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
This article has been corrected.
VIEW CORRECTIONAbstract
Background and Purpose—
The purpose of these guidelines is to provide an up-to-date comprehensive set of recommendations in a single document for clinicians caring for adult patients with acute arterial ischemic stroke. The intended audiences are prehospital care providers, physicians, allied health professionals, and hospital administrators. These guidelines supersede the 2013 Acute Ischemic Stroke (AIS) Guidelines and are an update of the 2018 AIS Guidelines.
Methods—
Members of the writing group were appointed by the American Heart Association (AHA) Stroke Council’s Scientific Statements Oversight Committee, representing various areas of medical expertise. Members were not allowed to participate in discussions or to vote on topics relevant to their relations with industry. An update of the 2013 AIS Guidelines was originally published in January 2018. This guideline was approved by the AHA Science Advisory and Coordinating Committee and the AHA Executive Committee. In April 2018, a revision to these guidelines, deleting some recommendations, was published online by the AHA. The writing group was asked review the original document and revise if appropriate. In June 2018, the writing group submitted a document with minor changes and with inclusion of important newly published randomized controlled trials with >100 participants and clinical outcomes at least 90 days after AIS. The document was sent to 14 peer reviewers. The writing group evaluated the peer reviewers’ comments and revised when appropriate. The current final document was approved by all members of the writing group except when relationships with industry precluded members from voting and by the governing bodies of the AHA. These guidelines use the American College of Cardiology/AHA 2015 Class of Recommendations and Level of Evidence and the new AHA guidelines format.
Results—
These guidelines detail prehospital care, urgent and emergency evaluation and treatment with intravenous and intra-arterial therapies, and in-hospital management, including secondary prevention measures that are appropriately instituted within the first 2 weeks. The guidelines support the overarching concept of stroke systems of care in both the prehospital and hospital settings.
Conclusions—
These guidelines provide general recommendations based on the currently available evidence to guide clinicians caring for adult patients with acute arterial ischemic stroke. In many instances, however, only limited data exist demonstrating the urgent need for continued research on treatment of acute ischemic stroke.
See related article, p 3331
New high-quality evidence has produced major changes in the evidence-based treatment of acute ischemic stroke (AIS) since the publication of the guidelines for the early management of patients with acute ischemic stroke in 2013.1 Much of this new evidence has been incorporated into American Heart Association (AHA) focused updates, guidelines, or scientific statements on specific topics relating to the management of patients with AIS since 2013. The purpose of these guidelines is to provide an up-to-date comprehensive set of recommendations for clinicians caring for adult patients with acute arterial ischemic stroke in a single document. These guidelines address prehospital care, urgent and emergency evaluation and treatment with intravenous (IV) and intra-arterial therapies, and in-hospital management, including secondary prevention measures that are often begun during the initial hospitalization. We have restricted our recommendations to adults and to secondary prevention measures that are appropriately instituted within the first 2 weeks. We have not included recommendations for cerebral venous sinus thrombosis because these were covered in a 2011 scientific statement and there is no new evidence that would change those conclusions.2
An independent Evidence Review Committee was commissioned to perform a systematic review of a limited number of clinical questions identified in conjunction with the writing group, the results of which were considered by the writing group for incorporation into the “2018 Guidelines for the Early Management of Patients With Acute Ischemic Stroke” (2018 AIS Guidelines)2a and this 2019 update. The systematic reviews for the 2018 AIS Guidelines have been previously published.3,4
These guidelines use the American College of Cardiology (ACC)/AHA Class of Recommendations (COR) and Level of Evidence (LOE) format shown in Table 1. New or revised recommendations that supersede previous guideline recommendations are accompanied by 250-word knowledge bytes and data supplement tables summarizing the key studies supporting the recommendations in place of extensive text. These data supplement tables can be found in Data Supplement 1 and literature search information for all data supplement tables can be found in Data Supplement 2. Because this guideline represents an update of the 2018 AIS Guidelines, the term “New Recommendation” refers to recommendations that are new to either the 2018 AIS Guidelines or to this 2019 update. Existing recommendations that are unchanged are reiterated with reference to the previous publication. These previous publications and their abbreviations used in this document are listed in Table 2. When there is no new pertinent evidence for these unchanged recommendations, no knowledge byte or data supplement is provided. For some unchanged recommendations, there are new pertinent data that support the existing recommendation, and these are provided. Additional abbreviations used in this guideline are listed in Table 3.
| Document Title | Year Published | Abbreviation Used in This Document |
|---|---|---|
| “Recommendations for the Implementation of Telemedicine Within Stroke Systems of Care: A Policy Statement From the American Heart Association”5 | 2009 | N/A |
| “Diagnosis and Management of Cerebral Venous Thrombosis: A Statement for Healthcare Professionals From the American Heart Association/American Stroke Association”2 | 2011 | N/A |
| “Guidelines for the Early Management of Patients With Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association”1 | 2013 | 2013 AIS Guidelines |
| “Interactions Within Stroke Systems of Care: A Policy Statement From the American Heart Association/American Stroke Association”6 | 2013 | 2013 Stroke Systems of Care |
| “2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society”7 | 2014 | N/A |
| “Recommendations for the Management of Cerebral and Cerebellar Infarction With Swelling: A Statement for Healthcare Professionals From the American Heart Association/American Stroke Association”8 | 2014 | 2014 Brain Swelling |
| “Palliative and End-of-Life Care in Stroke: A Statement for Healthcare Professionals From the American Heart Association/American Stroke Association”9 | 2014 | 2014 Palliative Care |
| “Guidelines for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association”10 | 2014 | 2014 Secondary Prevention |
| “Clinical Performance Measures for Adults Hospitalized With Acute Ischemic Stroke: Performance Measures for Healthcare Professionals From the American Heart Association/American Stroke Association”11 | 2014 | N/A |
| “Part 15: First Aid: 2015 American Heart Association and American Red Cross Guidelines Update for First Aid”12 | 2015 | 2015 CPR/ECC |
| “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: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association”13 | 2015 | 2015 Endovascular |
| “Scientific Rationale for the Inclusion and Exclusion Criteria for Intravenous Alteplase in Acute Ischemic Stroke: A Statement for Healthcare Professionals From the American Heart Association/American Stroke Association”14 | 2015 | 2015 IV Alteplase |
| “Guidelines for Adult Stroke Rehabilitation and Recovery: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association”15 | 2016 | 2016 Rehab Guidelines |
| “Poststroke Depression: A Scientific Statement for Healthcare Professionals From the American Heart Association/American Stroke Association”16 | 2017 | N/A |
| “Treatment and Outcome of Hemorrhagic Transformation After Intravenous Alteplase in Acute Ischemic Stroke: A Scientific Statement for Healthcare Professionals From the American Heart Association/American Stroke Association”17 | 2017 | N/A |
| “2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines”18 | 2018 | N/A |
| “2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines”19 | 2018 | 2018 Cholesterol Guidelines |
AACVPR indicates American Association of Cardiovascular and Pulmonary Rehabilitation; AAPA, American Academy of Physician Assistants; ABC, Association of Black Cardiologists; ACC, American College of Cardiology; ACPM, American College of Preventive Medicine; ADA, American Diabetes Association; AGS, American Geriatrics Society; AHA, American Heart Association; AIS, acute ischemic stroke; APhA, American Pharmacists Association; ASH, American Society of Hypertension; ASPC, American Society for Preventive Cardiology; CPR, cardiopulmonary resuscitation; ECC, emergency cardiovascular care; HRS, Heart Rhythm Society; IV, intravenous; N/A, not applicable; NLA, National Lipid Association; NMA, National Medical Association; and PCNA, Preventive Cardiovascular Nurses Association.
| ACC | American College of Cardiology |
| AHA | American Heart Association |
| AIS | Acute ischemic stroke |
| ARD | Absolute risk difference |
| ASA | American Stroke Association |
| ASCVD | Atherosclerotic cardiovascular disease |
| ASPECTS | Alberta Stroke Program Early Computed Tomography Score |
| BP | Blood pressure |
| CEA | Carotid endarterectomy |
| CeAD | Cervical artery dissection |
| CMB | Cerebral microbleed |
| COR | Class of recommendation |
| CPAP | Continuous positive airway pressure |
| CS | Conscious sedation |
| CT | Computed tomography |
| CTA | Computed tomographic angiography |
| CTP | Computed tomographic perfusion |
| DTN | Door-to-needle |
| DVT | Deep vein thrombosis |
| DW-MRI | Diffusion-weighted magnetic resonance imaging |
| ED | Emergency department |
| EMS | Emergency medical services |
| EVT | Endovascular therapy |
| GA | General anesthesia |
| GWTG | Get With The Guidelines |
| HBO | Hyperbaric oxygen |
| HR | Hazard ratio |
| HT | Hemorrhagic transformation |
| ICH | Intracerebral hemorrhage |
| IPC | Intermittent pneumatic compression |
| IV | Intravenous |
| LDL-C | Low-density lipoprotein cholesterol |
| LMWH | Low-molecular-weight heparin |
| LOE | Level of evidence |
| LVO | Large vessel occlusion |
| M1 | Middle cerebral artery segment 1 |
| M2 | Middle cerebral artery segment 2 |
| M3 | Middle cerebral artery segment 3 |
| MCA | Middle cerebral artery |
| MI | Myocardial infarction |
| MR | Magnetic resonance |
| MRA | Magnetic resonance angiography |
| MRI | Magnetic resonance imaging |
| mRS | Modified Rankin Scale |
| mTICI | Modified Thrombolysis in Cerebral Infarction |
| NCCT | Noncontrast computed tomography |
| NIHSS | National Institutes of Health Stroke Scale |
| NINDS | National Institute of Neurological Disorders and Stroke |
| OR | Odds ratio |
| OSA | Obstructive sleep apnea |
| PFO | Patent foramen ovale |
| RCT | Randomized clinical trial |
| RR | Relative risk |
| rt-PA | Recombinant tissue-type plasminogen activator |
| SBP | Systolic blood pressure |
| sICH | Symptomatic intracerebral hemorrhage |
| TIA | Transient ischemic attack |
| UFH | Unfractionated heparin |
Members of the writing committee were appointed by the AHA Stroke Council’s Scientific Statements Oversight Committee, representing various areas of medical expertise. Strict adherence to the AHA conflict-of-interest policy was maintained throughout the writing and consensus process. Members were not allowed to participate in discussions or to vote on topics relevant to their relations with industry. Writing group members accepted topics relevant to their areas of expertise, reviewed the stroke literature with emphasis on publications since the prior guidelines, and drafted recommendations. Draft recommendations and supporting evidence were discussed by the writing group, and the revised recommendations for each topic were reviewed by a designated writing group member. The full writing group then evaluated the complete guidelines. The members of the writing group unanimously approved all recommendations except when relations with industry precluded members voting. Prerelease review of the draft 2018 guidelines was performed by 4 expert peer reviewers and by the members of the Stroke Council’s Scientific Statements Oversight Committee and Stroke Council Leadership Committee. The 2018 AIS Guidelines were approved by the AHA Science Advisory and Coordinating Committee on November 29, 2017, and by the AHA Executive Committee on December 11, 2017. It was published online January 24, 2018. On April 18, 2018, the AHA published a revision to the AIS Guidelines online, deleting 7 specific recommendations and all of Section 6, In-Hospital Institution of Secondary Prevention. The writing group was asked to review the entire guideline, including the deleted recommendations. In June 2018, the writing group submitted a document with minor changes and with inclusion of important newly published randomized controlled trials (RCTs) with >100 participants and clinical outcomes at least 90 days after AIS. The document was sent out to 14 peer reviewers. The writing group evaluated the peer reviewers’ comments and revised when appropriate. This revised document was reviewed by Stroke Council’s Scientific Statements Oversight Committee and the AHA Science Advisory and Coordinating Committee. To allow these guidelines to be as timely as possible, RCTs addressing AIS published between November 2018 and April 2019 were reviewed by the writing group. Modifications of Section 3.5.6., Recommendation 1, Section 3.6., Recommendation 4, and Section 3.7.2., Recommendation 2 resulted. To allow these modifications to be incorporated, the standard peer review process was abbreviated, with review provided by the members of the Stroke Council’s Scientific Statements Oversight Committee and by liaisons from the endorsing organizations listed on the masthead. The list of these reviewers is provided at the end of the guideline. The final document was approved by the AHA Science Advisory and Coordinating Committee and Executive Committee.
These guidelines provide general recommendations based on the currently available evidence to guide clinicians caring for adult patients with acute arterial ischemic stroke. They will not be applicable to all patients. Local resources and expertise, specific clinical circumstances and patient preferences, and evidence published since the issuance of these guidelines are some of the additional factors that should be considered when making individual patient care decisions. In many instances, only limited data exist demonstrating the urgent need for continued research on treatment of AIS.
A focused update addressing data from additional relevant recent RCTs is in process.
1. Prehospital Stroke Management and Systems of Care
1.1. Prehospital Systems
1.2. EMS Assessment and Management
1.3. EMS Systems
1.4. Hospital Stroke Capabilities
1.5. Hospital Stroke Teams
1.6. Telemedicine
1.7. Organization and Integration of Components
1.8. Establishment of Data Repositories
1.9. Stroke System Care Quality Improvement Process
2. Emergency Evaluation and Treatment
2.1. Stroke Scales
| Tested Item | Title | Responses and Scores |
|---|---|---|
| 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 | ||
| 1C | Response to commands (2) | 0—Performs both tasks correctly |
| 1—Performs 1 task correctly | ||
| 2—Performs neither | ||
| 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) | 0—No drift |
| a. Left | 1—Drift before 10 s | |
| b. Right | 2—Falls before 10 s | |
| 3—No effort against gravity | ||
| 4—No movement | ||
| 6 | Motor function (leg) | 0—No drift |
| a. Left | 1—Drift before 5 s | |
| b. Right | 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—Normal |
| 1—Mild aphasia | ||
| 2—Severe aphasia | ||
| 3—Mute or global aphasia | ||
| 10 | Articulation | 0—Normal |
| 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) |
Adapted from Lyden et al.74 Copyright © 1994, American Heart Association, Inc.
2.2. Head and Neck Imaging
2.3. Other Diagnostic Tests
3. General Supportive Care and Emergency Treatment
3.1. Airway, Breathing, and Oxygenation
3.2. Blood Pressure
3.3. Temperature
3.4. Blood Glucose
3.5. IV Alteplase
| Infuse 0.9 mg/kg (maximum dose 90 mg) over 60 min, with 10% of the dose given as a bolus over 1 min. |
| Admit the patient to an intensive care or stroke unit for monitoring. |
| If the patient develops severe headache, acute hypertension, nausea, or vomiting or has a worsening neurological examination, discontinue the infusion (if IV alteplase is being administered) and obtain emergency head CT scan. |
| Measure BP and perform neurological assessments every 15 min during and after IV alteplase infusion for 2 h, then every 30 min for 6 h, then hourly until 24 h after IV alteplase treatment. |
| Increase the frequency of BP measurements if SBP is >180 mm Hg or if DBP is >105 mm Hg; administer antihypertensive medications to maintain BP at or below these levels (Table 5). |
| Delay placement of nasogastric tubes, indwelling bladder catheters, or intra-arterial pressure catheters if the patient can be safely managed without them. |
| Obtain a follow-up CT or MRI scan at 24 h after IV alteplase before starting anticoagulants or antiplatelet agents. |
AIS indicates acute ischemic stroke; BP, blood pressure; CT, computed tomography; DBP, diastolic blood pressure; IV, intravenous; MRI, magnetic resonance imaging; and SBP, systolic blood pressure.
Reprinted from Jauch et al.1 Copyright © 2013, American Heart Association, Inc.
3.6. Other IV Fibrinolytics and Sonothrombolysis
3.7. Mechanical Thrombectomy
3.8. Other Endovascular Therapies
3.9. Antiplatelet Treatment
3.10. Anticoagulants
3.11. Volume Expansion/Hemodilution, Vasodilators, and Hemodynamic Augmentation
3.12. Neuroprotective Agents
3.13. Emergency Carotid Endarterectomy Carotid Angioplasty and Stenting Without Intracranial Clot
3.14. Other
4. In-Hospital Management of AIS: General Supportive Care
4.1. Stroke Units
4.2 Head Positioning
4.3. Supplemental Oxygen
Note: Recommendations in this section are repeated from Section 3.1 because they apply to in-hospital management as well.
4.4. Blood Pressure
Note: Recommendation 1 in this section is repeated from Section 3.2 because it applies to in-hospital management as well.
4.5. Temperature
Note: Recommendations in this section are repeated from Section 3.3 because they apply to in-hospital management as well.
4.6. Glucose
Note: Recommendations in this section are repeated from Section 3.4 because they apply to in-hospital management as well.
4.7. Dysphagia
4.8. Nutrition
4.9. Deep Vein Thrombosis Prophylaxis
4.10. Depression Screening
4.11. Other
4.12. Rehabilitation
5. In-Hospital Management of AIS: Treatment of Acute Complications
5.1. Brain Swelling
5.2. Seizures
6. In-Hospital Institution of Secondary Stroke Prevention
The recommendations in this section reference other current AHA guidelines for secondary stroke prevention where applicable (Table 10). These other guidelines should be referred to for further information on secondary stroke prevention not covered in this document. These other guidelines are updated regularly, and the most recent versions should be used.
| Document Title | Year Published | Abbreviation Used in This Document |
|---|---|---|
| “Guidelines for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association”10 | 2014 | 2014 Secondary Prevention |
| “2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines”18 | 2017 | N/A |
| “2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines”19 | 2018 | 2018 Cholesterol Guidelines |
AACVPR indicates American Association of Cardiovascular and Pulmonary Rehabilitation; AAPA, American Academy of Physician Assistants; ABC, Association of Black Cardiologists; ACC, American College of Cardiology; ACPM, American College of Preventive Medicine; ADA, American Diabetes Association; AGS, American Geriatrics Society; AHA, American Heart Association; APhA, American Pharmacists Association; ASH, American Society of Hypertension; ASPC, American Society for Preventive Cardiology; N/A, not applicable; NLA, National Lipid Association; NMA, National Medical Association; and PCNA, Preventive Cardiovascular Nurses Association.
6.1. Brain Imaging
6.2. Vascular Imaging
6.3. Cardiac Evaluation
6.4. Glucose
6.5. Other Tests for Secondary Prevention
6.6. Antithrombotic Treatment
6.7. Carotid Revascularization
6.8. Treatment of Hyperlipidemia
6.9. Institution of Antihypertensive Medications
6.10. Smoking Cessation Intervention
6.11. Stroke Education
Additional reference support for this guideline is provided in online Data Supplement 1.394–544
Supplemental Material
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© 2019 American Heart Association, Inc.
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History
Published online: 30 October 2019
Published in print: December 2019
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Authors
Disclosures
| Writing Group Member | Employment | Research Grant | Other Research Support | Speakers’ Bureau/Honoraria | Expert Witness | Ownership Interest | Consultant/Advisory Board | Other |
|---|---|---|---|---|---|---|---|---|
| William J. Powers | University of North Carolina, Chapel Hill | None | None | None | Wake Forest University Baptist Medical Center* | None | None | None |
| Alejandro A. Rabinstein | Mayo Clinic | None | None | None | None | None | None | None |
| Teri Ackerson | Saint Luke’s Health System, AHA/ASA | None | None | None | None | None | None | None |
| Opeolu M. Adeoye | University of Cincinnati | None | None | None | None | None | None | None |
| Nicholas C. Bambakidis | University Hospitals, Cleveland Medical Center | None | None | None | None | None | None | None |
| Kyra Becker | University of Washington School of Medicine, Harborview Medical Center | None | None | None | Defense and prosecution* | None | None | None |
| José Biller | Loyola University Chicago | None | None | None | None | None | None | None |
| Michael Brown | Michigan State University College of Human Medicine, Emergency Medicine | None | None | None | 2018 Defense, Sandberg, Phoenix & Von Gontard*; 2018 Defense, Kamykowski, Gavin & Smith* | None | None | Cochrane (senior editor)† |
| Bart M. Demaerschalk | Mayo Clinic, Mayo Clinic Hospital | None | None | None | None | None | None | None |
| Brian Hoh | University of Florida | None | None | None | None | None | None | None |
| Edward C. Jauch | Mission Health System Research Institute | NINDS (StrokeNet coinvestigator)*; Diffusion Pharmaceuticals (PHAST-TSC DSMB member)* | None | None | Plaintiff and defense* | None | Biogen* | None |
| Chelsea S. Kidwell | University of Arizona | None | None | None | None | None | None | None |
| Thabele M. Leslie-Mazwi | Massachusetts General Hospital | None | None | None | None | None | None | None |
| Bruce Ovbiagele | UCSF | None | None | None | None | None | None | None |
| Phillip A. Scott | University of Michigan Department of Emergency Medicine | NIH (principal investigator)† | University of Michigan (co-medical director, Clinical Trials Support Unit)* | None | Expert testimony 2017*; 2018* | None | None | University of Michigan (associate chair, Research Department of Emergency Medicine)† |
| Kevin N. Sheth | Yale University School of Medicine | Astrocyte (advisory)*; Bard (PI, Stroke Trial)†; Biogen (PI Stroke Trial)†; Hyperfine (PI, Imaging Trial including stroke patients)†; Zoll (DSMB chair)* | None | None | None | Alva Health* | Biogen* | None |
| Andrew M. Southerland | University of Virginia | Diffusion Pharmaceuticals, Inc (Prehospital Administration of Acute Stroke Therapy with Trans-sodium Crocetinate [PHAST-TSC])†; NINDS UO1 NS069498 (SHINE Trial)*; NHLBI-NINDS U01 HL088942 (Cardiothoracic Surgical Trials Network)†; Coulter Translational Research Foundation (Brain and Neurological Deficit Identification Tool [BANDIT] Study)* | None | None | Plaintiff and defense cases focused on questions related to stroke* | iTREAT Project, US Patent Application No. 14/910,890*; BANDIT Project, US Provisional Patent Application No. 62/620,096* | None | None |
| Deborah V. Summers | Saint Luke’s Health System | None | None | None | None | None | None | None |
| David L. Tirschwell | Harborview Medical Center | NIH† | None | None | None | None | None | None |
This table represents the relationships of writing group members that may be perceived as actual or reasonably perceived conflicts of interest as reported on the Disclosure Questionnaire, which all members of the writing group are required to complete and submit. A relationship is considered to be “significant” if (a) the person receives $10 000 or more during any 12-month period, or 5% or more of the person’s gross income; or (b) the person owns 5% or more of the voting stock or share of the entity or owns $10 000 or more of the fair market value of the entity. A relationship is considered to be “modest” if it is less than “significant” under the preceding definition.
*
Modest.
†
Significant.
| Reviewer | Employment | Research Grant | Other Research Support | Speakers’ Bureau/Honoraria | Expert Witness | Ownership Interest | Consultant/Advisory Board | Other |
|---|---|---|---|---|---|---|---|---|
| Mark J. Alberts | Hartford HealthCare | None | None | Genentech (speakers’ bureau)† | None | None | None | None |
| Joseph P. Broderick | University of Cincinnati | NIH (trial)†; NIH (investigator)† | Genentech (PRISMS)†; Genentech (TNK)† | None | None | None | None | None |
| Colin P. Derdeyn | University of Iowa | None | None | None | None | Pulse therapeutics* | Penumbra* | None |
| Marc Fisher | Beth Israel Deaconess Medical Center | None | None | None | None | None | None | American Heart Association† |
| Karen L. Furie | Rhode Island Hospital | None | None | None | None | None | None | None |
| Philip B. Gorelick | Michigan State University | None | None | None | Employer received compensation for expert witness work† | None | IMPACT clinical trial*; NeuroSpring* | None |
| Walter N. Kernan | Yale University | None | None | None | None | None | None | None |
| Steven J. Kittner | Veterans Affairs Maryland Health Care System; University of Maryland School of Medicine | None | None | None | None | None | None | None |
| Patrick D. Lyden | Cedars-Sinai Medical Center | NIH* | None | None | None | None | None | None |
| Philip M. Meyers | Columbia University | None | None | None | None | None | None | None |
| Jeffrey L. Saver | UCLA | None | None | None | None | Rapid Medical* | Medtronic*; Stryker*; Neuravi/Ceronovus*; Boehringer Ingelheim*; St. Jude Medical* | University of California (employer)* |
| Steven Warach | University of Texas at Austin | State of Texas† | None | None | Private law firm* | Stock holdings in various pharma companies in a managed investment portfolio (myself)*; stock holdings in various pharma companies in a managed investment portfolio (family)* | Genentech* | None |
| Lawrence R. Wechsler | University of Pittsburgh | None | None | None | None | None | None | None |
| Babu G. Welch | UT Southwestern Medical Center | None | None | Stryker Neurovascular (speakers’ bureau)*; Stryker Neurovascular (honoraria)* | None | None | Stryker Neurovascular* | None |
This table represents the relationships of reviewers that may be perceived as actual or reasonably perceived conflicts of interest as reported on the Disclosure Questionnaire, which all reviewers are required to complete and submit. A relationship is considered to be “significant” if (a) the person receives $10 000 or more during any 12-month period, or 5% or more of the person’s gross income; or (b) the person owns 5% or more of the voting stock or share of the entity, or owns $10 000 or more of the fair market value of the entity. A relationship is considered to be “modest” if it is less than “significant” under the preceding definition.
*
Modest.
†
Significant.
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