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available to guide selection of medications for the lowering of blood pressure in the setting of acute ischemic stroke. The recommended medications and doses included in Table 10 are based on general consensus (Class IIa, Level of Evidence C). The recommendations in Table 10 have changed from the previous statements. 2.Evidence from one clinical trial indicates that initiation of antihypertensive therapy within 24 hours of stroke is relatively safe. Thus, it is generally agreed that antihypertensive medications should be restarted at ≈24 hours for patients who have preexisting hypertension and are neurologically stable unless a specific contraindication to restarting treatment is known (Class IIa, Level of Evidence B). This recommendation was not included in previous statements. 3. Evidence indicates that persistent hyperglycemia (>140 mg/dL) during the first 24 hours after stroke is associated with poor outcomes, and thus it is generally agreed that hyperglycemia should be treated in patients with acute ischemic stroke. The minimum threshold described in previous statements likely was too high, and lower serum glucose concentrations (possibly >140 to 185 mg/dL) probably should trigger administration of insulin, similar to the procedure in other acute situations accompanied by hyperglycemia (Class IIa, Level of Evidence C). This is a change from previous statements. Close monitoring of glucose concentrations with adjustment of insulin doses to avoid hypoglycemia is recommended. Simultaneous administration of glucose and potassium also may be appropriate. The results of ongoing research should clarify the management of hyperglycemia after stroke. Class III Recommendations 1. Nonhypoxic patients with acute ischemic stroke do not need supplemental oxygen therapy (Class III, Level of Evidence B). This recommendation has not changed from previous statements. 2. Data on the utility of hyperbaric oxygen are inconclusive, and some data imply that the intervention may be harmful. Thus, with the exception of stroke secondary to air embolization, this intervention is not recommended for treatment of patients with acute ischemic stroke (Class III, Level of Evidence B). This recommendation has changed from previous statements. 3. Although data demonstrate the efficacy of hypothermia for improving neurological outcomes after cardiac arrest, the utility of induced hypothermia for the treatment of patients with ischemic stroke is not established. At the present time, insufficient evidence exists to recommend hypothermia for treatment of patients with acute stroke (Class III, Level of Evidence B). This recommendation has not changed from previous statements. Additional research on the safety and efficacy of induced hypothermia for treatment of patients with stroke is under way. VI. INTRAVENOUS THROMBOLYSIS A. Recombinant Tissue Plasminogen ActivatorIntravenous thrombolytic therapy for acute stroke is now generally accepted.298 The US Food and Drug Administration (FDA) approved the use of intravenous rtPA in 1996, partly on the basis of the results of the NINDS rtPA Stroke Study, in which 624 patients with ischemic stroke were treated with placebo or rtPA (0.9 mg/kg IV, maximum 90 mg) within 3 hours of symptom onset, with approximately one half treated within 90 minutes.66 The study was conducted in 2 parts. In part I, the primary end point was neurological improvement at 24 hours, as indicated by complete neurological recovery or an improvement of ≥4 points on the NIHSS. In part II, the pivotal efficacy trial, the primary end point was a global odds ratio for a favorable outcome, defined as complete or nearly complete neurological recovery 3 months after stroke. Favorable outcomes were achieved in 31% to 50% of patients treated with rtPA, as compared with 20% to 38% of
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