172 in Acute Stroke Treatment (TOAST)". Neurology. 53 (1): 126–126. doi:10.1212/WNL.53.1.126. ISSN 0028-3878.
↑ ^23.0 ^23.1 "Pre-Stroke Modified Rankin Score (mRS) (v2018B)".
↑ ^24.0 ^24.1 "Home".
↑ Lyden, P; Brott, T; Tilley, B; Welch, K M; Mascha, E J; Levine, S; Haley, E C; Grotta, J; Marler, J (1994). "Improved reliability of the NIH Stroke Scale using video training. NINDS TPA Stroke Study Group". Stroke. 25 (11): 2220–2226. doi:10.1161/01.STR.25.11.2220. ISSN 0039-2499.
↑ Cheng, Yichun; Luo, Ran; Wang, Kun; Zhang, Meng; Wang, Zhixiang; Dong, Lei; Li, Junhua; Yao, Ying; Ge, Shuwang; Xu, Gang (2020). "Kidney disease is associated with in-hospital death of patients with COVID-19". Kidney International. 97 (5): 829–838. doi:10.1016/j.kint.2020.03.005. ISSN 0085-2538.
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↑ Smith, Eric E.; Kent, David M.; Bulsara, Ketan R.; Leung, Lester Y.; Lichtman, Judith H.; Reeves, Mathew J.; Towfighi, Amytis; Whiteley, William N.; Zahuranec, Darin B. (2018). "Accuracy of Prediction Instruments for Diagnosing Large Vessel Occlusion in Individuals With Suspected Stroke: A Systematic Review for the 2018 Guidelines for the Early Management of Patients With Acute Ischemic Stroke". Stroke. 49 (3). doi:10.1161/STR.0000000000000160. ISSN 0039-2499.
↑ Guan WJ, Ni ZY, Hu Y, Liang WH, Ou CQ, He JX, Liu L, Shan H, Lei CL, Hui D, Du B, Li LJ, Zeng G, Yuen KY, Chen RC, Tang CL, Wang T, Chen PY, Xiang J, Li SY, Wang JL, Liang ZJ, Peng YX, Wei L, Liu Y, Hu YH, Peng P, Wang JM, Liu JY, Chen Z, Li G, Zheng ZJ, Qiu SQ, Luo J, Ye CJ, Zhu SY, Zhong NS (April 2020). "Clinical Characteristics of Coronavirus Disease 2019 in China". N. Engl. J. Med. 382 (18): 1708–1720. doi:10.1056/NEJMoa2002032. PMC 7092819 Check |pmc= value (help). PMID 32109013 Check |pmid= value (help). Vancouver style error: initials (help)
↑ Aulicky, P.; Mikulik, R.; Goldemund, D.; Reif, M.; Dufek, M.; Kubelka, T. (2009). "Safety of performing CT angiography in stroke patients treated with intravenous thrombolysis". Journal of Neurology, Neurosurgery & Psychiatry. 81 (7): 783–787. doi:10.1136/jnnp.2009.184002. ISSN 0022-3050.
↑ Nacu, Aliona; Kvistad, Christopher E.; Naess, Halvor; Øygarden, Halvor; Logallo, Nicola; Assmus, Jörg; Waje-Andreassen, Ulrike; Kurz, Kathinka D.; Neckelmann, Gesche; Thomassen, Lars (2017). "NOR-SASS (Norwegian Sonothrombolysis in Acute Stroke Study)". Stroke. 48 (2): 335–341. doi:10.1161/STROKEAHA.116.014644. ISSN 0039-2499.
↑ Saver, Jeffrey L.; Goyal, Mayank; van der Lugt, Aad; Menon, Bijoy K.; Majoie, Charles B. L. M.; Dippel, Diederik W.; Campbell, Bruce C.; Nogueira, Raul G.; Demchuk, Andrew M.; Tomasello, Alejandro; Cardona, Pere; Devlin, Thomas G.; Frei, Donald F.; du Mesnil de Rochemont, Richard; Berkhemer, Olvert A.; Jovin, Tudor G.; Siddiqui, Adnan H.; van Zwam, Wim H.; Davis, Stephen M.; Castaño, Carlos; Sapkota, Biggya L.; Fransen, Puck S.; Molina, Carlos; van Oostenbrugge, Robert J.; Chamorro, Ángel; Lingsma, Hester; Silver, Frank L.; Donnan, Geoffrey A.; Shuaib, Ashfaq; Brown, Scott; Stouch, Bruce; Mitchell, Peter J.; Davalos, Antoni; Roos, Yvo B. W. E. M.; Hill, Michael D. (2016). "Time to Treatment With Endovascular Thrombectomy and Outcomes From Ischemic Stroke: A Meta-analysis". JAMA. 316 (12): 1279. doi:10.1001/jama.2016.13647. ISSN 0098-7484.
↑ Gioia, Laura C.; Kate, Mahesh; Sivakumar, Leka; Hussain, Dulara; Kalashyan, Hayrapet; Buck, Brian; Bussiere, Miguel; Jeerakathil, Thomas; Shuaib, Ashfaq; Emery, Derek; Butcher, Ken (2016). "Early Rivaroxaban Use After Cardioembolic Stroke May Not Result in Hemorrhagic Transformation". Stroke. 47 (7): 1917–1919. doi:10.1161/STROKEAHA.116.013491. ISSN 0039-2499.
↑ Sanossian, Nerses; Saver, Jeffrey L.; Liebeskind, David S.; Kim, Doojin; Razinia, Tannaz; Ovbiagele, Bruce (2006). "Achieving Target Cholesterol Goals After Stroke". Archives of Neurology. 63 (8): 1081. doi:10.1001/archneur.63.8.1081. ISSN 0003-9942.
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↑ Powers, William J.; Derdeyn, Colin P.; Biller, José; Coffey, Christopher S.; Hoh, Brian L.; Jauch, Edward C.; Johnston, Karen C.; Johnston, S. Claiborne; Khalessi, Alexander A.; Kidwell, Chelsea S.; Meschia, James F.; Ovbiagele, Bruce; Yavagal, Dileep R. (2015). "2015 American Heart Association/American Stroke Association Focused Update of the 2013 Guidelines for the Early Management of Patients With Acute Ischemic Stroke Regarding Endovascular Treatment". Stroke. 46 (10): 3020–3035. doi:10.1161/STR.0000000000000074. ISSN 0039-2499.
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@@ Line 182: / Line 182: @@
 *[[Diagnosis]] of [[stroke]] associated to [[COVID-19]] is based on history of [[Symptoms|symptoms development]], [[physical examination]], [[Imaging studies|imaging findings]], plus a positive [[COVID-19 diagnostic study of choice|COVID-19 test]].
 * There are no standard established criteria for the evaluation of [[stroke]] associated to [[COVID-19]].
-*General management protocols for [[COVID-19]]-associated [[stroke]] should be established so that brain imaging can be realized as promt as possible in patients who may be candidates for [[Fibrinolysis|IV fibrinolysis]] or mechanical [[thrombectomy]] or both.<ref name="PowersRabinstein2019" />
+*General management protocols for [[COVID-19]]-associated [[stroke]] should be established so that brain imaging can be realized as prompt as possible in patients who may be candidates for [[Fibrinolysis|IV fibrinolysis]] or mechanical [[thrombectomy]] or both.<ref name="PowersRabinstein2019" />
 ===Diagnostic Study of Choice===
@@ Line 225: / Line 225: @@
 |83-year old, Female
-|[[fever]], [[slurring of speech]], [[facial droop]], and reduced oral intake <ref name="AvulaNalleballe2020">{{cite journal|last1=Avula|first1=Akshay|last2=Nalleballe|first2=Krishna|last3=Narula|first3=Naureen|last4=Sapozhnikov|first4=Steven|last5=Dandu|first5=Vasuki|last6=Toom|first6=Sudhamshi|last7=Glaser|first7=Allison|last8=Elsayegh|first8=Dany|title=COVID-19 presenting as stroke|journal=Brain, Behavior, and Immunity|volume=87|year=2020|pages=115–119|issn=08891591|doi=10.1016/j.bbi.2020.04.077}}</ref>
+|[[Fever]], [[slurring of speech]], [[facial droop]], and reduced oral intake <ref name="AvulaNalleballe2020">{{cite journal|last1=Avula|first1=Akshay|last2=Nalleballe|first2=Krishna|last3=Narula|first3=Naureen|last4=Sapozhnikov|first4=Steven|last5=Dandu|first5=Vasuki|last6=Toom|first6=Sudhamshi|last7=Glaser|first7=Allison|last8=Elsayegh|first8=Dany|title=COVID-19 presenting as stroke|journal=Brain, Behavior, and Immunity|volume=87|year=2020|pages=115–119|issn=08891591|doi=10.1016/j.bbi.2020.04.077}}</ref>
 |-
@@ Line 245: / Line 245: @@
 |88-year old, Female
-| An 15 minute episode of weakness and numbness of right arm and word finding difficulty <ref name="AvulaNalleballe2020">{{cite journal|last1=Avula|first1=Akshay|last2=Nalleballe|first2=Krishna|last3=Narula|first3=Naureen|last4=Sapozhnikov|first4=Steven|last5=Dandu|first5=Vasuki|last6=Toom|first6=Sudhamshi|last7=Glaser|first7=Allison|last8=Elsayegh|first8=Dany|title=COVID-19 presenting as stroke|journal=Brain, Behavior, and Immunity|volume=87|year=2020|pages=115–119|issn=08891591|doi=10.1016/j.bbi.2020.04.077}}</ref>
+| An 15 minute episode of [[Muscle weakness|weakness]] and [[numbness]] of right arm and word finding difficulty <ref name="AvulaNalleballe2020">{{cite journal|last1=Avula|first1=Akshay|last2=Nalleballe|first2=Krishna|last3=Narula|first3=Naureen|last4=Sapozhnikov|first4=Steven|last5=Dandu|first5=Vasuki|last6=Toom|first6=Sudhamshi|last7=Glaser|first7=Allison|last8=Elsayegh|first8=Dany|title=COVID-19 presenting as stroke|journal=Brain, Behavior, and Immunity|volume=87|year=2020|pages=115–119|issn=08891591|doi=10.1016/j.bbi.2020.04.077}}</ref>
 |-
@@ Line 255: / Line 255: @@
 |58-year old, Male
-| Dense Right-sided weakness and acute onset [[aphasia]] <ref name="ZandiManji2020">{{cite journal|last1=Zandi|first1=Michael S|last2=Manji|first2=Hadi|last3=Jäger|first3=Hans Rolf|last4=Hoskote|first4=Chandrashekar|last5=Werring|first5=David J|last6=Vincent|first6=Angela|last7=Howard|first7=Robin|last8=Spillane|first8=Jennifer|last9=Lunn|first9=Michael P|last10=Thom|first10=Maria|last11=Houlihan|first11=Catherine|last12=Carletti|first12=Francesco|last13=Farmer|first13=Simon F|last14=Longley|first14=Nicky|last15=Checkley|first15=Anna|last16=Simister|first16=Robert|last17=Perry|first17=Richard J|last18=Chandratheva|first18=Arvind|last19=Schott|first19=Jonathan M|last20=Silber|first20=Eli|last21=Sreedharan|first21=Jemeen|last22=Attwell|first22=David|last23=Yoong|first23=Michael|last24=Davies|first24=Nicholas W S|last25=Carswell|first25=Christopher|last26=Everitt|first26=Alex D|last27=Miller|first27=Thomas D|last28=Hotton|first28=Gary|last29=Foulkes|first29=Alexander J M|last30=Trip|first30=S Anand|last31=Yong|first31=Wisdom|last32=Keddie|first32=Stephen|last33=Levee|first33=Viva|last34=Mehta|first34=Puja R|last35=Lim|first35=Soon Tjin|last36=McLoughlin|first36=Benjamin|last37=McNamara|first37=Patricia|last38=Morrow|first38=Jasper|last39=Christofi|first39=Gerry|last40=Price|first40=Gary|last41=Tuzlali|first41=Hatice|last42=Boyd|first42=Elena|last43=Chinthapalli|first43=Krishna|last44=Geraldes|first44=Ruth|last45=Khoo|first45=Anthony|last46=Vivekanandam|first46=Vinojini|last47=Zambreanu|first47=Laura|last48=Raftopoulos|first48=Rhian E|last49=Kumar|first49=Guru|last50=Jayaseelan|first50=Dipa L|last51=Bharucha|first51=Tehmina|last52=Wiethoff|first52=Sarah|last53=Nortley|first53=Ross|last54=Benjamin|first54=Laura|last55=Brown|first55=Rachel L|last56=Paterson|first56=Ross W|title=The emerging spectrum of COVID-19 neurology: clinical, radiological and laboratory findings|journal=Brain|year=2020|issn=0006-8950|doi=10.1093/brain/awaa240}}</ref>
+| Dense Right-sided [[Muscle weakness|weakness]] and acute onset [[aphasia]] <ref name="ZandiManji2020">{{cite journal|last1=Zandi|first1=Michael S|last2=Manji|first2=Hadi|last3=Jäger|first3=Hans Rolf|last4=Hoskote|first4=Chandrashekar|last5=Werring|first5=David J|last6=Vincent|first6=Angela|last7=Howard|first7=Robin|last8=Spillane|first8=Jennifer|last9=Lunn|first9=Michael P|last10=Thom|first10=Maria|last11=Houlihan|first11=Catherine|last12=Carletti|first12=Francesco|last13=Farmer|first13=Simon F|last14=Longley|first14=Nicky|last15=Checkley|first15=Anna|last16=Simister|first16=Robert|last17=Perry|first17=Richard J|last18=Chandratheva|first18=Arvind|last19=Schott|first19=Jonathan M|last20=Silber|first20=Eli|last21=Sreedharan|first21=Jemeen|last22=Attwell|first22=David|last23=Yoong|first23=Michael|last24=Davies|first24=Nicholas W S|last25=Carswell|first25=Christopher|last26=Everitt|first26=Alex D|last27=Miller|first27=Thomas D|last28=Hotton|first28=Gary|last29=Foulkes|first29=Alexander J M|last30=Trip|first30=S Anand|last31=Yong|first31=Wisdom|last32=Keddie|first32=Stephen|last33=Levee|first33=Viva|last34=Mehta|first34=Puja R|last35=Lim|first35=Soon Tjin|last36=McLoughlin|first36=Benjamin|last37=McNamara|first37=Patricia|last38=Morrow|first38=Jasper|last39=Christofi|first39=Gerry|last40=Price|first40=Gary|last41=Tuzlali|first41=Hatice|last42=Boyd|first42=Elena|last43=Chinthapalli|first43=Krishna|last44=Geraldes|first44=Ruth|last45=Khoo|first45=Anthony|last46=Vivekanandam|first46=Vinojini|last47=Zambreanu|first47=Laura|last48=Raftopoulos|first48=Rhian E|last49=Kumar|first49=Guru|last50=Jayaseelan|first50=Dipa L|last51=Bharucha|first51=Tehmina|last52=Wiethoff|first52=Sarah|last53=Nortley|first53=Ross|last54=Benjamin|first54=Laura|last55=Brown|first55=Rachel L|last56=Paterson|first56=Ross W|title=The emerging spectrum of COVID-19 neurology: clinical, radiological and laboratory findings|journal=Brain|year=2020|issn=0006-8950|doi=10.1093/brain/awaa240}}</ref>
 |-
@@ Line 265: / Line 265: @@
 * The use of [[stroke]] scales such as the [[National Institutes of Health Stroke Scale|National Institutes of Health Stroke Scale (NIHSS)]] (Table 1) helps to measure the degree of [[neurological]] [[Disability|impairment]], ease communication, may help select patients candidates for [[Fibrinolysis|fibrinolytic]] or [[Thrombectomy|mechanical]] therapy, permits the evaluation of changing clinical status, and identifies those patients at higher risk for complications (eg. [[intracerebral hemorrhage]]).<ref name="AdamsDavis1999">{{cite journal|last1=Adams|first1=H. P.|last2=Davis|first2=P. H.|last3=Leira|first3=E. C.|last4=Chang|first4=K.-C.|last5=Bendixen|first5=B. H.|last6=Clarke|first6=W. R.|last7=Woolson|first7=R. F.|last8=Hansen|first8=M. D.|title=Baseline NIH Stroke Scale score strongly predicts outcome after stroke: A report of the Trial of Org 10172 in Acute Stroke Treatment (TOAST)|journal=Neurology|volume=53|issue=1|year=1999|pages=126–126|issn=0028-3878|doi=10.1212/WNL.53.1.126}}</ref>
 *The pre-stroke Modified Rankin Score (mRS) is an estimated score used to assess the patient’s pre-[[stroke]] level of function. An estimated mRS should be abstracted from current [[medical record]] documentation about the patient’s ability to perform activities of daily living prior to the hospitalization for the acute [[ischemic stroke]] event.<ref name="urlPre-Stroke Modified Rankin Score (mRS) (v2018B)" />
-*[[ASPECT|Alberta stroke program early CT score (ASPECTS)]] is a 10 point quantitative score used to asses early [[Ischemia|ischemic]] changes in patients suspected of having acute large vessel anterior circulation oclussion.<ref name="urlHome" />
+*[[ASPECT|Alberta stroke program early CT score (ASPECTS)]] is a 10 point quantitative score used to asses early [[Ischemia|ischemic]] changes in patients suspected of having acute large vessel anterior circulation [[occlusion]].<ref name="urlHome" />
 {| class="wikitable"
@@ Line 274: / Line 274: @@
 |-
 | rowspan="4" |1A
-| rowspan="4" |Level of consciousness
+| rowspan="4" |Level of [[consciousness]]
-|0—Alert
+|0—[[Alertness|Alert]]
 |-
-|1—Drowsy
+|1—[[Drowsiness|Drowsy]]
 |-
-|2—Obtunded
+|2—[[Obtundation|Obtunded]]
 |-
-|3—Coma/unresponsive
+|3—[[Coma]]/unresponsive
 |-
 | rowspan="3" |1B
@@ Line 295: / Line 295: @@
 |0—Normal horizontal movements
 |-
-|1—Partial gaze palsy
+|1—Partial [[gaze palsy]]
 |-
-|2—Complete gaze palsy
+|2—Complete [[gaze palsy]]
 |-
 | rowspan="4" |3
 | rowspan="4" |[[Visual fields]]
-|0—No visual field defect
+|0—No [[Vision loss|visual field defect]]
 |-
-|1—Partial hemianopia
+|1—Partial [[Hemianopsia|hemianopia]]
 |-
-|2—Complete hemianopia
+|2—Complete [[Hemianopsia|hemianopia]]
 |-
-|3—Bilateral hemianopia
+|3—Bilateral [[hemianopia]]
 |-
 | rowspan="4" |4
@@ Line 313: / Line 313: @@
 |0—Normal
 |-
-|1—Minor facial weakness
+|1—Minor [[facial weakness]]
 |-
-|2—Partial facial weakness
+|2—Partial [[facial weakness]]
 |-
-|3—Complete unilateral palsy
+|3—Complete unilateral [[palsy]]
 |-
 | rowspan="5" |5
@@ Line 324: / Line 324: @@
 b. Right
-|0—No drift
+|0—No [[drift]]
 |-
 |1—Drift before 10 s
@@ Line 330: / Line 330: @@
 |2—Falls before 10 s
 |-
-|3—No effort against gravity
+|3—No effort against [[gravity]]
 |-
 |4—No movement
@@ Line 351: / Line 351: @@
 | rowspan="3" |7
 | rowspan="3" |Limb [[ataxia]]
-|0—No ataxia
+|0—No [[ataxia]]
 |-
-|1—Ataxia in 1 limb
+|1—[[Ataxia]] in 1 limb
 |-
-|2—Ataxia in 2 limbs
+|2—[[Ataxia]] in 2 limbs
 |-
 | rowspan="3" |8
 | rowspan="3" |[[Sensory]]
-|0—No sensory loss
+|0—No [[sensory loss]]
 |-
-|1—Mild sensory loss
+|1—Mild [[sensory loss]]
 |-
-|2—Severe sensory loss
+|2—Severe [[sensory loss]]
 |-
 | rowspan="4" |9
@@ Line 369: / Line 369: @@
 |0—Norma
 |-
-|1—Mild aphasia
+|1—Mild [[aphasia]]
 |-
-|2—Severe aphasia
+|2—Severe [[aphasia]]
 |-
-|3—Mute or global aphasia
+|3—Mute or global [[aphasia]]
 |-
 | rowspan="3" |10
@@ Line 379: / Line 379: @@
 |0—Norma
 |-
-|1—Mild dysarthria
+|1—Mild [[dysarthria]]
 |-
-|2—Severe dysarthria
+|2—Severe [[dysarthria]]
 |-
 | rowspan="3" |11
@@ Line 467: / Line 467: @@
 ===Laboratory Findings===
-*[[Serum glucose]] assesment is the only lab study that should preceed [[Alteplase|IV alteplase]] initiation, this should be over 50 mg/dL for its administration.<ref name="PowersRabinstein2019" />
+*[[Serum glucose]] assessment is the only lab study that should proceed [[Alteplase|IV alteplase]] initiation, this should be over 50 mg/dL for its administration.<ref name="PowersRabinstein2019" />
 *[[Coagulation studies]] and [[complete blood count]] should be delayed until after [[Alteplase|IV alteplase]] initiation unless there is suspicion for a [[coagulopathy]] disorder.<ref name="PowersRabinstein2019" />
-* Troponin should be assesed in patients presenting with ischemic stroke.<ref name="PowersRabinstein2019" />
+* Troponin should be assessed in patients presenting with ischemic stroke.<ref name="PowersRabinstein2019" />
 *In adults who are 20 years of age or older and not on [[Lipid-lowering medication|lipid-lowering therapy]], measurement of either a fasting or a nonfasting [[Lipid profile|plasma lipid profile]] is effective in estimating [[Coronary heart disease|atherosclerotic cardiovascular disease (ASCVD)]] risk and documenting baseline low-density lipoprotein cholesterol (LDL-C).  4 to 12 weeks after statin initiation or dose adjustment and every 3 to 12 months thereafter based on need to assess adherence or safety.<ref name="PowersRabinstein2019" />*
 *In patients older than 75 years of age with clinical [[Coronary heart disease|ASCVD]], it is reasonable to initiate moderate or high-intensity [[statin]] therapy after evaluation of the potential for [[Coronary heart disease|ASCVD]] risk reduction, [[adverse effects]], and [[Drug interaction|drug interactions]].*
@@ Line 494: / Line 494: @@
 ===MRI===
-*[[MRI]] of the head before [[Alteplase|IV alteplase]] administration to exlude microbleeds is not recommended.<ref name="PowersRabinstein2019" />
+*[[MRI]] of the head before [[Alteplase|IV alteplase]] administration to exclude microbleeds is not recommended.<ref name="PowersRabinstein2019" />
-* Multinodal [[MRI]] of the head should be done in patients who present within 24 hours of the initiation of symptoms.<ref name="QureshiAbd-Allah2020" />
+* Multimodal [[MRI]] of the head should be done in patients who present within 24 hours of the initiation of symptoms.<ref name="QureshiAbd-Allah2020" />
 * In patients who wake up with clinical symptoms of [[stroke]] of unknown onset (more than 3 hours?), an [[MRI]] with diffusion-positive [[Fluid attenuated inversion recovery|FLAIR]] may be useful for selecting those who can benefit from [[Alteplase|IV alteplase]] administration.<ref name="PowersRabinstein2019" />
@@ Line 504: / Line 504: @@
 ===Medical therapy===
-* The reported cases of treatment for [[COVID-19]]-associated [[stroke]] have followed the same pattern as regular [[stroke]] with few changes. The following recomendations are mainly based on the current guidelines of management for stroke of the AHA 2019.
+* The reported cases of treatment for [[COVID-19]]-associated [[stroke]] have followed the same pattern as regular [[stroke]] with few changes. The following recommendations are mainly based on the current guidelines of management for stroke of the AHA 2019.
 * The use of [[thrombolysis]] via ultrasound waves concomitant to [[Fibrinolysis|IV fibrinolysis]] is not recommended.<ref name="NacuKvistad2017">{{cite journal|last1=Nacu|first1=Aliona|last2=Kvistad|first2=Christopher E.|last3=Naess|first3=Halvor|last4=Øygarden|first4=Halvor|last5=Logallo|first5=Nicola|last6=Assmus|first6=Jörg|last7=Waje-Andreassen|first7=Ulrike|last8=Kurz|first8=Kathinka D.|last9=Neckelmann|first9=Gesche|last10=Thomassen|first10=Lars|title=NOR-SASS (Norwegian Sonothrombolysis in Acute Stroke Study)|journal=Stroke|volume=48|issue=2|year=2017|pages=335–341|issn=0039-2499|doi=10.1161/STROKEAHA.116.014644}}</ref>
-*[[Alteplase|IV alteplase]] is always prefered over mechanical [[thrombectomy]] when there are no contraindications.<ref name="SaverGoyal2016">{{cite journal|last1=Saver|first1=Jeffrey L.|last2=Goyal|first2=Mayank|last3=van der Lugt|first3=Aad|last4=Menon|first4=Bijoy K.|last5=Majoie|first5=Charles B. L. M.|last6=Dippel|first6=Diederik W.|last7=Campbell|first7=Bruce C.|last8=Nogueira|first8=Raul G.|last9=Demchuk|first9=Andrew M.|last10=Tomasello|first10=Alejandro|last11=Cardona|first11=Pere|last12=Devlin|first12=Thomas G.|last13=Frei|first13=Donald F.|last14=du Mesnil de Rochemont|first14=Richard|last15=Berkhemer|first15=Olvert A.|last16=Jovin|first16=Tudor G.|last17=Siddiqui|first17=Adnan H.|last18=van Zwam|first18=Wim H.|last19=Davis|first19=Stephen M.|last20=Castaño|first20=Carlos|last21=Sapkota|first21=Biggya L.|last22=Fransen|first22=Puck S.|last23=Molina|first23=Carlos|last24=van Oostenbrugge|first24=Robert J.|last25=Chamorro|first25=Ángel|last26=Lingsma|first26=Hester|last27=Silver|first27=Frank L.|last28=Donnan|first28=Geoffrey A.|last29=Shuaib|first29=Ashfaq|last30=Brown|first30=Scott|last31=Stouch|first31=Bruce|last32=Mitchell|first32=Peter J.|last33=Davalos|first33=Antoni|last34=Roos|first34=Yvo B. W. E. M.|last35=Hill|first35=Michael D.|title=Time to Treatment With Endovascular Thrombectomy and Outcomes From Ischemic Stroke: A Meta-analysis|journal=JAMA|volume=316|issue=12|year=2016|pages=1279|issn=0098-7484|doi=10.1001/jama.2016.13647}}</ref>
+*[[Alteplase|IV alteplase]] is always preferred over mechanical [[thrombectomy]] when there are no contraindications.<ref name="SaverGoyal2016">{{cite journal|last1=Saver|first1=Jeffrey L.|last2=Goyal|first2=Mayank|last3=van der Lugt|first3=Aad|last4=Menon|first4=Bijoy K.|last5=Majoie|first5=Charles B. L. M.|last6=Dippel|first6=Diederik W.|last7=Campbell|first7=Bruce C.|last8=Nogueira|first8=Raul G.|last9=Demchuk|first9=Andrew M.|last10=Tomasello|first10=Alejandro|last11=Cardona|first11=Pere|last12=Devlin|first12=Thomas G.|last13=Frei|first13=Donald F.|last14=du Mesnil de Rochemont|first14=Richard|last15=Berkhemer|first15=Olvert A.|last16=Jovin|first16=Tudor G.|last17=Siddiqui|first17=Adnan H.|last18=van Zwam|first18=Wim H.|last19=Davis|first19=Stephen M.|last20=Castaño|first20=Carlos|last21=Sapkota|first21=Biggya L.|last22=Fransen|first22=Puck S.|last23=Molina|first23=Carlos|last24=van Oostenbrugge|first24=Robert J.|last25=Chamorro|first25=Ángel|last26=Lingsma|first26=Hester|last27=Silver|first27=Frank L.|last28=Donnan|first28=Geoffrey A.|last29=Shuaib|first29=Ashfaq|last30=Brown|first30=Scott|last31=Stouch|first31=Bruce|last32=Mitchell|first32=Peter J.|last33=Davalos|first33=Antoni|last34=Roos|first34=Yvo B. W. E. M.|last35=Hill|first35=Michael D.|title=Time to Treatment With Endovascular Thrombectomy and Outcomes From Ischemic Stroke: A Meta-analysis|journal=JAMA|volume=316|issue=12|year=2016|pages=1279|issn=0098-7484|doi=10.1001/jama.2016.13647}}</ref>
 *The usefulness of [[anticoagulants]] such as [[thrombin]] inhibitors ([[dabigatran]]) and [[factor Xa]] inhibitors ([[rivaroxaban]], [[apixaban]], [[edoxaban]]) is not well established in the acute setting of [[stroke]].<ref name="GioiaKate2016">{{cite journal|last1=Gioia|first1=Laura C.|last2=Kate|first2=Mahesh|last3=Sivakumar|first3=Leka|last4=Hussain|first4=Dulara|last5=Kalashyan|first5=Hayrapet|last6=Buck|first6=Brian|last7=Bussiere|first7=Miguel|last8=Jeerakathil|first8=Thomas|last9=Shuaib|first9=Ashfaq|last10=Emery|first10=Derek|last11=Butcher|first11=Ken|title=Early Rivaroxaban Use After Cardioembolic Stroke May Not Result in Hemorrhagic Transformation|journal=Stroke|volume=47|issue=7|year=2016|pages=1917–1919|issn=0039-2499|doi=10.1161/STROKEAHA.116.013491}}</ref>
 *In patients who are 75 years of age or younger with clinical [[Coronary heart disease|ASCVD]], high-intensity [[statin]] therapy should be initiated or continued with the aim of achieving a 50% or greater reduction in [[LDL-C]] levels.*
@@ Line 517: / Line 517: @@
 * The dose of [[Alteplase|IV alteplase]] is 0.9 mg/kg (maximum dose 90 mg) over 60 min, with 10% of the dose given as a bolus over 1 min.<ref name="PowersRabinstein2019" />
 *[[Hyperglycemia]] should be treated during the first 24 hours after [[ischemic stroke]], to achieve values of 140 to 180 mg/dL.<ref name="PowersRabinstein2019" />
-*[[Alteplase|IV alteplase]] should be iniciated as soon as possible, having been demostrated better outcomes the sooner is administered.<ref name="PowersRabinstein2019" />
+*[[Alteplase|IV alteplase]] should be initiated as soon as possible, having been demonstrated better outcomes the sooner is administered.<ref name="PowersRabinstein2019" />
 *[[Alteplase|IV alteplase]] may cause bleeding and [[angioedema]].<ref name="PowersRabinstein2019" />
 *[[Alteplase|IV alteplase]] (0.9 mg/kg, maximum dose 90 mg over 60 minutes with initial 10% of dose given as [[bolus]] over 1 minute) is recommended for selected patients who can be treated within 3-4.5 hours of [[ischemic stroke]] [[symptom]] [[onset]] or patient last known well or at [[Baseline (medicine)|baseline]] state.<ref name="LeesEmberson2016">{{cite journal|last1=Lees|first1=Kennedy R.|last2=Emberson|first2=Jonathan|last3=Blackwell|first3=Lisa|last4=Bluhmki|first4=Erich|last5=Davis|first5=Stephen M.|last6=Donnan|first6=Geoffrey A.|last7=Grotta|first7=James C.|last8=Kaste|first8=Markku|last9=von Kummer|first9=Rüdiger|last10=Lansberg|first10=Maarten G.|last11=Lindley|first11=Richard I.|last12=Lyden|first12=Patrick|last13=Murray|first13=Gordon D.|last14=Sandercock|first14=Peter A.G.|last15=Toni|first15=Danilo|last16=Toyoda|first16=Kazunori|last17=Wardlaw|first17=Joanna M.|last18=Whiteley|first18=William N.|last19=Baigent|first19=Colin|last20=Hacke|first20=Werner|last21=Howard|first21=George|last22=Marler|first22=John|last23=Halls|first23=Heather|last24=Holland|first24=Lisa|last25=Mathews|first25=Clare|last26=Smith|first26=Samantha|last27=Wilson|first27=Kate|last28=Koga|first28=Masatoshi|last29=Albers|first29=Gregory|last30=Brott|first30=Thomas|last31=Cohen|first31=Geoffrey|last32=Koga|first32=Masatoshi|last33=Olivot|first33=Jean Marc|last34=Parsons|first34=Mark|last35=Tilley|first35=Barbara|last36=Wahlgren|first36=Nils|last37=del Zoppo|first37=Gregory J|title=Effects of Alteplase for Acute Stroke on the Distribution of Functional Outcomes|journal=Stroke|volume=47|issue=9|year=2016|pages=2373–2379|issn=0039-2499|doi=10.1161/STROKEAHA.116.013644}}</ref><ref name="PowersRabinstein2019" /><ref>{{cite journal|title=The benefits and harms of intravenous thrombolysis with recombinant tissue plasminogen activator within 6 h of acute ischaemic stroke (the third international stroke trial [IST-3]): a randomised controlled trial|journal=The Lancet|volume=379|issue=9834|year=2012|pages=2352–2363|issn=01406736|doi=10.1016/S0140-6736(12)60768-5}}</ref>
 *[[Glycoprotein IIb/IIIa inhibitors]] ([[Tirofiban detailed information|tirofiban]], [[apiximab]], [[eptifibatide]]) should not be coadministered with [[Alteplase|IV alteplase]].<ref name="PowersRabinstein2019" /><ref name="AdeoyeSucharew2015">{{cite journal|last1=Adeoye|first1=Opeolu|last2=Sucharew|first2=Heidi|last3=Khoury|first3=Jane|last4=Tomsick|first4=Thomas|last5=Khatri|first5=Pooja|last6=Palesch|first6=Yuko|last7=Schmit|first7=Pamela A.|last8=Pancioli|first8=Arthur M.|last9=Broderick|first9=Joseph P.|title=Recombinant Tissue-Type Plasminogen Activator Plus Eptifibatide Versus Recombinant Tissue-Type Plasminogen Activator Alone in Acute Ischemic Stroke|journal=Stroke|volume=46|issue=2|year=2015|pages=461–464|issn=0039-2499|doi=10.1161/STROKEAHA.114.006743}}</ref>
-*[[Alteplase|IV alteplase]] may be used in patients under warfarin if the [[INR]] is lower than1.7.<ref name="PowersRabinstein2019" />
+*[[Alteplase|IV alteplase]] may be used in patients under warfarin if the [[INR]] is lower than 1.7.<ref name="PowersRabinstein2019" />
 *[[Alteplase|IV alteplase]] should not be administered to patients who have received a full dose of [[low-molecular-weight heparin]] within the previous 24 hours (including [[Prophylaxis|prophylactic]] doses).<ref name="PowersRabinstein2019" /><ref name="PowersDerdeyn2015">{{cite journal|last1=Powers|first1=William J.|last2=Derdeyn|first2=Colin P.|last3=Biller|first3=José|last4=Coffey|first4=Christopher S.|last5=Hoh|first5=Brian L.|last6=Jauch|first6=Edward C.|last7=Johnston|first7=Karen C.|last8=Johnston|first8=S. Claiborne|last9=Khalessi|first9=Alexander A.|last10=Kidwell|first10=Chelsea S.|last11=Meschia|first11=James F.|last12=Ovbiagele|first12=Bruce|last13=Yavagal|first13=Dileep R.|title=2015 American Heart Association/American Stroke Association Focused Update of the 2013 Guidelines for the Early Management of Patients With Acute Ischemic Stroke Regarding Endovascular Treatment|journal=Stroke|volume=46|issue=10|year=2015|pages=3020–3035|issn=0039-2499|doi=10.1161/STR.0000000000000074}}</ref>
 *[[Blood pressure]] should be sustained lower than 180/105 mmHg the first 24 hours after [[Alteplase|IV alteplase]] administration. 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Huy|first632=T.|last633=Le Tuan|first633=A. Truong|last634=Cam|first634=L. Dam Thi|last635=Kim|first635=T. Ngo Thi|last636=Nguyen|first636=B. Pham|last637=Dat|first637=A. Nguyen|last638=Van|first638=C. Nguyen|last639=Duy|first639=T. Mai|last640=Viet|first640=P. Dao|last641=Tien|first641=D. Nguyen|last642=Van|first642=T. Vo|last643=Le Kim|first643=K.|last644=Ngoc|first644=T. Bui|last645=Le Thanh|first645=T. Tran|last646=Hoanh|first646=S. Nguyen|last647=Phuoc|first647=S. Pham|last648=Van|first648=T. Tran|last649=Thi|first649=B. Doan|last650=Thu|first650=H. Nguyen Thi|last651=Duy|first651=M. Nguyen|last652=Van|first652=D. Ngo|title=Intensive blood pressure reduction with intravenous thrombolysis therapy for acute ischaemic stroke (ENCHANTED): an international, randomised, open-label, blinded-endpoint, phase 3 trial|journal=The Lancet|volume=393|issue=10174|year=2019|pages=877–888|issn=01406736|doi=10.1016/S0140-6736(19)30038-8}}</ref>
-* In case of [[Intracranial hemorrhage|intracranial bleeding]] due to [[alteplase]] administration, [[alteplase]] should be suspended, blood draws should be taken ([[Complete blood count|CBC]], [[coagulation studies]]), [[tranexamic acid]] should be administeered (1000 mg IV infused over 10 min), and a subsecuent non-contratested [[Computed tomography|CT scan]] of the head taken.<ref name="SloanPrice1995">{{cite journal|last1=Sloan|first1=M. A.|last2=Price|first2=T.R.|last3=Petito|first3=C. K.|last4=Randall|first4=A. M. Y.|last5=Solomon|first5=R. E.|last6=Terrin|first6=M. L.|last7=Gore|first7=J.|last8=Collen|first8=D.|last9=Kleiman|first9=N.|last10=Feit|first10=F.|last11=Babb|first11=J.|last12=Herman|first12=M.|last13=Roberts|first13=W. C.|last14=Sopko|first14=G.|last15=Bovill|first15=E.|last16=Forman|first16=S.|last17=Knatterud|first17=G. L.|title=Clinical features and pathogenesis of intracerebral hemorrhage after rt-PA and heparin therapy for acute myocardial infarction: The Thrombolysis in Myocardial Infarction (TIMI) II Pilot and Randomized Clinical Trial Combined experience|journal=Neurology|volume=45|issue=4|year=1995|pages=649–658|issn=0028-3878|doi=10.1212/WNL.45.4.649}}</ref>
+* In case of [[Intracranial hemorrhage|intracranial bleeding]] due to [[alteplase]] administration, [[alteplase]] should be suspended, blood draws should be taken ([[Complete blood count|CBC]], [[coagulation studies]]), [[tranexamic acid]] should be administered (1000 mg IV infused over 10 min), and a subsecuent non-contratested [[Computed tomography|CT scan]] of the head taken.<ref name="SloanPrice1995">{{cite journal|last1=Sloan|first1=M. A.|last2=Price|first2=T.R.|last3=Petito|first3=C. K.|last4=Randall|first4=A. M. Y.|last5=Solomon|first5=R. E.|last6=Terrin|first6=M. L.|last7=Gore|first7=J.|last8=Collen|first8=D.|last9=Kleiman|first9=N.|last10=Feit|first10=F.|last11=Babb|first11=J.|last12=Herman|first12=M.|last13=Roberts|first13=W. C.|last14=Sopko|first14=G.|last15=Bovill|first15=E.|last16=Forman|first16=S.|last17=Knatterud|first17=G. L.|title=Clinical features and pathogenesis of intracerebral hemorrhage after rt-PA and heparin therapy for acute myocardial infarction: The Thrombolysis in Myocardial Infarction (TIMI) II Pilot and Randomized Clinical Trial Combined experience|journal=Neurology|volume=45|issue=4|year=1995|pages=649–658|issn=0028-3878|doi=10.1212/WNL.45.4.649}}</ref>
 * The use of [[Alteplase|IV alteplase]] should be used cautiously in patients who undergone a [[major surgery]] in the past 2 weeks.<ref name="PowersRabinstein2019" />
-*[[Alteplase|IV alteplase]] In ischemis stroke is contraindicated in patients with a severe head trauma or [[Subarachnoid hemorrhage|subarachnoid hemorrage]] in the preceeding 3 months.<ref name="PowersRabinstein2019" />
+*[[Alteplase|IV alteplase]] In ischemis stroke is contraindicated in patients with a severe head trauma or [[Subarachnoid hemorrhage|subarachnoid hemorrage]] in the preceding 3 months.<ref name="PowersRabinstein2019" />
 ==== Tenecteplase ====
-* The dose of [[tenecteplase]] is a single IV bolus of 0.25-mg/kg (maximum 25 mg).<ref name="CampbellMitchell2018">{{cite journal|last1=Campbell|first1=Bruce C.V.|last2=Mitchell|first2=Peter J.|last3=Churilov|first3=Leonid|last4=Yassi|first4=Nawaf|last5=Kleinig|first5=Timothy J.|last6=Dowling|first6=Richard J.|last7=Yan|first7=Bernard|last8=Bush|first8=Steven J.|last9=Dewey|first9=Helen M.|last10=Thijs|first10=Vincent|last11=Scroop|first11=Rebecca|last12=Simpson|first12=Marion|last13=Brooks|first13=Mark|last14=Asadi|first14=Hamed|last15=Wu|first15=Teddy Y.|last16=Shah|first16=Darshan G.|last17=Wijeratne|first17=Tissa|last18=Ang|first18=Timothy|last19=Miteff|first19=Ferdinand|last20=Levi|first20=Christopher R.|last21=Rodrigues|first21=Edrich|last22=Zhao|first22=Henry|last23=Salvaris|first23=Patrick|last24=Garcia-Esperon|first24=Carlos|last25=Bailey|first25=Peter|last26=Rice|first26=Henry|last27=de Villiers|first27=Laetitia|last28=Brown|first28=Helen|last29=Redmond|first29=Kendal|last30=Leggett|first30=David|last31=Fink|first31=John N.|last32=Collecutt|first32=Wayne|last33=Wong|first33=Andrew A.|last34=Muller|first34=Claire|last35=Coulthard|first35=Alan|last36=Mitchell|first36=Ken|last37=Clouston|first37=John|last38=Mahady|first38=Kate|last39=Field|first39=Deborah|last40=Ma|first40=Henry|last41=Phan|first41=Thanh G.|last42=Chong|first42=Winston|last43=Chandra|first43=Ronil V.|last44=Slater|first44=Lee-Anne|last45=Krause|first45=Martin|last46=Harrington|first46=Timothy J.|last47=Faulder|first47=Kenneth C.|last48=Steinfort|first48=Brendan S.|last49=Bladin|first49=Christopher F.|last50=Sharma|first50=Gagan|last51=Desmond|first51=Patricia M.|last52=Parsons|first52=Mark W.|last53=Donnan|first53=Geoffrey A.|last54=Davis|first54=Stephen M.|title=Tenecteplase versus Alteplase before Thrombectomy for Ischemic Stroke|journal=New England Journal of Medicine|volume=378|issue=17|year=2018|pages=1573–1582|issn=0028-4793|doi=10.1056/NEJMoa1716405}}</ref>
+* The dose of [[tenecteplase]] is a single IV [[bolus]] of 0.25-mg/kg (maximum 25 mg).<ref name="CampbellMitchell2018">{{cite journal|last1=Campbell|first1=Bruce C.V.|last2=Mitchell|first2=Peter J.|last3=Churilov|first3=Leonid|last4=Yassi|first4=Nawaf|last5=Kleinig|first5=Timothy J.|last6=Dowling|first6=Richard J.|last7=Yan|first7=Bernard|last8=Bush|first8=Steven J.|last9=Dewey|first9=Helen M.|last10=Thijs|first10=Vincent|last11=Scroop|first11=Rebecca|last12=Simpson|first12=Marion|last13=Brooks|first13=Mark|last14=Asadi|first14=Hamed|last15=Wu|first15=Teddy Y.|last16=Shah|first16=Darshan G.|last17=Wijeratne|first17=Tissa|last18=Ang|first18=Timothy|last19=Miteff|first19=Ferdinand|last20=Levi|first20=Christopher R.|last21=Rodrigues|first21=Edrich|last22=Zhao|first22=Henry|last23=Salvaris|first23=Patrick|last24=Garcia-Esperon|first24=Carlos|last25=Bailey|first25=Peter|last26=Rice|first26=Henry|last27=de Villiers|first27=Laetitia|last28=Brown|first28=Helen|last29=Redmond|first29=Kendal|last30=Leggett|first30=David|last31=Fink|first31=John N.|last32=Collecutt|first32=Wayne|last33=Wong|first33=Andrew A.|last34=Muller|first34=Claire|last35=Coulthard|first35=Alan|last36=Mitchell|first36=Ken|last37=Clouston|first37=John|last38=Mahady|first38=Kate|last39=Field|first39=Deborah|last40=Ma|first40=Henry|last41=Phan|first41=Thanh G.|last42=Chong|first42=Winston|last43=Chandra|first43=Ronil V.|last44=Slater|first44=Lee-Anne|last45=Krause|first45=Martin|last46=Harrington|first46=Timothy J.|last47=Faulder|first47=Kenneth C.|last48=Steinfort|first48=Brendan S.|last49=Bladin|first49=Christopher F.|last50=Sharma|first50=Gagan|last51=Desmond|first51=Patricia M.|last52=Parsons|first52=Mark W.|last53=Donnan|first53=Geoffrey A.|last54=Davis|first54=Stephen M.|title=Tenecteplase versus Alteplase before Thrombectomy for Ischemic Stroke|journal=New England Journal of Medicine|volume=378|issue=17|year=2018|pages=1573–1582|issn=0028-4793|doi=10.1056/NEJMoa1716405}}</ref>
 *[[Tenecteplase]] may be useful in patients with minor [[neurological]] impairment.<ref name="HuangCheripelli2015">{{cite journal|last1=Huang|first1=Xuya|last2=Cheripelli|first2=Bharath Kumar|last3=Lloyd|first3=Suzanne M|last4=Kalladka|first4=Dheeraj|last5=Moreton|first5=Fiona Catherine|last6=Siddiqui|first6=Aslam|last7=Ford|first7=Ian|last8=Muir|first8=Keith W|title=Alteplase versus tenecteplase for thrombolysis after ischaemic stroke (ATTEST): a phase 2, randomised, open-label, blinded endpoint study|journal=The Lancet Neurology|volume=14|issue=4|year=2015|pages=368–376|issn=14744422|doi=10.1016/S1474-4422(15)70017-7}}</ref>
 ==== Antiplatelet therapy ====
-* The dose of aspirin is usually between 160-300mg daily.<ref name="pmid9174558">{{cite journal |vauthors= |title=The International Stroke Trial (IST): a randomised trial of aspirin, subcutaneous heparin, both, or neither among 19435 patients with acute ischaemic stroke. International Stroke Trial Collaborative Group |journal=Lancet |volume=349 |issue=9065 |pages=1569–81 |date=May 1997 |pmid=9174558 |doi= |url=}}</ref>
+* The dose of [[aspirin]] is usually between 160-300mg daily.<ref name="pmid9174558">{{cite journal |vauthors= |title=The International Stroke Trial (IST): a randomised trial of aspirin, subcutaneous heparin, both, or neither among 19435 patients with acute ischaemic stroke. International Stroke Trial Collaborative Group |journal=Lancet |volume=349 |issue=9065 |pages=1569–81 |date=May 1997 |pmid=9174558 |doi= |url=}}</ref>
-* Administration of aspirin is recommended in patients with AIS within 24 to 48 hours after onset. For those treated with [[Alteplase|IV alteplase]], aspirin administration is generally delayed until 24 hours later.<ref name="JeongKim2016">{{cite journal|last1=Jeong|first1=Han-Gil|last2=Kim|first2=Beom Joon|last3=Yang|first3=Mi Hwa|last4=Han|first4=Moon-Ku|last5=Bae|first5=Hee-Joon|last6=Lee|first6=Seung-Hoon|title=Stroke outcomes with use of antithrombotics within 24 hours after recanalization treatment|journal=Neurology|volume=87|issue=10|year=2016|pages=996–1002|issn=0028-3878|doi=10.1212/WNL.0000000000003083}}</ref>
+* Administration of [[aspirin]] is recommended in patients with AIS within 24 to 48 hours after onset. For those treated with [[Alteplase|IV alteplase]], aspirin administration is generally delayed until 24 hours later.<ref name="JeongKim2016">{{cite journal|last1=Jeong|first1=Han-Gil|last2=Kim|first2=Beom Joon|last3=Yang|first3=Mi Hwa|last4=Han|first4=Moon-Ku|last5=Bae|first5=Hee-Joon|last6=Lee|first6=Seung-Hoon|title=Stroke outcomes with use of antithrombotics within 24 hours after recanalization treatment|journal=Neurology|volume=87|issue=10|year=2016|pages=996–1002|issn=0028-3878|doi=10.1212/WNL.0000000000003083}}</ref>
-*IV aspirin administration within 90 minutes after the start of [[Alteplase|IV alteplase]] is associated with symptomatic intracranial hemorrhage, for which coadministration is discouraged but benefits should be assesed in each individual case.<ref name="PowersRabinstein2019" /><ref name="ZinkstokRoos2012">{{cite journal|last1=Zinkstok|first1=Sanne M|last2=Roos|first2=Yvo B|title=Early administration of aspirin in patients treated with alteplase for acute ischaemic stroke: a randomised controlled trial|journal=The Lancet|volume=380|issue=9843|year=2012|pages=731–737|issn=01406736|doi=10.1016/S0140-6736(12)60949-0}}</ref>
+*[[Aspirin|IV aspirin]] administration within 90 minutes after the start of [[Alteplase|IV alteplase]] is associated with symptomatic intracranial hemorrhage, for which co administration is discouraged but benefits should be assessed in each individual case.<ref name="PowersRabinstein2019" /><ref name="ZinkstokRoos2012">{{cite journal|last1=Zinkstok|first1=Sanne M|last2=Roos|first2=Yvo B|title=Early administration of aspirin in patients treated with alteplase for acute ischaemic stroke: a randomised controlled trial|journal=The Lancet|volume=380|issue=9843|year=2012|pages=731–737|issn=01406736|doi=10.1016/S0140-6736(12)60949-0}}</ref>
-* Dual antiplatelet therapy with aspirin and clopidogrel (75 mg/d, with a loading dose of 600mg) may be started within 24 hours after symptom onset and continued for 21 days in patients with no cardioembolic ischemic stroke.<ref name="JohnstonEaston2018">{{cite journal|last1=Johnston|first1=S. Claiborne|last2=Easton|first2=J. Donald|last3=Farrant|first3=Mary|last4=Barsan|first4=William|last5=Conwit|first5=Robin A.|last6=Elm|first6=Jordan J.|last7=Kim|first7=Anthony S.|last8=Lindblad|first8=Anne S.|last9=Palesch|first9=Yuko Y.|title=Clopidogrel and Aspirin in Acute Ischemic Stroke and High-Risk TIA|journal=New England Journal of Medicine|volume=379|issue=3|year=2018|pages=215–225|issn=0028-4793|doi=10.1056/NEJMoa1800410}}</ref>
+*[[Dual antiplatelet therapy]] with [[aspirin]] and [[clopidogrel]] (75 mg/d, with a loading dose of 600mg) may be started within 24 hours after [[symptom]] onset and continued for 21 days in patients with no cardioembolic [[ischemic stroke]].<ref name="JohnstonEaston2018">{{cite journal|last1=Johnston|first1=S. Claiborne|last2=Easton|first2=J. Donald|last3=Farrant|first3=Mary|last4=Barsan|first4=William|last5=Conwit|first5=Robin A.|last6=Elm|first6=Jordan J.|last7=Kim|first7=Anthony S.|last8=Lindblad|first8=Anne S.|last9=Palesch|first9=Yuko Y.|title=Clopidogrel and Aspirin in Acute Ischemic Stroke and High-Risk TIA|journal=New England Journal of Medicine|volume=379|issue=3|year=2018|pages=215–225|issn=0028-4793|doi=10.1056/NEJMoa1800410}}</ref>
-* Aspirin should not substitute [[Alteplase|IV alteplase]] or mechanical thrombectomy in patients eligible for these therapies.
+*[[Aspirin]] should not substitute [[Alteplase|IV alteplase]] or mechanical thrombectomy in patients eligible for these therapies.
 ===Surgery===
-* Mechanical thrombectomy may be useful in selected patients with up to 24 hours of initiation of stroke.<ref name="PowersRabinstein2019" /><ref name="AlbersMarks2018">{{cite journal|last1=Albers|first1=Gregory W.|last2=Marks|first2=Michael P.|last3=Kemp|first3=Stephanie|last4=Christensen|first4=Soren|last5=Tsai|first5=Jenny P.|last6=Ortega-Gutierrez|first6=Santiago|last7=McTaggart|first7=Ryan A.|last8=Torbey|first8=Michel T.|last9=Kim-Tenser|first9=May|last10=Leslie-Mazwi|first10=Thabele|last11=Sarraj|first11=Amrou|last12=Kasner|first12=Scott E.|last13=Ansari|first13=Sameer A.|last14=Yeatts|first14=Sharon D.|last15=Hamilton|first15=Scott|last16=Mlynash|first16=Michael|last17=Heit|first17=Jeremy J.|last18=Zaharchuk|first18=Greg|last19=Kim|first19=Sun|last20=Carrozzella|first20=Janice|last21=Palesch|first21=Yuko Y.|last22=Demchuk|first22=Andrew M.|last23=Bammer|first23=Roland|last24=Lavori|first24=Philip W.|last25=Broderick|first25=Joseph P.|last26=Lansberg|first26=Maarten G.|title=Thrombectomy for Stroke at 6 to 16 Hours with Selection by Perfusion Imaging|journal=New England Journal of Medicine|volume=378|issue=8|year=2018|pages=708–718|issn=0028-4793|doi=10.1056/NEJMoa1713973}}</ref>
+* Mechanical [[thrombectomy]] may be useful in selected patients with up to 24 hours of initiation of [[stroke]].<ref name="PowersRabinstein2019" /><ref name="AlbersMarks2018">{{cite journal|last1=Albers|first1=Gregory W.|last2=Marks|first2=Michael P.|last3=Kemp|first3=Stephanie|last4=Christensen|first4=Soren|last5=Tsai|first5=Jenny P.|last6=Ortega-Gutierrez|first6=Santiago|last7=McTaggart|first7=Ryan A.|last8=Torbey|first8=Michel T.|last9=Kim-Tenser|first9=May|last10=Leslie-Mazwi|first10=Thabele|last11=Sarraj|first11=Amrou|last12=Kasner|first12=Scott E.|last13=Ansari|first13=Sameer A.|last14=Yeatts|first14=Sharon D.|last15=Hamilton|first15=Scott|last16=Mlynash|first16=Michael|last17=Heit|first17=Jeremy J.|last18=Zaharchuk|first18=Greg|last19=Kim|first19=Sun|last20=Carrozzella|first20=Janice|last21=Palesch|first21=Yuko Y.|last22=Demchuk|first22=Andrew M.|last23=Bammer|first23=Roland|last24=Lavori|first24=Philip W.|last25=Broderick|first25=Joseph P.|last26=Lansberg|first26=Maarten G.|title=Thrombectomy for Stroke at 6 to 16 Hours with Selection by Perfusion Imaging|journal=New England Journal of Medicine|volume=378|issue=8|year=2018|pages=708–718|issn=0028-4793|doi=10.1056/NEJMoa1713973}}</ref>
-* In patients who undergo mechanical thrombectomy,blood pressure should be maintained below 180/105 mmHg during and for 24 hours after the procedure.<ref name="PowersRabinstein2019" />
+* In patients who undergo mechanical [[thrombectomy]],[[blood pressure]] should be maintained below 180/105 mmHg during and for 24 hours after the procedure.<ref name="PowersRabinstein2019" />
-*Mechanical thrombectomy with stent retrievers is recommended over intraarterial fibrinolysis as first-line therapy.<ref name="PowersRabinstein2019" />
+*Mechanical [[thrombectomy]] with stent retrievers is recommended over intra arterial [[fibrinolysis]] as first-line [[therapy]].<ref name="PowersRabinstein2019" />
-*The usefulness of emergency carotid endarterectomy, carotid angioplasty and stenting in the abscence of an intracranial clot is not well established.<ref name="PowersRabinstein2019" />
+*The usefulness of emergency carotid endarterectomy, [[carotid]] [[angioplasty]] and stenting in the absence of an intracranial clot is not well established.<ref name="PowersRabinstein2019" />
 ==== Mechanical thrombectomy with a stent retriever ====
-* Patients should receive mechanical thrombectomy with a stent retriever if they meet all the following criteria:<ref name="GoyalMenon2016">{{cite journal|last1=Goyal|first1=Mayank|last2=Menon|first2=Bijoy K|last3=van Zwam|first3=Wim H|last4=Dippel|first4=Diederik W J|last5=Mitchell|first5=Peter J|last6=Demchuk|first6=Andrew M|last7=Dávalos|first7=Antoni|last8=Majoie|first8=Charles B L M|last9=van der Lugt|first9=Aad|last10=de Miquel|first10=Maria A|last11=Donnan|first11=Geoffrey A|last12=Roos|first12=Yvo B W E M|last13=Bonafe|first13=Alain|last14=Jahan|first14=Reza|last15=Diener|first15=Hans-Christoph|last16=van den Berg|first16=Lucie A|last17=Levy|first17=Elad I|last18=Berkhemer|first18=Olvert A|last19=Pereira|first19=Vitor M|last20=Rempel|first20=Jeremy|last21=Millán|first21=Mònica|last22=Davis|first22=Stephen M|last23=Roy|first23=Daniel|last24=Thornton|first24=John|last25=Román|first25=Luis San|last26=Ribó|first26=Marc|last27=Beumer|first27=Debbie|last28=Stouch|first28=Bruce|last29=Brown|first29=Scott|last30=Campbell|first30=Bruce C V|last31=van Oostenbrugge|first31=Robert J|last32=Saver|first32=Jeffrey L|last33=Hill|first33=Michael D|last34=Jovin|first34=Tudor G|title=Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials|journal=The Lancet|volume=387|issue=10029|year=2016|pages=1723–1731|issn=01406736|doi=10.1016/S0140-6736(16)00163-X}}</ref>
+* Patients should receive mechanical [[thrombectomy]] with a stent retriever if they meet all the following criteria:<ref name="GoyalMenon2016">{{cite journal|last1=Goyal|first1=Mayank|last2=Menon|first2=Bijoy K|last3=van Zwam|first3=Wim H|last4=Dippel|first4=Diederik W J|last5=Mitchell|first5=Peter J|last6=Demchuk|first6=Andrew M|last7=Dávalos|first7=Antoni|last8=Majoie|first8=Charles B L M|last9=van der Lugt|first9=Aad|last10=de Miquel|first10=Maria A|last11=Donnan|first11=Geoffrey A|last12=Roos|first12=Yvo B W E M|last13=Bonafe|first13=Alain|last14=Jahan|first14=Reza|last15=Diener|first15=Hans-Christoph|last16=van den Berg|first16=Lucie A|last17=Levy|first17=Elad I|last18=Berkhemer|first18=Olvert A|last19=Pereira|first19=Vitor M|last20=Rempel|first20=Jeremy|last21=Millán|first21=Mònica|last22=Davis|first22=Stephen M|last23=Roy|first23=Daniel|last24=Thornton|first24=John|last25=Román|first25=Luis San|last26=Ribó|first26=Marc|last27=Beumer|first27=Debbie|last28=Stouch|first28=Bruce|last29=Brown|first29=Scott|last30=Campbell|first30=Bruce C V|last31=van Oostenbrugge|first31=Robert J|last32=Saver|first32=Jeffrey L|last33=Hill|first33=Michael D|last34=Jovin|first34=Tudor G|title=Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials|journal=The Lancet|volume=387|issue=10029|year=2016|pages=1723–1731|issn=01406736|doi=10.1016/S0140-6736(16)00163-X}}</ref>
-*# Prestroke mRS score of 0 to 1
+*# Pre[[stroke]] mRS score of 0 to 1
 *# Causative occlusion of the internal carotid artery or MCA segment 1 (M1)
 *# Age ≥18 years
-*# NIHSS score of ≥6
+*#[[National Institutes of Health Stroke Scale|NIHSS]] score of ≥6
-*# ASPECTS of ≥6; and
+*#[[ASPECT|ASPECTS]] of ≥6; and
-*# Treatment can be initiated within 6 hours of symptom onset
+*#[[Treatment]] can be initiated within 6 hours of [[Symptom|symptom onset]]
 ==== Aspiration thrombectomy ====
-* Aspiration thrombectomy has not been shown to be inferior to stent retriever.<ref name="TurkSiddiqui2019" />
+* Aspiration [[thrombectomy]] has not been shown to be inferior to [[stent]] retriever.<ref name="TurkSiddiqui2019" />
-* Direct aspiration thrombectomy as first-pass mechanical thrombectomy is recommended as noninferior to stent retriever for patients who meet all the following criteria:<ref name="TurkSiddiqui2019">{{cite journal|last1=Turk|first1=Aquilla S|last2=Siddiqui|first2=Adnan|last3=Fifi|first3=Johanna T|last4=De Leacy|first4=Reade A|last5=Fiorella|first5=David J|last6=Gu|first6=Eugene|last7=Levy|first7=Elad I|last8=Snyder|first8=Kenneth V|last9=Hanel|first9=Ricardo A|last10=Aghaebrahim|first10=Amin|last11=Woodward|first11=B Keith|last12=Hixson|first12=Harry R|last13=Chaudry|first13=Mohammad I|last14=Spiotta|first14=Alejandro M|last15=Rai|first15=Ansaar T|last16=Frei|first16=Donald|last17=Almandoz|first17=Josser E Delgado|last18=Kelly|first18=Mike|last19=Arthur|first19=Adam|last20=Baxter|first20=Blaise|last21=English|first21=Joey|last22=Linfante|first22=Italo|last23=Fargen|first23=Kyle M|last24=Mocco|first24=J|title=Aspiration thrombectomy versus stent retriever thrombectomy as first-line approach for large vessel occlusion (COMPASS): a multicentre, randomised, open label, blinded outcome, non-inferiority trial|journal=The Lancet|volume=393|issue=10175|year=2019|pages=998–1008|issn=01406736|doi=10.1016/S0140-6736(19)30297-1}}</ref>
+* Direct aspiration [[thrombectomy]] as first-pass mechanical [[thrombectomy]] is recommended as noninferior to stent retriever for patients who meet all the following criteria:<ref name="TurkSiddiqui2019">{{cite journal|last1=Turk|first1=Aquilla S|last2=Siddiqui|first2=Adnan|last3=Fifi|first3=Johanna T|last4=De Leacy|first4=Reade A|last5=Fiorella|first5=David J|last6=Gu|first6=Eugene|last7=Levy|first7=Elad I|last8=Snyder|first8=Kenneth V|last9=Hanel|first9=Ricardo A|last10=Aghaebrahim|first10=Amin|last11=Woodward|first11=B Keith|last12=Hixson|first12=Harry R|last13=Chaudry|first13=Mohammad I|last14=Spiotta|first14=Alejandro M|last15=Rai|first15=Ansaar T|last16=Frei|first16=Donald|last17=Almandoz|first17=Josser E Delgado|last18=Kelly|first18=Mike|last19=Arthur|first19=Adam|last20=Baxter|first20=Blaise|last21=English|first21=Joey|last22=Linfante|first22=Italo|last23=Fargen|first23=Kyle M|last24=Mocco|first24=J|title=Aspiration thrombectomy versus stent retriever thrombectomy as first-line approach for large vessel occlusion (COMPASS): a multicentre, randomised, open label, blinded outcome, non-inferiority trial|journal=The Lancet|volume=393|issue=10175|year=2019|pages=998–1008|issn=01406736|doi=10.1016/S0140-6736(19)30297-1}}</ref>
-*# Prestroke mRS score of 0 to 1;
+*# Pre[[stroke]] mRS score of 0 to 1;
 *# Causative occlusion of the internal carotid artery or M1;
 *# Age ≥18 years;
-*# NIHSS score of ≥6;
+*#[[National Institutes of Health Stroke Scale|NIHSS]] score of ≥6;
-*# ASPECTS ≥6; and
+*#[[ASPECT|ASPECTS]] ≥6; and
-*# Treatment initiation within 6 hours of symptom onset.
+*#[[Treatment]] initiation within 6 hours of symptom onset.
-==== Intraarterial fibrinolysis ====
+==== Intra arterial fibrinolysis ====
-* Intra-arterial fibrinolysis mat be initiated within 6 hours of stroke onset in selected patients in whom IV alteplase is contraindicated.
+* Intra-arterial fibrinolysis may be initiated within 6 hours of [[stroke]] onset in selected patients in whom [[Alteplase|IV alteplase]] is contraindicated.
 === Other aspects of management ===
-* Volume expansors are not recommended in ischemic stroke.<ref name="PowersRabinstein2019" /><ref name="GulumaLiebeskind2015">{{cite journal|last1=Guluma|first1=Kama Z.|last2=Liebeskind|first2=David S.|last3=Raman|first3=Rema|last4=Rapp|first4=Karen S.|last5=Ernstrom|first5=Karin B.|last6=Alexandrov|first6=Andrei V.|last7=Shahripour|first7=Reza B.|last8=Barlinn|first8=Kristian|last9=Starkman|first9=Sidney|last10=Grunberg|first10=Ileana D.|last11=Hemmen|first11=Thomas M.|last12=Meyer|first12=Brett C.|last13=Alexandrov|first13=Anne W.|title=Feasibility and Safety of Using External Counterpulsation to Augment Cerebral Blood Flow in Acute Ischemic Stroke—The Counterpulsation to Upgrade Forward Flow in Stroke (CUFFS) Trial|journal=Journal of Stroke and Cerebrovascular Diseases|volume=24|issue=11|year=2015|pages=2596–2604|issn=10523057|doi=10.1016/j.jstrokecerebrovasdis.2015.07.013}}</ref>
+* Volume expansors are not recommended in [[ischemic stroke]].<ref name="PowersRabinstein2019" /><ref name="GulumaLiebeskind2015">{{cite journal|last1=Guluma|first1=Kama Z.|last2=Liebeskind|first2=David S.|last3=Raman|first3=Rema|last4=Rapp|first4=Karen S.|last5=Ernstrom|first5=Karin B.|last6=Alexandrov|first6=Andrei V.|last7=Shahripour|first7=Reza B.|last8=Barlinn|first8=Kristian|last9=Starkman|first9=Sidney|last10=Grunberg|first10=Ileana D.|last11=Hemmen|first11=Thomas M.|last12=Meyer|first12=Brett C.|last13=Alexandrov|first13=Anne W.|title=Feasibility and Safety of Using External Counterpulsation to Augment Cerebral Blood Flow in Acute Ischemic Stroke—The Counterpulsation to Upgrade Forward Flow in Stroke (CUFFS) Trial|journal=Journal of Stroke and Cerebrovascular Diseases|volume=24|issue=11|year=2015|pages=2596–2604|issn=10523057|doi=10.1016/j.jstrokecerebrovasdis.2015.07.013}}</ref>
 * The best head positioning after stroke is not well established.<ref name="PowersRabinstein2019" /><ref name="AndersonArima2017">{{cite journal|last1=Anderson|first1=Craig S.|last2=Arima|first2=Hisatomi|last3=Lavados|first3=Pablo|last4=Billot|first4=Laurent|last5=Hackett|first5=Maree L.|last6=Olavarría|first6=Verónica V.|last7=Muñoz Venturelli|first7=Paula|last8=Brunser|first8=Alejandro|last9=Peng|first9=Bin|last10=Cui|first10=Liying|last11=Song|first11=Lily|last12=Rogers|first12=Kris|last13=Middleton|first13=Sandy|last14=Lim|first14=Joyce Y.|last15=Forshaw|first15=Denise|last16=Lightbody|first16=C. Elizabeth|last17=Woodward|first17=Mark|last18=Pontes-Neto|first18=Octavio|last19=De Silva|first19=H. Asita|last20=Lin|first20=Ruey-Tay|last21=Lee|first21=Tsong-Hai|last22=Pandian|first22=Jeyaraj D.|last23=Mead|first23=Gillian E.|last24=Robinson|first24=Thompson|last25=Watkins|first25=Caroline|title=Cluster-Randomized, Crossover Trial of Head Positioning in Acute Stroke|journal=New England Journal of Medicine|volume=376|issue=25|year=2017|pages=2437–2447|issn=0028-4793|doi=10.1056/NEJMoa1615715}}</ref>
-* Supplemental oxygen and mechanical ventilation support should be provided when necessary to maintain oxygen saturation higher than 93%.<ref name="PowersRabinstein2019" /><ref name="RoffeNevatte2017">{{cite journal|last1=Roffe|first1=Christine|last2=Nevatte|first2=Tracy|last3=Sim|first3=Julius|last4=Bishop|first4=Jon|last5=Ives|first5=Natalie|last6=Ferdinand|first6=Phillip|last7=Gray|first7=Richard|title=Effect of Routine Low-Dose Oxygen Supplementation on Death and Disability in Adults With Acute Stroke|journal=JAMA|volume=318|issue=12|year=2017|pages=1125|issn=0098-7484|doi=10.1001/jama.2017.11463}}</ref>
+* Supplemental [[oxygen]] and [[mechanical ventilation]] support should be provided when necessary to maintain [[oxygen saturation]] higher than 93%.<ref name="PowersRabinstein2019" /><ref name="RoffeNevatte2017">{{cite journal|last1=Roffe|first1=Christine|last2=Nevatte|first2=Tracy|last3=Sim|first3=Julius|last4=Bishop|first4=Jon|last5=Ives|first5=Natalie|last6=Ferdinand|first6=Phillip|last7=Gray|first7=Richard|title=Effect of Routine Low-Dose Oxygen Supplementation on Death and Disability in Adults With Acute Stroke|journal=JAMA|volume=318|issue=12|year=2017|pages=1125|issn=0098-7484|doi=10.1001/jama.2017.11463}}</ref>
-*Sources of hyperthermia (>38°C) should be identified and treated with antipyretics in patients with stroke.<ref name="PowersRabinstein2019" /><ref name="SaxenaYoung2015">{{cite journal|last1=Saxena|first1=Manoj|last2=Young|first2=Paul|last3=Pilcher|first3=David|last4=Bailey|first4=Michael|last5=Harrison|first5=David|last6=Bellomo|first6=Rinaldo|last7=Finfer|first7=Simon|last8=Beasley|first8=Richard|last9=Hyam|first9=Jonathan|last10=Menon|first10=David|last11=Rowan|first11=Kathryn|last12=Myburgh|first12=John|title=Early temperature and mortality in critically ill patients with acute neurological diseases: trauma and stroke differ from infection|journal=Intensive Care Medicine|volume=41|issue=5|year=2015|pages=823–832|issn=0342-4642|doi=10.1007/s00134-015-3676-6}}</ref>
+*Sources of [[hyperthermia]] (>38°C) should be identified and treated with [[Antipyretic|antipyretics]] in patients with [[stroke]].<ref name="PowersRabinstein2019" /><ref name="SaxenaYoung2015">{{cite journal|last1=Saxena|first1=Manoj|last2=Young|first2=Paul|last3=Pilcher|first3=David|last4=Bailey|first4=Michael|last5=Harrison|first5=David|last6=Bellomo|first6=Rinaldo|last7=Finfer|first7=Simon|last8=Beasley|first8=Richard|last9=Hyam|first9=Jonathan|last10=Menon|first10=David|last11=Rowan|first11=Kathryn|last12=Myburgh|first12=John|title=Early temperature and mortality in critically ill patients with acute neurological diseases: trauma and stroke differ from infection|journal=Intensive Care Medicine|volume=41|issue=5|year=2015|pages=823–832|issn=0342-4642|doi=10.1007/s00134-015-3676-6}}</ref>
-* Hypoglycemia (<60 mg/dL) should be treated in the acute setting in patients with ischemic stroke.<ref name="PowersRabinstein2019" />
+*[[Hypoglycemia]] (<60 mg/dL) should be treated in the acute setting in patients with [[ischemic stroke]].<ref name="PowersRabinstein2019" />
-*Blood pressure ≥220/120 in patients who did not receive TPA should be treated within the first 48 to 72 hours after the onset of ischemic stroke.<ref name="SchraderLüders2003">{{cite journal|last1=Schrader|first1=Joachim|last2=Lüders|first2=Stephan|last3=Kulschewski|first3=Anke|last4=Berger|first4=Jürgen|last5=Zidek|first5=Walter|last6=Treib|first6=Johannes|last7=Einhäupl|first7=Karl|last8=Diener|first8=Hans Christoph|last9=Dominiak|first9=Peter|title=The ACCESS Study|journal=Stroke|volume=34|issue=7|year=2003|pages=1699–1703|issn=0039-2499|doi=10.1161/01.STR.0000075777.18006.89}}</ref>
+*[[Blood pressure]] ≥220/120 in patients who did not receive [[Tissue plasminogen activator|TPA]] should be treated within the first 48 to 72 hours after the onset of [[ischemic stroke]].<ref name="SchraderLüders2003">{{cite journal|last1=Schrader|first1=Joachim|last2=Lüders|first2=Stephan|last3=Kulschewski|first3=Anke|last4=Berger|first4=Jürgen|last5=Zidek|first5=Walter|last6=Treib|first6=Johannes|last7=Einhäupl|first7=Karl|last8=Diener|first8=Hans Christoph|last9=Dominiak|first9=Peter|title=The ACCESS Study|journal=Stroke|volume=34|issue=7|year=2003|pages=1699–1703|issn=0039-2499|doi=10.1161/01.STR.0000075777.18006.89}}</ref>
-*Enteral feeding should be started within 7 days of admission after an acute stroke when there is no contraindications.<ref name="pmid16409880">{{cite journal |vauthors=Dennis M, Lewis S, Cranswick G, Forbes J |title=FOOD: a multicentre randomised trial evaluating feeding policies in patients admitted to hospital with a recent stroke |journal=Health Technol Assess |volume=10 |issue=2 |pages=iii–iv, ix–x, 1–120 |date=January 2006 |pmid=16409880 |doi=10.3310/hta10020 |url=}}</ref>
+*[[Enteral feeding]] should be started within 7 days of admission after an acute [[stroke]] when there is no [[Contraindication|contraindications]].<ref name="pmid16409880">{{cite journal |vauthors=Dennis M, Lewis S, Cranswick G, Forbes J |title=FOOD: a multicentre randomised trial evaluating feeding policies in patients admitted to hospital with a recent stroke |journal=Health Technol Assess |volume=10 |issue=2 |pages=iii–iv, ix–x, 1–120 |date=January 2006 |pmid=16409880 |doi=10.3310/hta10020 |url=}}</ref>
-*Psychological screening is always recommended to exclude poststroke depression.<ref name="MeaderMoe-Byrne2013">{{cite journal|last1=Meader|first1=N.|last2=Moe-Byrne|first2=T.|last3=Llewellyn|first3=A.|last4=Mitchell|first4=A. J.|title=Screening for poststroke major depression: a meta-analysis of diagnostic validity studies|journal=Journal of Neurology, Neurosurgery & Psychiatry|volume=85|issue=2|year=2013|pages=198–206|issn=0022-3050|doi=10.1136/jnnp-2012-304194}}</ref>
+*[[Psychological]] screening is always recommended to exclude poststroke depression.<ref name="MeaderMoe-Byrne2013">{{cite journal|last1=Meader|first1=N.|last2=Moe-Byrne|first2=T.|last3=Llewellyn|first3=A.|last4=Mitchell|first4=A. J.|title=Screening for poststroke major depression: a meta-analysis of diagnostic validity studies|journal=Journal of Neurology, Neurosurgery & Psychiatry|volume=85|issue=2|year=2013|pages=198–206|issn=0022-3050|doi=10.1136/jnnp-2012-304194}}</ref>
-*Early rehabilitation in patients with stroke is adviced.<ref name="PowersRabinstein2019" />
+*Early [[Rehabilitation counseling|rehabilitation]] in patients with [[stroke]] is adviced.<ref name="PowersRabinstein2019" />
 === Primary Prevention ===
-*There are no established measures for the primary prevention of COVID-19 associated stroke.
+*[[Smoking cessation]] should be highly encouraged in patients who suffered from [[stroke]], behavioral interventions and [[Nicotine replacement therapy|nicotine replacement]] may be necessary.
-*Smoking cessation should be highly encouraged in patients who suffered from stroke, behavioral interventions and nicotine replacement may be necessary.
 ===Secondary Prevention===
-*There are no established measures for the secondary prevention of COVID-19 associated stroke.
+*There are no established measures for the [[secondary prevention]] of [[COVID-19]] associated stroke.
 ==References==