Advances in the treatment of acute ischemic stroke: the 2018 American Stroke Association recommendation

The imaging studies should be performed within 20 minutes after arrival and the door-to-needle time should be less than 60 minutes in more than 50 % of the patients. The time-windows and the outcome should be evaluated systematically. If the patient is suitable for intravenous (IV) thrombolysis within 3 hours (based on imaging) only the blood glucose measurement should precede the IV lysis. IV thrombolysis within 3 hours is recommended not only in case of severe stroke, but also in patients with severe isolated symptoms (e.g. aphasia or visual field defect) and in patients with improving paresis. The IV lysis should be considered both in patients on aspirin monotherapy or aspirin+clopidogrel therapy. The criteria for stroke cases between 3 to 4.5 hours became less exclusive: IV intervention can be considered in patients ≥80years, in patients with previous stroke and diabetes and also in patients with INR < 1.7. Mechanical thrombectomy (for interna or media occlusion) can be also considered within 4.5 hours after a non-successful intravenous thrombolysis. Other criteria for mechanical thrombectomy (interna or media occlusion) between 4.5 and 6 hours: NIHSS ≥ 6, ASPECTS score ≥ 6. For patients with interna or media occlusion between 6 and 16 hours, only mechanical thrombectomy could be recommended (by Solitaire or TREVO retriever), if the patient has large penumbra (confirmed by either perfusion CT or MRI and following the criteria of DAWN and DEFUSE-3 studies). Between 16 and 24 hours after stroke, a mechanical thrombectomy can be considered (selected by perfusion CT or MRI), if the patient fulfills DAWN criteria.