2013 stroke management guidelines

7/27/2019 2013 Stroke Management Guidelines

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T. Lianne Beck, MD, FAAFP

Assistant Professor

Emory Family Medicine Residency Program


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Sudden focal neurological deficit or acuteneurological impairment caused by the interruptionof blood flow to a specific region of the brain

780,000 suffer a new or repeat stroke in U.S. eachyear

4th leading cause of death in US in 2008

Leading cause of disability in US

Updated guidelines by the AHA and ASA released in

January 31, 2013


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Classically a focal neurologic event lasting < 24hours

Epidemiology

180,000 TIA/yr in US About half those experiencing TIA do not report it

Pathophysiology - similar to stroke, but unknownwhy similar events produce TIA only

Recent studies find most TIAs resolve by one hour Up to half of traditionally defined patients with TIA

will show ischemia on diffusion weighted MRI


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History/PE

Unilateral arm drift, facial paresis and dysphasia are most

predictive symptoms

All sxs +LR 14 and None -LR 0.39 (SORT B) Etiology

Atherosclerotic

Embolic

Nonatherosclerotic vasculopathies

Other

Goldstein LB, Simel DL. Is this patient having a stroke?Jama. May 18 2005;293(19):2391-2402.


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TIA should be considered a stroke-prone state

(SORT A)

60% of the 90 day CVA risk after TIA is in first week.

Range for 48h risk 1.4-4.9%; for 1 week risk 3-8.6%.

Individuals who have a TIA have a 10-year stroke

risk of 18.8% and a combined 10-year stroke, MI, or

vascular death risk of42.8% (4% per year).

Johnston SC, Rothwell PM, Nguyen-Huynh MN, etal. Lancet. Jan 27 2007;369(9558):283-292.


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Non-Modifiable RF

Age

Race Sex

Low BW

FamHx

Modifiable RF withevidence of benefit (SORT)

HTN (A)

Smoking (B) Diabetes (A)

Hyperlipidemia (A)

Atrial fibrillation (A)

Asymptomatic high-grade

(>60%) carotid stenosis (B) Transfusion therapy for Sickle

Cell Disease - (B)

Goldstein LB, Adams R, Alberts MJ, et al. Primaryprevention of ischemic stroke. Circulation. Jun 20

2006;113(24):e873-923.


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Yes10 year CVD risk

> 6-10%SORT A

MaybeLower risk women

especially > 65 y/oSORT B

NoLower risk men of

any ageSORT A

Source: UPSTF and AHA Guidelines


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CHADS2

Score

Risk Level Stroke

Rate (%/y)

Treatment

0 Low 1 ASA

1-2 Intermediate 1.5 - 2.5ASA or

Warfarin

3 High 5 Warfarin

JAMA 2003;290:2685 and AHA/ASA Primary Stroke Prevention

Guideline, 2006


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Selected modifiable RF

without evidence for

benefit

Sodium intake Physical activity

Obesity

ETOH > 5 drinks/day

Inflammatory markers& conditions

Stroke Risk Assessment

Recommended by

AHA/ASA (Level I-A)

No trial data to supportbenefit (SORT C)

Web calculators http://www.stroke-

education.com/calc/risk_calc.do

http://www.thecni.org/stroke/risktest.htm

Goldstein LB, Adams R, Alberts MJ, et al. Primary prevention of ischemic stroke. Circulation. Jun 20

2006;113(24):e873-923.
http://www.stroke-education.com/calc/risk_calc.dohttp://www.stroke-education.com/calc/risk_calc.dohttp://www.thecni.org/stroke/risktest.htmhttp://www.thecni.org/stroke/risktest.htmhttp://www.thecni.org/stroke/risktest.htmhttp://www.thecni.org/stroke/risktest.htmhttp://www.stroke-education.com/calc/risk_calc.dohttp://www.stroke-education.com/calc/risk_calc.dohttp://www.stroke-education.com/calc/risk_calc.do


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Cause

Thrombotic

Embolic

Vasoconstriction

Manifestation

Occlusion of artery to specific area of braincauses specific neurologic syndrome


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Cause

Primary (70-90%)

- Hypertension, amyloidangiopathy

Secondary (10-30%)- Vascular malformation

(aneurysm, AVM, tumor,thrombolytic agents)

Manifestation Rupture of blood vessel with

surrounding tissue damage

- symptoms of increased ICP

KEY POINTS

- Non-contrast CTpositive for bleed

- 50% mortality (80% ofthese with permanentdisability)

- ICP monitoring

- Neurosurgicalintervention


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Stroke education 911

Prehospital assessment tools

Field management Rapid transport to stroke center

Prehospital notification

The Bottom Line: Focus on limiting delays andrecognizes that interhospital transfers of acute

stroke patients for higher-level care are

increasingly common


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Unchanged: Physicians and hospital (EMS) personnelshould participate in stroke education programs; 911services should be used with stroke reports prioritized; andprehospital providers should use diagnostic criteria, such asthe Los Angeles Prehospital Stroke Screen or the Cincinnati

Prehospital Stroke Scale, and initiate management in thefield.

Revised: Patients should be transported to the closestcertified primary or comprehensive stroke center or, whensuch an institution is not available, the closest facility

offering emergency stroke care. In some instances, thismay involve air medical transport and hospital bypass.Field personnel should notify the receiving facility that apotential stroke patient will be arriving to facilitateresource mobilization


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Establish primary and comprehensive stroke centers Establish acute stroke-ready hospitals

Independent, external certification

Quality improvement committee

Bypass unequipped hospitals Teleradiology when necessary

Telestroke consultation

The Bottom Line: The section highlights the emergence

of comprehensive stroke centers and their integrationinto regional systems of care. Teleradiology isdeveloping as a resource while data continue tosupport the use of telemedicine and qualityimprovement processes in stroke care.


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Unchanged: Where resources are available, establishing affiliated

primary and comprehensive stroke centers is recommended. Hospitalswithout adequate stroke care resources should be bypassed by EMSpersonnel in favor of the closest facility with adequate resources.

Revised: Stroke centers should ideally be certified by an independentexternal organization (ie, The Joint Commission, state health

department).

New: Forming quality improvement committees and stroke care databanks is recommended. US Food and Drug Administration (FDA)-approved teleradiology systems are recommended for CT and MRI scanreview in patients with a suspected acute stroke when the care sites

lack in-house imaging interpretation expertise; such systems can aid infibrinolysis decision-making. Telestroke consultation, along witheducation and training, at centers without adequate stroke expertisecan increase the appropriate use of intravenous (IV) recombinanttissue-type plasminogen activator (rtPA). Establishing acute stroke-ready hospitals affiliated with primary and comprehensive strokecenters is recommended when possible.


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Organized protocol

Stroke rating scale

Hematologic, coagulation, and biochemistry tests

Only blood glucose must precede rtPA

The Bottom Line: Fibrinolytic therapy should now

not be delayed while awaiting laboratory test

results other than a glucose determination, exceptin selected patients.


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Unchanged: Apply an organized protocol for the emergencyevaluation of patients with suspected stroke, ideally completingevaluation and fibrinolytic treatment within 60 minutes of patientarrival. A neurologic exam should be included in the clinicalassessment and a stroke team including physicians, nurses,laboratory personnel, and radiology personnel should bedesignated. Using a stroke rating scale -- namely the NationalInstitutes of Health Stroke Scale (NIHSS) -- is recommended.

Revised: Recommended tests for all patients* suspected of anacute ischemic stroke include blood glucose, oxygen saturation,

electrolytes/renal function tests, complete blood count,troponin assessment, prothrombin time/internationalnormalized ratio (INR), activated partial thromboplastin time,and an ECG; only a blood glucose measurement must precede IVrtPA administration.


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Noncontrast CT or MRI prior to therapy

IV fibrinolysis if ischemic changes present

Possible intracranial vascular study

Consider CT/MRI perfusion and diffusion imaging Large CT hypodensity withhold rtPA

The Bottom Line: While advanced imaging techniquesmay help to select patients outside of the fibrinolysis

time window, noncontrast CT or MRI can excludehemorrhage and hypodensity involving more than onethird of the middle cerebral artery territory prior tofibrinolytic therapy.


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Unchanged: In patients in whom ischemic symptoms have notresolved, brain imaging is recommended prior to initiatingtherapy. In most cases, a CT scan provides adequate informationto inform treatment decisions.

Revised: Noncontrast CT scan or MRI -- ideally interpreted within

45 minutes -- is recommended prior to rtPA administration toexclude hemorrhagic stroke and assess for signs of ischemia. Ifearly ischemic changes are present, IV fibrinolytic therapy isrecommended. And if intra-arterial fibrinolysis or mechanicalthrombectomy is being considered -- which should not delay IVrtPA -- a noninvasive intracranial vascular study is recommended

during imaging. Consider CT/MRI perfusion and diffusion imagingto help select patients for reperfusion therapy beyond thefibrinolysis time window. Lastly, fibrinolysis in the setting of a"frank hypodensity" on noncontrast CT may increase hemorrhagerisk; if more than one third of the middle cerebral artery territoryis involved IV rtPA should be avoided.


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Suspected transient ischemic attacks (TIAs)

Noninvasive cervical vessel imaging

Transient ischemic symptoms Neuroimaging

within 24 hours Steno-occlusive disease CT angiography or MR

angiography of intracranial vasculature

The Bottom Line: MRI remains preferred over CTfor imaging patients with suspected TIAs because it

can provide insight into whether a stroke has

occurred


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Unchanged: In patients with suspected TIAs, noninvasiveimaging of cervical vessels is indicated. In those withtransient ischemic neurologic symptoms, neuroimaging isrecommended within 24 hours of symptom onset or assoon as possible in cases of delayed presentation. MRI ispreferred over CT.

Revised: In cases of known steno-occlusive disease, CTangiography or MR angiography of intracranialvasculature is recommended to assess for proximalintracranial stenosis and/or occlusion. Catheterangiography is necessary to confirm diagnosis and assessstenosis severity.


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Lower blood pressure (BP) to < 185/110 mm Hg before rtPA

Maintain BP below 180/105 mm Hg for at least 24 hoursafter rtPA

Airway support if necessary

Treat hyperthermia

No O2 if not hypoxic

The Bottom Line: While the recommendation is to pursuecontinuous cardiac monitoring for at least 24 hours, recent

data suggest that Holter monitoring for longer periods maybe more useful for the detection of atrial fibrillation. BPmanagement in those acute stroke patients who have notreceived fibrinolytics continues to be limited by insufficientdata to guide timing and target pressure goals.


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Unchanged: Though data do not exist guidingantihypertensive selection in acute ischemic stroke,elevated BP should be lowered to < 185 mm Hg/< 110mm Hg before rtPA is given and maintained below

180/105 mm Hg for at least 24 hours after startingtherapy; these recommendations also apply to patientsundergoing recanalization procedures (including intra-arterial fibrinolysis). In cases of decreased

consciousness or bulbar dysfunction, airway supportand ventilatory assistance are recommended. Sourcesof hyperthermia should be identified and treated and,in nonhypoxic patients, supplemental oxygen is notrecommended.


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Cardiac monitoring

Oxygen and hypovolemia correction

Lower BP in those not receiving fibrinolysis;

medication only if BP > 200 mm Hg/120 mmHg

Pre-existing hypertension Restart medication

Treat glucose abnormalities


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Revised: Cardiac monitoring for at least 24 hours isrecommended to screen for arrhythmias, which, if present,should be corrected. Hypovolemia should be corrected with IVsaline, and supplemental oxygen should be administered toachieve > 94% saturation. Lowering BP by 15% during the first 24

hours following stroke onset is considered a reasonable goal inpatients with high BP not receiving fibrinolysis, bearing in mindthat, according to the new guidelines, "consensus exists thatmedications should be withheld unless the systolic BP is > 220mm Hg or the diastolic BP is > 120 mm Hg." Antihypertensivemedications can be restarted in stable patients with pre-existing

hypertension after 24 hours, and one trial[2] even supportsresuming therapy within 24 hours. Blood glucose < 60 mg/dLshould be treated, ideally to normal, and hyperglycemia shouldbe treated to a range of 140-180 mg/dL.


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IV rtPA in eligible patients at up to 4.5 hours;treatment within 60 minutes of presentation tohospital ideal

IV rtPA contingent upon BP control

Additional rtPA exclusion criteria for 3- to 4.5-hourwindow

Other fibrinolytic or defibrinogenating agents notrecommended

Sonothrombolysis efficacy not well established rtPA is not recommended if taking direct thrombin

inhibitors or direct factor Xa inhibitors, unless qualifiedbased on lab panel (see caption)


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The Bottom Line: The authors of the current guidelines

note that the FDA declined to approve IV rtPA within

the 3- to 4.5-hour window in the United States but,

after reviewing the decision correspondence to which

the authors had partial access, felt that the existing

grade B recommendation remained reasonable. The

guidelines also provide support for the use of rtPA in

certain previously excluded groups, such as those with

rapidly improving neurologic symptoms or with recent

myocardial infarction, while weighing potential risks

and benefits. They also emphasize early treatment.


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Unchanged: IV rtPA at a dose of 0.9 mg/kg

(maximum dose 90 mg) is recommended if patients

can be treated within 3 hours of symptom onset

and if BP can be lowered with antihypertensives tobelow 185/110 mm Hg. rtPA is appropriate in

patients who have also suffered a seizure, provided

residual symptoms are stroke related and not

postictal.


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Revised: rtPA is recommended in eligible patients in the3- to 4.5-hour window. Eligibility criteria are similar tothose for the 3-hour window except for the exclusion ofpatients over 80 years old, those on oral anticoagulants,

those with a baseline NIHSS score > 25, those withimaging evidence of ischemic damage to more than onethird of the middle cerebral artery (MCA) territory, andthose with a history of both stroke and diabetesmellitus. Physicians should be prepared to managepotential side effects such as bleeding and angioedema.Streptokinase is not recommended for acute stroke, norare other fibrinolytic or defibrinogenating agents.


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New: Eligible patients should receive rtPA therapy as soonas possible, ideally within 60 minutes of hospital arrival. IVfibrinolysis can be considered in patients with rapidlyimproving symptoms, mild stroke deficits, major surgerywithin the past 3 months, and recent myocardial infarction;risks should be weighed against benefits. The guidelinesstate that "the effectiveness of sonothrombolysis fortreatment of patients with acute stroke is not wellestablished." Lastly, rtPA is not recommended in patients

taking direct thrombin inhibitors or direct factor Xainhibitors unless tests including activated partialthromboplastin time, INR, platelet count, ecarin clottingtime, thrombin time, or direct factor Xa activity are normal;or they haven't taken these agents for > 2 days.


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Give IV rtPA, even if considering intra-arterial management

Early intra-arterial fibrinolysis in select patients at qualifiedfacility

Outcomes with mechanical thrombectomy devices not fully

established but can be useful in achieving recanalization inselect patients

Stent retrievers preferred to coil devices; Penumbra Systemvs stent retrievers not yet characterized

Emergent intracranial angioplasty and/or shunting not

recommended The Bottom Line: Two mechanical embolectomy trials in

acute stroke published in 2012, SWIFT[3] and TREVO 2,[4]support the use of stent retriever devices over the use ofthe Merci Retriever.


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Unchanged: IV rtPA should be administered to eligiblepatients even if intra-arterial interventions are beingconsidered

Revised: Select patients with MCA strokes of < 6 hoursduration who are not IV rtPA candidates can benefit fromintra-arterial fibrinolysis, which should be administered at anexperienced stroke center with rapid cerebral angiographycapabilities and defined qualification criteria. Though theirultimate impact on patient outcomes has yet to be

determined, the Merci, Penumbra System, Solitaire FR, andTrevo devices can be useful in recanalizing the occludedartery, either alone or in combination with pharmacologicfibrinolysis. Intra-arterial fibrinolysis or mechanicalthrombectomy can be considered in patients unqualified forIV fibrinolysis.


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New: Minimizing delays in administering intra-arterialfibrinolysis improves outcomes. Stent retrievers such asSolitaire FR and Trevo are preferred to coil retrieverssuch as Merci, whereas the effectiveness of thePenumbra System vs stent retrievers is, as of the newguideline's publication, not yet determined. In patientswith a large artery stroke who have not responded to IVfibrinolysis, intra-arterial fibrinolysis and mechanicalthrombectomy are reasonable approaches. Emergentintracranial angioplasty and/or shunting do not have

proven usefulness, nor does the use of theseapproaches in the extracranial carotid or vertebralarteries in unselected patients.


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Urgent anticoagulation not recommended inacute ischemic stroke

Urgent anticoagulation not recommended fornoncerebrovascular conditions in the setting of

stroke Anticoagulation with 24 hours of IV rtPA not

recommended

Efficacy of thrombin inhibitors not well

established in acute stroke

The Bottom Line: Trials have not yet providedindications for anticoagulation in acute stroke.


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Unchanged: Urgent anticoagulation is notrecommended in acute ischemic stroke, nor is it fornoncerebrovascular conditions in the setting ofmoderate-to-severe strokes due to an increased risk

for intracerebral hemorrhage. Anticoagulation within24 hours of IV rtPA administration is also notrecommended.

New: The usefulness of argatroban and other

thrombin inhibitors in acute ischemic stroke is not wellestablished at the time of guideline publication, nor isthe usefulness of anticoagulating patients with severestenosis of an internal carotid artery ipsilateral to anischemic stroke.


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Aspirin within 24-48 hours

Other antiplatelet agents not recommended

The Bottom Line: Aspirin remains the only antiplatelet

agent for which data support use in acute stroke,although trials with other agents are in progress.

Unchanged: Oral aspirin is recommended for most

patients within 24-48 hours of initial symptoms;

however, it is not a suitable substitute for other acutestroke interventions, including rtPA.


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Revised: Clopidogrel's usefulness is not well

established, and the use of IV antiplatelet drugs

that inhibit the glycoprotein IIb/IIIa receptor is not

recommended. Adjunctive aspirin, or otherantiplatelet therapies, within 24 hours of IV

fibrinolysis are also not recommended.

New: The efficacy of glycoprotein IIb/IIIa inhibitors

tirofiban and eptifibatide is not well-established.


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Vasodilators not recommended

Consider vasopressors with symptomatic hypotension

Efficacy of drug-induced hypertension and hemodilutionby volume not well established

The Bottom Line: In the fall of 2012, the data and safetymonitoring board terminated the Albumin in AcuteStroke (ALIAS) trial[5] following an interim analysis. In theSENTIS trial[6] of mechanical augmentation of collateral

flow, the group treated with the NeuroFlo device failedto meet primary efficacy outcomes compared with thecontrol population, although they showed a trendtoward reduced mortality.


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Unchanged: Vasodilators such as pentoxifylline are notrecommended.

Revised: In patients with neurologic symptoms due tohypotension, vasopressors are warranted. Cardiacmonitoring is recommended if drug-inducedhypertension is used; however, in most patients withacute ischemic stroke the usefulness of this approach isnot well established, nor is the usefulness of

hemodilution by volume expansion. New: Until additional evidence is available, high-dose

albumin is not appropriate for most patients, nor aredevices to increase cerebral blood flow.


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Hyperbaric oxygen not recommended, except for airembolization

Continue statins

Transcranial near-infrared laser therapy and otherneuroprotective drugs not recommended

The Bottom Line: No trial has yet shown benefit for a

neuroprotective agent in acute stroke. A few agents remain intrials, such as a phase 3 trial of magnesium delivered in the fieldby paramedics.

Unchanged: Hyperbaric oxygen is not recommended except incases of stroke due to air embolization.

Revised: No other potentially neuroprotective drugs arerecommended, nor is induced hypothermia.

New: In patients taking statins at the time of stroke, continuingstatin therapy is reasonable. The usefulness of transcranial near-infrared laser therapy is not well established at this time.


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Urgent carotid endarterectomy efficacy not established incertain patients

The Bottom Line: Data do not currently support the use ofurgent carotid endarterectomy in patients with unstable

neurologic status. The risks of endarterectomy in this settingmust be weighed against the risks of medical therapy.

New: When imaging studies or clinical indicators suggest a smallinfarct core with a large area at risk due to inadequate flow from

carotid stenosis or occlusion, or in cases of neurologic sequelaefollowing carotid endarterectomy, emergent or urgent carotidendarterectomy does not have well-established efficacy, nor isthere convincing evidence that carotid endarterectomy shouldbe used in patients with unstable neurologic status.


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Comprehensive stroke management with standardized careorders and rehabilitation

Swallowing assessment

Deep vein thrombosis (DVT) prevention/early mobilization

Manage comorbidities and institute recurrent strokeprevention

Bladder catheters not recommended

Tube feeding if necessary

Nutritional supplements and prophylactic antibiotics not

proven effective The Bottom Line: The authors recommend the use of

comprehensive, specialized stroke care (stroke units) and donot make significant changes to earlier guidelines in thisarea.


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Unchanged: Comprehensive stroke care, standardizedstroke care order sets, and rehabilitation arerecommended, and swallowing ability should beassessed before patients eat, drink, or receive oral

medications. Immobilized patients should be treatedwith subcutaneous anticoagulants to prevent DVT,while less severely affected patients should bemobilized early. Comorbid medical conditions shouldbe managed appropriately, and recurrent stroke

prevention interventions should be instituted. Inpatients in whom anticoagulation is contraindicated,consider aspirin for DVT prevention. Lastly, routineindwelling bladder catheters are not recommended.


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Revised: Antibiotics should be used in cases ofpotential pneumonia or UTIs. Nasogastric,nasoduodenal, or percutaneous endoscopicgastrostomy tube feeding should be used in patients

unable to take liquids or solid food. Nasogastric feedingis preferred to percutaneous endoscopy gastrostomytube feeding until 2-3 weeks post-stroke in patientswho cannot take oral liquid and food. In patients inwhom anticoagulation is contraindicated, consider

external compression devices. Routine nutritionalsupplements and prophylactic antibiotics have not beenshown to be beneficial.


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Antiepileptics for recurrent seizures but not forprophylaxis

Corticosteroids not recommended

Minimize brain edema/intracranial pressure

Monitor closely and facilitate access toneurosurgical center if necessary

Decompressive surgery if necessary

Consider ventricular drain for acute hydrocephalus The Bottom Line: While decompressive surgery has

been shown to be lifesaving, the guidelines urgethat the decision be made on an individual basis.


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Unchanged: Antiepileptic therapy should beadministered in cases of recurrent seizures following

a stroke; however, prophylactic anticonvulsants are

not recommended. Corticosteroids are not

recommended for cerebral edema and increasedintracranial pressure.


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Revised: Measures should be taken to reduce risk for brain edemaand increased intracranial pressure in patients with majorinfarctions. Patients should be closely monitored for worseningstroke symptoms and, in those at risk for malignant brain edema,consider early transfer to a facility with adequate neurologicresources if necessary. Aggressive medical treatment has been

previously recommended in deteriorating patients with malignantedema due to a large cerebral infarction; however, the usefulnessof this approach is not well established. Decompressive surgicalevacuation of a space-occupying cerebellar infarction can preventand treat herniation and potential compression of the brain stem.Decompressive surgery is also effective for malignant cerebral

edema; however, patient age and achievable outcomes should beweighed and patient/family wishes considered. In cases of stroke-induced acute hydrocephalus, a ventricular drain can beconsidered.


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SORT A Antiplatlet therapy

CVA - Aspirin 325mg within 24-48 hours

TIA - Aspirin (50-325mg), clopidogrel (75mg) or

ASA/Dipyridamole Statins - LDL < 100

Antihypertensives - beyond acute period

Carotid Endarterectomy (CEA) >50% stenosis

Anticoagulation for cardioembolic disease

Sacco RL, Adams R, Albers G, et al. Circulation. Mar 14 2006;113(10):e409-449.


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SORT B

Statins for all TIA/CVA patients

Early CEA (


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SORT C

Smoking cessation

Alcohol moderation

Weight reduction BMI < 25 Physical activity 30 min/d moderate intensity

Sacco RL, Adams R, Albers G, et al. Circulation. Mar 14 2006;113(10):e409-449.


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Jauch EC, Saver JL, Adams HP Jr, et al. Guidelines for the early management ofpatients with acute ischemic stroke: a guideline for healthcare professionalsfrom the American Heart Association/American Stroke Association. Stroke. 2013Jan 31. [Epub ahead of print]

Potter JF, Robinson TG, Ford GA, et al. Controlling hypertension and hypotensionimmediately post-stroke (CHHIPS): a randomised, placebo-controlled, double-blind pilot trial. Lancet Neurol. 2009;8:48-56.

Saver JL, Jahan R, Levy EI, et al. Solitaire flow restoration device versus the MerciRetriever in patients with acute ischaemic stroke (SWIFT): a randomised,parallel-group, non-inferiority trial. Lancet. 2012;380:1241-1249.

Nogueira RG, Lutsep HL, Gupta R, et al. Trevo versus Merci retrievers forthrombectomy revascularisation of large vessel occlusions in acute ischaemicstroke (TREVO 2): a randomised trial. Lancet. 2012;380:1231-1240.

ClinicalTrials.gov. Albumin in Acute Ischemic Stroke Trial (ALIAS). November2012. http://clinicaltrials.gov/show/NCT00235495 Accessed February 19, 2013.

Shuaib A, Bornstein NM, Diener HC, et al. Partial aortic occlusion for cerebralperfusion augmentation: safety and efficacy of NeuroFlo in Acute IschemicStroke trial. Stroke. 2011;42:1680-1690.

2013 stroke management guidelines

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