{"id":7430,"date":"2026-06-20T03:12:00","date_gmt":"2026-06-20T03:12:00","guid":{"rendered":"https:\/\/gothi.gov.eg\/?page_id=7430"},"modified":"2026-06-20T03:14:31","modified_gmt":"2026-06-20T03:14:31","slug":"%d8%b7%d8%a8-%d8%a7%d9%84%d9%85%d8%ae-%d9%88%d8%a7%d9%84%d8%a3%d8%b9%d8%b5%d8%a7%d8%a8","status":"publish","type":"page","link":"https:\/\/gothi.gov.eg\/?page_id=7430","title":{"rendered":"\u0637\u0628 \u0627\u0644\u0645\u062e \u0648\u0627\u0644\u0623\u0639\u0635\u0627\u0628"},"content":{"rendered":"\t\t
\n\t\t\t\t
\n\t\t\t\t\t
\n\t\t\t\t
\n\t\t\t\t
\n\t\t\t\t\t\t\t\t\t\n
    \n
  1. <\/li>\n<\/ol>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t
    \n\t\t\t\t\t
    \n\t\t\t\t
    \n\t\t\t\t
    \n\t\t\t\t\t\t\t\t\t\n
      \n
    1. <\/li>\n<\/ol>\n\n\n\n

      <\/p>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t

      \n\t\t\t\t\t
      \n\t\t\t\t
      \n\t\t\t\t
      \n\t\t\t\t\t

      \u0637\u0628 \u0627\u0644\u0645\u062e \u0648\u0627\u0644\u0623\u0639\u0635\u0627\u0628\n<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t
      \n\t\t\t\t
      \n\t\t\t\t\t
      \n\n
      \n\n
      \n\n \n\n \n <\/path><\/svg> <\/span>\n\n \n <\/path><\/svg> <\/span>\n \n <\/span>\n \n \n Ischemic Stroke <\/span>\n\n <\/h5>\n\n
      \n
      \n
      \n
      \n
      “last update: 25 Feb, 2025”\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0\u00a0Download Guideline<\/u><\/strong><\/a><\/h5>\n<\/div>\n<\/div>\n<\/div>\n
      \n
      \n
      \n
      \u00a0<\/div>\n<\/div>\n<\/div>\n<\/div>\n
      \n

      – Executive Summary<\/h3>\n
      \n

      \u00a0<\/p>\n

      \n

      These Guidelines are concerned with the diagnosis and treatment decisions of Ischemic Stroke.
      <\/span>(A)\u00a0\u00a0<\/span><\/strong>Management of TIA And Minor Stroke<\/span><\/strong><\/h4>\n<\/div>\n

      1-\u00a0\u00a0\u00a0\u00a0<\/strong>Patients with acute focal neurological symptoms that resolve completely within 24 hours of onset (i.e. suspected TIA) should be given aspirin 300 mg immediately, unless contraindicated by current medical condition of the patient, e.g. active bleeding varices, gastric ulcer or lower GIT bleeding, and\u00a0<\/span>assessed\u00a0urgently within 24 hours by a stroke specialist clinician in a neurovascular clinic or an acute stroke unit.\u00a0Strong recommendation<\/i><\/strong><\/span><\/p>\n

      2-\u00a0\u00a0\u00a0\u00a0<\/i><\/strong>Patients with suspected TIA that occurred more than a week previously should be assessed by a stroke specialist clinician as soon as possible within 7 days.\u00a0Strong recommendation<\/i><\/strong><\/span><\/i><\/p>\n

      \n

      3-\u00a0\u00a0\u00a0\u00a0<\/span><\/strong>Patients with TIA or minor ischemic stroke should be given antiplatelet therapy provided there is neither a contraindication nor a high risk of bleeding.\u00a0 The following regimens should be considered as soon as possible:<\/p>\n<\/div>\n

      \n

      –\u00a0\u00a0\u00a0For patients within 24 hours of onset of TIA or minor ischemic stroke and with a low risk of bleeding, the following dual antiplatelet therapy should be given:
      Clopidogrel (initial dose 300\u00a0mg followed by 75\u00a0mg per day) plus aspirin (initial dose 300\u00a0mg followed by 75\u00a0mg per day for 21 days) followed by monotherapy with clopidogrel 75\u00a0mg once daily
      OR<\/strong><\/p>\n

      –\u00a0\u00a0\u00a0Ticagrelor (initial dose 180\u00a0mg followed by 90\u00a0mg twice daily) plus aspirin (300\u00a0mg followed by 75\u00a0mg daily for 30 days) followed by antiplatelet monotherapy with ticagrelor 90\u00a0mg twice daily or clopidogrel 75\u00a0mg once daily at the discretion of the prescriber;<\/p>\n

      –\u00a0\u00a0\u00a0For patients with TIA or minor ischemic stroke who are not appropriate for dual antiplatelet therapy, clopidogrel 300\u00a0mg loading dose followed by 75\u00a0mg daily should be given;<\/p>\n

      –\u00a0\u00a0\u00a0A proton pump inhibitor should be considered for concurrent use with dual antiplatelet therapy to reduce the risk of gastrointestinal hemorrhage;<\/p>\n

      –\u00a0\u00a0\u00a0For patients with recurrent TIA or stroke whilst taking clopidogrel, consideration should be given to clopidogrel resistance.<\/p>\n

      Strong recommendation<\/span><\/i><\/strong><\/p>\n<\/div>\n

      \n

      4-\u00a0\u00a0\u00a0\u00a0<\/i><\/strong>Patients with TIA or ischemic \u00a0stroke should receive high-intensity statin therapy (e.g. atorvastatin 20-80 mg daily) started immediately.\u00a0Strong recommendation<\/i><\/strong><\/span><\/i><\/p>\n

      5-\u00a0\u00a0\u00a0\u00a0<\/strong>Patients with non-disabling ischemic \u00a0stroke or TIA in atrial fibrillation should be anticoagulated, as soon as intracranial bleeding has been excluded, with an anticoagulant that has rapid onset, provided there are no other contraindications.\u00a0Strong recommendation<\/i><\/strong><\/span><\/p>\n

      6-\u00a0\u00a0\u00a0\u00a0<\/strong>Patients with\u00a0<\/span>ischemic<\/span>\u00a0stroke or TIA who after specialist assessment are considered candidates for carotid intervention should have carotid imaging performed within 24 hours of assessment. This includes carotid duplex ultrasound or either CT angiography or MR angiography.\u00a0Strong recommendation<\/i><\/strong><\/span><\/p>\n

      7-\u00a0\u00a0\u00a0\u00a0<\/i><\/strong>Patients with TIA or acute non-disabling ischemic stroke with stable neurological symptoms who have symptomatic severe carotid stenosis of 50\u201399% should be assessed and referred for carotid revascularization intervention to be performed as soon as possible within 7 days of the onset of symptoms.\u00a0Strong recommendation<\/span><\/i><\/strong><\/i><\/p>\n

      8-\u00a0\u00a0\u00a0\u00a0<\/i><\/strong>Patients with TIA or acute non-disabling ischemic stroke who have mild or moderate carotid stenosis of less than 50% should not undergo carotid intervention.\u00a0Strong recommendation<\/span><\/i><\/strong><\/i><\/p>\n

      (B)\u00a0\u00a0<\/span><\/strong>Management of Acute Ischemic Stroke<\/span><\/strong><\/h4>\n<\/div>\n

      1-\u00a0\u00a0\u00a0\u00a0<\/span><\/i><\/strong>Patients with suspected acute stroke should be admitted directly to a hyperacute stroke service and be assessed for emergency stroke treatments by a specialist clinician without delay.\u00a0Strong recommendation<\/i><\/strong><\/span><\/p>\n

      2-\u00a0\u00a0\u00a0\u00a0<\/span><\/i><\/strong>Patients with suspected acute stroke should receive brain imaging as soon as possible (at most within 1 hour of arrival at hospital).\u00a0Strong recommendation<\/i><\/strong><\/span><\/p>\n

      3-\u00a0\u00a0\u00a0\u00a0<\/span><\/strong>Patients with stroke with a delayed presentation for whom reperfusion is potentially indicated may have CT or MR perfusion as soon as possible (at most within 1 hour of arrival at hospital). An alternative for patients who wake up with stroke is MRI measuring DWI-FLAIR mismatch.\u00a0Conditional recommendation<\/i><\/strong><\/span><\/p>\n

      4-\u00a0\u00a0\u00a0\u00a0<\/span><\/i><\/strong>Patients with acute ischemic stroke, regardless of age or stroke severity, in whom treatment can be started within 4.5 hours of known onset, should be considered for thrombolysis with\u00a0tenecteplase.<\/span>\u00a0<\/span>Strong recommendation<\/i><\/strong><\/span><\/p>\n

      5-\u00a0\u00a0\u00a0\u00a0<\/span><\/strong>Patients with acute ischemic stroke, regardless of age or stroke severity, who were last known to be well more than 4.5 hours earlier, may be considered for thrombolysis with\u00a0t<\/span>enecteplase<\/span>\u00a0<\/span>if:<\/span><\/p>\n

      \n

      –\u00a0\u00a0\u00a0<\/span>treatment can be started between 4.5 and 9 hours of known onset, or within 9 hours of the midpoint of sleep when they have woken with symptoms<\/span><\/p>\n<\/div>\n

      \n

      AND<\/span><\/strong><\/p>\n<\/div>\n

      \n

      –\u00a0\u00a0\u00a0<\/span>they have evidence from CT\/MR perfusion (core-perfusion mismatch) or MRI (DWI-FLAIR mismatch) of the potential to salvage brain tissue.<\/span><\/p>\n

      This should be irrespective of whether they have a large artery occlusion and require mechanical thrombectomy.\u00a0Conditional recommendation<\/i><\/strong><\/span><\/p>\n<\/div>\n

      6-\u00a0\u00a0\u00a0\u00a0<\/span><\/i><\/strong>Thrombolysis should only be administered within a well-organised stroke service.\u00a0Strong recommendation<\/i><\/strong><\/span><\/p>\n

      7-\u00a0\u00a0\u00a0\u00a0<\/span><\/strong>Patients with acute ischemic stroke eligible for mechanical thrombectomy should receive prior intravenous thrombolysis (unless contraindicated) irrespective of whether they have presented to an acute stroke centre or a thrombectomy centre.\u00a0 Every effort should be made to minimise process times throughout the treatment pathway and thrombolysis should not delay urgent transfer to a thrombectomy centre.\u00a0Strong recommendation<\/i><\/strong><\/span><\/p>\n

      8-\u00a0\u00a0\u00a0\u00a0<\/span><\/strong>Patients with acute anterior circulation ischemic stroke, who were previously independent (mRS 0-2), should be considered for combination intravenous thrombolysis and intra-arterial clot extraction (using a stent retriever and\/or aspiration techniques) if they have a proximal intracranial large artery occlusion causing a disabling neurological deficit (NIHSS score of 6 or more) and the procedure can begin within 6 hours of known onset.\u00a0Strong recommendation<\/i><\/strong><\/span><\/p>\n

      9-\u00a0\u00a0\u00a0\u00a0<\/span><\/strong>Patients with acute anterior circulation ischemic stroke and a contraindication to intravenous thrombolysis but not to thrombectomy, who were previously independent (mRS 0-2), should be considered for intra-arterial clot extraction (using a stent retriever and\/or aspiration techniques) if they have a proximal intracranial large artery occlusion causing a disabling neurological deficit (NIHSS score of 6 or more) and the procedure can begin within 6 hours of known onset.\u00a0Strong recommendation<\/i><\/strong><\/span><\/p>\n

      10-\u00a0<\/span><\/strong>Patients with acute anterior circulation ischemic stroke and a proximal intracranial large artery occlusion (ICA and\/or M1) causing a disabling neurological deficit (NIHSS score of 6 or more) of onset between 6 and 24 hours ago, including wake-up stroke, and with no previous disability (mRS 0 or 1) may be considered for intra-arterial clot extraction (using a stent retriever and\/or aspiration techniques, combined with thrombolysis if eligible) providing the following imaging criteria are met:<\/span><\/p>\n

      \n

      –\u00a0\u00a0\u00a0<\/span>Between 6 and 12 hours: an ASPECTS score of 3 or more,\u00a0irrespective of the core\u00a0infarct size;<\/span><\/p>\n

      –\u00a0\u00a0\u00a0<\/span>Between 12 and 24 hours: an ASPECTS score of 3 or more and CT or MRI perfusion mismatch of greater than 15\u00a0mL, irrespective of the core\u00a0infarct size.<\/span><\/p>\n

      Conditional recommendation<\/span><\/i><\/strong><\/p>\n<\/div>\n

      11-\u00a0<\/span><\/i><\/strong>Patients with acute ischemic stroke in the posterior circulation within 12 hours of onset may be considered for mechanical thrombectomy (combined with thrombolysis if eligible) if they have a confirmed intracranial vertebral or basilar artery occlusion and their NIHSS score is 10 or more, combined with a favourable PC-ASPECTS score and Pons-Midbrain Index.\u00a0 Caution should be exercised when considering mechanical thrombectomy for patients presenting between 12 and 24 hours of onset and\/or over the age of 80 owing to the paucity of data in these groups.\u00a0Conditional recommendation<\/i><\/strong><\/span><\/p>\n

      12-\u00a0<\/span><\/i><\/strong>Patients with acute ischemic stroke treated with thrombolysis should be started on an antiplatelet agent after 24 hours unless contraindicated, once significant haemorrhage has been excluded.\u00a0Strong recommendation<\/i><\/strong><\/i><\/span><\/p>\n

      \n

      (C)\u00a0\u00a0<\/span><\/strong>LONG-TERM MANAGEMENT AND SECONDARY PREVENTION<\/span><\/strong><\/h4>\n<\/div>\n
      \n

      1-\u00a0\u00a0\u00a0\u00a0<\/span><\/strong>Patients with minor\u00a0<\/span>ischemic\u00a0stroke or TIA should\u00a0<\/span>receive treatment\u00a0for secondary prevention as soon as the diagnosis is confirmed.\u00a0Strong recommendation<\/i><\/strong><\/span><\/p>\n<\/div>\n

      2-\u00a0\u00a0\u00a0\u00a0<\/span><\/strong>People with stroke or TIA should receive a comprehensive and personalised strategy for vascular prevention including medication and lifestyle factors, which should be implemented as soon as possible and should continue long-term.\u00a0Strong recommendation<\/i><\/strong><\/span><\/p>\n

      \n

      3-\u00a0\u00a0\u00a0\u00a0<\/span><\/strong>People with stroke or TIA should have their risk factors and secondary prevention reviewed and monitored at least once a year in primary care.\u00a0Strong recommendation<\/i><\/strong><\/span><\/p>\n

      4-\u00a0\u00a0\u00a0\u00a0<\/span><\/strong>People with stroke or TIA for whom secondary prevention is appropriate should be investigated for risk factors as soon as possible within 1 week of onset.\u00a0Strong recommendation<\/i><\/strong><\/span><\/p>\n

      5-\u00a0\u00a0\u00a0\u00a0<\/span><\/strong>Provided they are eligible for any resultant intervention, people with stroke or TIA should be investigated for the following risk factors:<\/span><\/p>\n<\/div>\n

      \n

      a.\u00a0\u00a0<\/span>ipsilateral carotid artery stenosis;<\/span><\/p>\n

      b.\u00a0\u00a0<\/span>atrial fibrillation;<\/span><\/p>\n

      c.\u00a0\u00a0<\/span>structural cardiac disease.<\/span><\/p>\n

      Strong recommendation<\/span><\/i><\/strong><\/p>\n<\/div>\n

      6-\u00a0\u00a0\u00a0\u00a0<\/span><\/strong>People with non-disabling carotid artery territory stroke or TIA should be considered for carotid revascularisation, and if they agree with intervention:<\/span><\/p>\n

      \n

      a.\u00a0\u00a0<\/span>they should have carotid imaging (duplex ultrasound, MR or CT angiography) performed urgently to assess the degree of stenosis;<\/span><\/p>\n

      b.\u00a0\u00a0<\/span>if the initial test identifies a relevant severe stenosis (greater than or equal to 50%), a second or repeat non-invasive imaging investigation should be performed to confirm the degree of stenosis. This confirmatory test should be carried out urgently to avoid delaying any intervention.<\/span><\/p>\n

      Strong recommendation<\/span><\/i><\/strong><\/p>\n<\/div>\n

      \n

      7-\u00a0\u00a0\u00a0\u00a0<\/span><\/i><\/strong>People with non-disabling carotid artery territory stroke or TIA should be considered for carotid revascularisation if the symptomatic internal carotid artery has a stenosis of greater than or equal to 50%.\u00a0Strong recommendation<\/i><\/strong><\/span><\/p>\n<\/div>\n

      8-\u00a0\u00a0\u00a0\u00a0<\/span><\/strong>Patients with atrial fibrillation and symptomatic internal carotid artery stenosis should be managed for both conditions unless there are contraindications.\u00a0Strong recommendation<\/i><\/strong><\/span><\/p>\n

      \n

      9-\u00a0\u00a0\u00a0\u00a0<\/span><\/i><\/strong>People with stroke or TIA should have their blood pressure checked, and treatment should be initiated or increased as tolerated to consistently achieve a clinic systolic blood pressure below 130 mmHg, equivalent to a home systolic blood pressure below 125 mmHg. The exception is for people with severe bilateral carotid artery stenosis, for whom a systolic blood pressure target of 140\u2013150 mmHg is appropriate.\u00a0 Concern about potential adverse effects should not impede the initiation of treatment that prevents stroke, major cardiovascular events or mortality.\u00a0Strong recommendation<\/i><\/strong><\/span><\/p>\n

      10-\u00a0<\/span><\/i><\/strong>For people with stroke or TIA aged 55 or over, antihypertensive treatment should be initiated with a long-acting dihydropyridine calcium-channel blocker or a thiazide-like diuretic.\u00a0 If target blood pressure is not achieved, an angiotensin converting enzyme inhibitor or angiotensin II receptor blocker should be added.\u00a0Strong recommendation<\/i><\/strong><\/span><\/p>\n

      11-\u00a0<\/span><\/i><\/strong>For people with stroke or TIA younger than 55 years, antihypertensive treatment should be initiated with an angiotensin converting enzyme inhibitor or an angiotensin II receptor blocker.\u00a0Strong recommendation<\/i><\/strong><\/span><\/p>\n

      12-\u00a0<\/span><\/i><\/strong>People with stroke or TIA should have their blood pressure-lowering treatment monitored frequently in primary care and increased to achieve target blood pressure as quickly and safely as tolerated.\u00a0 People whose blood pressure remains above target despite treatment should be checked for medication adherence at each visit before escalation of treatment, and people who do not achieve their target blood pressure despite escalated treatment should be referred for a specialist opinion.\u00a0 Once blood pressure is controlled to target, people taking antihypertensive treatment should be reviewed at least annually.\u00a0Strong recommendation<\/i><\/strong><\/span><\/p>\n

      13-\u00a0<\/span><\/i><\/strong>People with ischemic stroke or TIA should be offered personalised advice and support on lifestyle factors to reduce cardiovascular risk, including diet, physical activity, weight reduction, alcohol moderation and smoking cessation.\u00a0Strong recommendation<\/i><\/strong><\/span><\/p>\n

      14-\u00a0<\/span><\/strong>People with ischemic stroke or TIA should be offered treatment with a statin unless contraindicated or investigation of their stroke or TIA confirms no evidence of atherosclerosis.\u00a0 Treatment should:<\/span><\/p>\n<\/div>\n

      \n

      a.\u00a0\u00a0<\/span>begin with a high-intensity statin such as atorvastatin 80 mg daily. A lower dose should be used if there is the potential for medication interactions or a high risk of adverse effects;<\/span><\/p>\n

      b.\u00a0\u00a0<\/span>be with an alternative statin at the maximum tolerated dose if a high-intensity statin is unsuitable or not tolerated.<\/span><\/p>\n

      Strong recommendation<\/span><\/i><\/strong><\/p>\n<\/div>\n

      \n

      15-\u00a0<\/span><\/strong>Lipid-lowering treatment for people with ischemic stroke or TIA and evidence of atherosclerosis should aim to reduce fasting LDL-cholesterol to below 1.8\u00a0mmol\/L (equivalent to a non-HDL-cholesterol of below 2.5\u00a0mmol\/L in a non-fasting sample).\u00a0 If this is not achieved at first review at 4-6 weeks, the prescriber should:<\/span><\/p>\n<\/div>\n

      \n

      a.\u00a0\u00a0<\/span>discuss adherence and tolerability;<\/span><\/p>\n

      b.\u00a0\u00a0<\/span>optimise dietary and lifestyle measures through personalised advice and support;<\/span><\/p>\n

      c.\u00a0\u00a0\u00a0<\/span>consider increasing to a higher dose of statin if this was not prescribed from the outset;<\/span><\/p>\n

      d.\u00a0\u00a0<\/span>consider adding ezetimibe 10\u00a0mg daily;<\/span><\/p>\n

      e.\u00a0\u00a0<\/span>consider the use of additional agents such as injectables (inclisiran or monoclonal antibodies to PCSK9) or bempedoic acid (for statin-intolerant people taking ezetimibe monotherapy);<\/span><\/p>\n

      f.\u00a0\u00a0\u00a0continue to escalate lipid-lowering therapy (in combination if necessary) at regular intervals in order to reduce LDL-cholesterol to below 1.8\u00a0mmol\/L.<\/span><\/p>\n

      Strong recommendation<\/span><\/i><\/strong><\/p>\n<\/div>\n

      \n

      16-\u00a0<\/span><\/i><\/strong>In people with ischemic \u00a0stroke or TIA below 60 years of age with very high cholesterol (below 30 years with total cholesterol above 7.5\u00a0mmol\/L or 30 years or older with total cholesterol concentration above 9.0\u00a0mmol\/L) consider a diagnosis of familial hypercholesterolaemia.\u00a0Strong recommendation<\/i><\/strong><\/span><\/p>\n

      17-\u00a0<\/span><\/strong>For long-term prevention of vascular events in people with ischemic \u00a0stroke or TIA without paroxysmal or permanent atrial fibrillation:<\/span><\/p>\n<\/div>\n

      \n

      a.\u00a0\u00a0<\/span>clopidogrel 75\u00a0mg daily should be the standard antithrombotic treatment;<\/span><\/p>\n

      b.\u00a0\u00a0<\/span>aspirin 75\u00a0mg daily should be used for those who are unable to tolerate clopidogrel;<\/span><\/p>\n

      c.\u00a0\u00a0\u00a0<\/span>if a patient has a recurrent cardiovascular event on clopidogrel, clopidogrel resistance may be considered.<\/span><\/p>\n

      d.\u00a0\u00a0<\/span>The combination of aspirin and clopidogrel is not recommended for long-term prevention of vascular events unless there is another indication e.g. acute coronary syndrome, recent coronary stent.<\/span><\/p>\n

      Strong recommendation<\/span><\/i><\/strong><\/p>\n<\/div>\n

      \n

      18-\u00a0<\/span><\/strong>People with ischemic stroke with acute haemorrhagic transformation may be treated with long-term antiplatelet or anticoagulant therapy unless the prescriber considers that the risks outweigh the benefits.\u00a0Conditional recommendation<\/i><\/strong><\/span><\/p>\n<\/div>\n

      19-\u00a0<\/span><\/strong>Patients who have a spontaneous (non-traumatic) intracerebral haemorrhage (ICH) whilst taking an antithrombotic (antiplatelet or anticoagulant) medication for the prevention of occlusive vascular events should be considered for restarting antiplatelet treatment beyond 24 hours after ICH symptom onset provided stabilization of general condition and blood pressure.\u00a0Strong recommendation<\/i><\/strong><\/span><\/p>\n

      \n

      20-\u00a0<\/span><\/strong>For people with ischemic \u00a0stroke or TIA and paroxysmal, persistent or permanent atrial fibrillation (AF: valvular or non-valvular) or atrial flutter, oral anticoagulation should be the standard long-term treatment for stroke prevention.\u00a0 Anticoagulant treatment:<\/span><\/p>\n<\/div>\n

      \n

      a.\u00a0\u00a0<\/span>should not be given if brain imaging has identified significant haemorrhage;<\/span><\/p>\n

      b.\u00a0\u00a0<\/span>should not be commenced in people with severe hypertension (clinic blood pressure of 180\/120 or higher), which should be treated first;<\/span><\/p>\n

      c.\u00a0\u00a0\u00a0<\/span>may be considered for patients with moderate-to-severe stroke from 5-14 days after onset. Wherever possible these patients should be offered participation in a trial of the timing of initiation of anticoagulation after stroke.\u00a0 Aspirin 300 mg daily should be used in the meantime;<\/span><\/p>\n

      d.\u00a0\u00a0<\/span>should be considered for patients with mild stroke earlier than 5 days if the prescriber considers the benefits to outweigh the risk of early intracranial haemorrhage. Aspirin 300 mg daily should be used in the meantime;<\/span><\/p>\n

      e.\u00a0\u00a0<\/span>should be initiated within 14 days of onset of stroke in all those considered appropriate for secondary prevention;<\/span><\/p>\n

      f.\u00a0\u00a0\u00a0\u00a0<\/span>should be initiated immediately after a TIA once brain imaging has excluded haemorrhage, using an agent with a rapid onset (e.g. DOAC in non-valvular AF or subcutaneous low molecular weight heparin while initiating a VKA for those with valvular AF);<\/span><\/p>\n

      g.\u00a0\u00a0<\/span>should include measures to reduce bleeding risk, using a validated tool to identify modifiable risk factors.<\/span><\/p>\n

      Strong recommendation<\/span><\/i><\/strong><\/p>\n<\/div>\n

      21-\u00a0<\/span><\/strong>First-line treatment for people with ischemic \u00a0stroke or TIA due to non valvular AF should be anticoagulation with a DOAC.\u00a0Strong recommendation<\/i><\/strong><\/span><\/p>\n

      \n

      22-\u00a0<\/span><\/i><\/strong>People with ischemic \u00a0stroke or TIA due to valvular\/rheumatic AF or with mechanical heart valve replacement, and those with contraindications or intolerance to DOAC treatment, should receive anticoagulation with adjusted-dose warfarin (target INR 2.5, range 2.0 to 3.0) with a target time in the therapeutic range of greater than 72%.\u00a0Strong recommendation<\/i><\/strong><\/span><\/p>\n<\/div>\n

      23-\u00a0<\/span><\/strong>For people with cardioembolic TIA or stroke for whom treatment with anticoagulation is considered inappropriate because of a high risk of bleeding:<\/span><\/p>\n

      \n

      a.\u00a0\u00a0<\/span>antiplatelet treatment should not be used as an alternative when there are absolute contraindications to anticoagulation (e.g. undiagnosed bleeding);<\/span><\/p>\n

      b.\u00a0\u00a0<\/span>measures should be taken to reduce bleeding risk, using a validated tool to identify modifiable risk factors. If after intervention for relevant risk factors the bleeding risk is considered too high for anticoagulation, antiplatelet treatment should not be routinely used as an alternative;<\/span><\/p>\n

      c.\u00a0\u00a0\u00a0<\/span>a left atrial appendage occlusion device may be considered as an alternative, provided the short-term peri-procedural use of antiplatelet therapy is an acceptable risk.<\/span><\/p>\n

      Strong recommendation<\/span><\/i><\/strong><\/p>\n<\/div>\n

      \n

      24-\u00a0<\/span><\/i><\/strong>People with cardioembolic TIA or stroke for whom treatment with anticoagulation is considered inappropriate for reasons other than the risk of bleeding may be considered for antiplatelet treatment to reduce the risk of recurrent vaso-occlusive disease.\u00a0Conditional recommendation<\/i><\/strong><\/span><\/p>\n

      25-\u00a0<\/span><\/i><\/strong>Patients with ischemic \u00a0stroke or TIA not already diagnosed with atrial fibrillation or flutter should undergo an initial period of cardiac monitoring for a minimum of 24 hours if they are appropriate for anticoagulation.\u00a0Strong recommendation<\/i><\/strong><\/span><\/p>\n

      26-\u00a0<\/span><\/i><\/strong>People with ischemic \u00a0stroke or TIA and a PFO should receive optimal secondary prevention treatment, including antiplatelet therapy, treatment for high blood pressure, lipid-lowering therapy and lifestyle modification.\u00a0 Anticoagulation is not recommended unless there is another recognised indication.\u00a0Strong recommendation<\/i><\/strong><\/span><\/p>\n

      27-\u00a0<\/span><\/i><\/strong>Selected people below the age of 60 with ischemic \u00a0stroke or TIA of otherwise undetermined aetiology, in association with a PFO and a right-to-left shunt or an atrial septal aneurysm, may be considered for endovascular PFO device closure within six months of the index event to prevent recurrent stroke.\u00a0 This decision should be made after careful consideration of the benefits and risks by a multidisciplinary team including the patient\u2019s physician and the cardiologist performing the procedure.\u00a0 The balance of risk and benefit from the procedure, including the risk of atrial fibrillation and other recognised peri-procedural complications should be fully considered and explained to the person with stroke.\u00a0Strong recommendation<\/i><\/strong><\/span><\/p>\n

      28-\u00a0<\/span><\/i><\/strong>People older than 60 years with ischemic \u00a0stroke or TIA of otherwise undetermined aetiology and a PFO may be offered closure in the context of a clinical trial or prospective registry.\u00a0Conditional recommendation<\/i><\/strong><\/span><\/p>\n

      29-\u00a0<\/span><\/strong>People with stroke or TIA should be investigated with transthoracic echocardiography if the detection of a structural cardiac abnormality would prompt a change of management and if they have:<\/span><\/p>\n<\/div>\n

      \n

      a.\u00a0\u00a0\u00a0\u00a0\u00a0<\/span>clinical or ECG findings suggestive of structural cardiac disease that would require assessment in its own right, or<\/span><\/p>\n

      b.\u00a0\u00a0\u00a0\u00a0\u00a0<\/span>unexplained stroke or TIA, especially if other brain imaging features suggestive of cardioembolism are present.<\/span><\/p>\n

      Strong recommendation<\/span><\/i><\/strong><\/p>\n<\/div>\n

      \n

      30-\u00a0<\/span><\/strong>People with ischemic stroke or TIA due to severe symptomatic intracranial stenosis should be offered dual antiplatelet therapy with aspirin and clopidogrel for the first three months in addition to optimal secondary prevention including blood pressure treatment, lipid-lowering therapy and lifestyle modification.\u00a0 Endovascular or surgical intervention should only be offered in the context of a clinical trial.\u00a0Strong recommendation<\/i><\/strong><\/span><\/p>\n<\/div>\n31-<\/strong>\u00a0People with stroke or TIA who smoke should be advised to stop immediately.\u00a0 Smoking cessation should be promoted in an individualised prevention plan using interventions which may include pharmacotherapy, psychosocial support and referral to statutory stop smoking services.\u00a0Strong recommendation<\/i><\/strong><\/span>
      \n

      \u00a0<\/p>\n<\/div>\n<\/div>\n

      \n
      \n
      \n
      \u00a0<\/div>\n<\/div>\n
      \n
      \n
      \u00a0<\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div> <\/div>\n\n <\/div>\n
      \n\n
      \n\n \n\n \n <\/path><\/svg> <\/span>\n\n \n <\/path><\/svg> <\/span>\n \n <\/span>\n \n \n Multiple Sclerosis <\/span>\n\n <\/h5>\n\n
      \n
      \n
      \n
      \n
      “last update: 22 Dec. 2025 “\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0\u00a0<\/span>Download Guideline<\/u><\/strong><\/a><\/h5>\n<\/div>\n<\/div>\n<\/div>\n
      \n
      \n
      \n
      \u00a0<\/div>\n<\/div>\n<\/div>\n<\/div>\n
      \n

      – Executive Summary<\/h3>\n
      \n

      \u00a0<\/p>\n

      \u00a0<\/p>\n

      \u00a0<\/p>\n

      \u25aa\ufe0fAcute MS relapses should be diagnosed when the patient develops symptoms that occur over a minimum of 24 hours and separated from a previous attack by at least 30 days, in the absence of fever or infection. In the radiological domain, the criteria for relapses are defined as an increase in lesion load\/size on T2 imaging or gadolinium enhancement of lesions on magnetic resonance imaging (MRI) in the brain or spinal cord (strong recommendation) .<\/p>\n

      \u25aa\ufe0fIt is recommended to treat initially acute MS relapses with a 3\u20135 day course of intravenous methylprednisolone (strong recommendation) .\u00a0<\/p>\n

      \u25aa\ufe0fThe diagnosis of relapsing remittent multiple sclerosis (RRMS) should be promptly considered after the patient experiences the first symptoms that may be suggestive of MS relapse, what is termed as clinical isolated syndrome (CIS)\u00a0 (strong recommendation) .<\/p>\n

      \u25aa\ufe0fAccording to the 2017 McDonald criteria, RRMS should be diagnosed if there is a proof for dissemination in space (DIS) and dissemination in time (DIT). DIS is proved if there is one or more lesion in each of two or more of the four following areas: periventricular, cortical\/juxtacortical, infratentorial, and spinal cord, taking into consideration that symptomatic lesions can be used to demonstrate DIS. DIT is proved if there is simultaneous presence of gadolinium enhancing and non-enhancing lesions at any time, or if a new T2 lesion on follow up MRI irrespective of timing of baseline scan, or the demonstration of cerebrospinal fluid oligoclonal bands in the absence of atypical CSF findings\u00a0 (strong recommendation) .<\/p>\n

      \u25aa\ufe0fBrain MRI should be obtained in all patients being considered for an MS diagnosis. Spinal MRI is recommended when the presentation suggests a spinal cord localization, when there is a primary progressive course, or when additional data are needed to increase diagnostic confidence\u00a0 (strong recommendation) .<\/p>\n

      \u25aa\ufe0fIn patients with typical CIS, fulfillment of MRI criteria for DIS, and no better explanation for the clinical presentation, demonstration of CSF oligoclonal bands (OCBs) allows a diagnosis of MS to be made, even if the MRI findings on the baseline scan do not meet the criteria for DIT and in advance of either a second attack or MRI evidence of a new or active lesion on serial imaging. This recommendation allows the presence of CSF OCBs to substitute for the requirement for fulfilling DIT in this situation (strong recommendation) .<\/p>\n

      \u00a0<\/p>\n

      \u25aa\ufe0fWe suggest that secondary progressive MS (SPMS) is diagnosed if there is a history of confirmed gradual progression for 3 months at least without preceding relapse, with a minimum Expanded Disability Status Scale (EDSS) score of 4, after an initial RRMS course (conditional recommendation) .<\/p>\n

      \u25aa\ufe0fAccording to the 2017 McDonald criteria, primary progressive MS (PPMS) should be diagnosed in patients who experience worsening disability for at least one year (based on previous symptoms or ongoing observation), and who exhibit at least two of the following criteria: at least one MS-like lesion in the brain, at least two lesions in the spinal cord, or positive test for oligoclonal bands in the CSF (strong recommendation) .<\/p>\n

      \u25aa\ufe0fNeurologists should offer early treatment with disease modifying therapies (DMTs) in patients with relapsing remitting MS as defined by clinical relapses and\/or MRI activity (strong recommendation) . Please check the annexes for the list of the available DMTs in RRMS.<\/p>\n

      \u25aa\ufe0f\u00a0Neurologists should counsel patients with MS that DMTs are prescribed to reduce relapses and new MRI lesion activity, and should counsel on the importance of adherence to DMT (strong recommendation).<\/p>\n

      \u25aa\ufe0fNeurologists must ascertain and incorporate\/review preferences in terms of safety, route of administration, accessibility of the drug, efficacy, common adverse effects, and tolerability in the choice of DMT in MS patients (6) (strong recommendation) (high quality evidence).<\/p>\n

      \u25aa\ufe0f\u00a0<\/strong>Neurologists should monitor the reproductive plans of women with MS and counsel regarding reproductive risks and use of birth control during DMT use in women of childbearing potential who have MS\u00a0 (strong recommendation) .<\/p>\n

      \u25aa\ufe0f<\/strong>\u00a0Neurologists could prescribe highly effective DMTs (such as fingolimod, cladribine, natalizumab, or ocrelizumab) from the beginning for highly active MS patients and aggressive MS patients. The choice depends on the patient\u2019s characteristics and comorbidities, drug safety profile, pregnancy issue and accessibility of the drug\u00a0 (conditional recommendation).<\/p>\n

      The following clinical and radiological features should determine if a patient has highly active MS:<\/u><\/strong><\/i><\/p>\n

      – Relapse frequency in the previous year (\u22652 relapses).<\/p>\n

      – Relapse severity (pyramidal\/cerebellar systems involvement).<\/p>\n

      – Incomplete recovery from relapses.<\/p>\n

      – High T2 lesion load on MRI (\u226510 lesions), especially with spinal or infratentorial lesions.<\/p>\n

      – Multiple Gadolinium enhancing lesions.<\/p>\n

      The following clinical and radiological features should determine if a patient has aggressive MS:<\/strong><\/u><\/i><\/p>\n

      – Patients reaching an EDSS score of 6.0 within 5 years of disease onset or by 40 years of age.<\/p>\n

      – Treatment na\u00efve patients who had 2 or more relapses with incomplete recovery in the past year.<\/p>\n

      – Two or more disabling relapses in 1 year with \u22651 Gadolinium enhancing lesion or significant high T2 lesion load on MRI (\u226510 lesions) .<\/p>\n

      \u25aa\ufe0f<\/strong>\u00a0Neurologists should monitor MRI disease activity from the clinical onset of disease to detect the accumulation of new lesions in order to inform treatment decisions in people with MS using DMTs\u00a0 (strong recommendation) .<\/p>\n

      \u25aa\ufe0fNeurologists should discuss switching from one DMT to another in MS patients who have been using a DMT long enough for the treatment to take full effect and are adherent to their therapy when they experience 1 or more relapses, 2 or more unequivocally new MRI-detected lesions, or increased disability on examination, over a 1-year period of using a DMT (6) (strong recommendation) .<\/p>\n

      \u25aa\ufe0f<\/strong>Neurologists should discuss a medication switch with people with MS for whom these adverse effects negatively influence adherence (strong recommendation) .<\/p>\n

      \u25aa\ufe0fNeurologists should offer siponimod for active SPMS patients evidenced by relapses or imaging-features of inflammatory activity\u00a0 (strong recommendation) .<\/p>\n

      \u25aa\ufe0fNeurologists should offer ocrelizumab for PPMS patients\u00a0 (strong recommendation) .<\/p>\n

      \u00a0<\/p>\n

      \u00a0<\/p>\n

      \u00a0<\/p>\n

      \u00a0<\/p>\n

      \u00a0<\/p>\n<\/div>\n<\/div>\n

      \n
      \n
      \n
      \u00a0<\/div>\n<\/div>\n
      \n
      \n
      \u00a0<\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div> <\/div>\n\n <\/div>\n
      \n\n
      \n\n \n\n \n <\/path><\/svg> <\/span>\n\n \n <\/path><\/svg> <\/span>\n \n <\/span>\n \n \n the Management of Epilepsy in Egypt <\/span>\n\n <\/h5>\n\n
      \n
      \n
      \n
      \n
      “last update: 19 May 2025\u00a0\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0\u00a0<\/span>Download Guideline<\/u><\/strong><\/a><\/h5>\n<\/div>\n<\/div>\n<\/div>\n
      \n
      \n
      \n
      \u00a0<\/div>\n<\/div>\n<\/div>\n<\/div>\n
      \n

      – Executive Summary<\/h3>\n
      \n

      \u00a0<\/p>\n

      –\u00a0\u00a0To determine whether the patient might have had an epileptic seizure, the patient’s and eyewitness’s (where possible) detailed histories should be taken . (strong recommendation)\u00a0<\/p>\n

      –\u00a0\u00a0A\u00a0 neurological examination\u00a0\u00a0<\/span>should be performed since recurrence can be predicted through an abnormal examination after a first seizure. (strong recommendation)\u00a0 .<\/p>\n

      –\u00a0\u00a0In children and young people, a specialist neurologist with good training and expertise in epilepsy should establish the diagnosis of epilepsy\u00a0 (strong recommendation).<\/p>\n

      –\u00a0\u00a0We recommend referral to a more specialized Epilepsy clinic If the epilepsy diagnosis cannot be definitely confirmed. (strong recommendation)<\/p>\n

      –\u00a0\u00a0A normal EEG should not exclude the diagnosis of epilepsy . (strong recommendation)\u00a0 .<\/p>\n

      –\u00a0\u00a0Epilepsy is a clinical diagnosis; however, EEG can be indicated\u00a0 .(conditional recommendation)\u00a0 .<\/p>\n

      –\u00a0\u00a0If\u00a0 there is clinical doubt, EEG\u00a0 should be used to classify epileptic seizures and epilepsy syndromes . (strong recommendation)\u00a0<\/p>\n

      –\u00a0\u00a0In case of equivocal epilepsy diagnosis or suspected non-epileptic events, refer to tertiary center (strong recommendation)\u00a0<\/p>\n

      –\u00a0When findings of a standard EEG have not supported epilepsy diagnosis or classification, a sleep EEG should be performed . (strong recommendation)\u00a0<\/p>\n

      –\u00a0\u00a0Increasing recording time to 60 minutes on conventional EEG is a more convenient and cost-effective method of enhancing the EEG diagnostic yield compared to multiple conventional EEGs (strong recommendation)\u00a0 ..<\/p>\n

      –\u00a0In the case of patients with a likelihood of a non-convulsive epileptic seizure, as suggested by the clinical history, the finding of epileptiform abnormalities in EEG is specific to assess the risk of seizure recurrence . (strong recommendation)\u00a0 .<\/p>\n

      –\u00a0\u00a0We strong recommend using 21 electrodes should be used (10-20 system) periods when the eyes are closed and open should be included in the recordings (strong recommendation)\u00a0 .<\/p>\n

      –\u00a0During EEG Photic stimulation, sleep deprivation, and hyperventilation can be used routinely (unless contraindicated ) (conditional recommendation)\u00a0 .<\/p>\n

      –\u00a0\u00a0In all patients with blackouts,\u00a0 we recommend the 12-lead electrocardiography (ECG) in\u00a0 older age groups with blackouts (strong recommendation) .<\/p>\n

      –\u00a0Consider ECG as a routine channel during EEG recording and should be performed as a baseline before starting ASM (conditional recommendation)\u00a0 .<\/p>\n

      –\u00a0\u00a0Magnetic resonance imaging (MRI) epilepsy protocol should follow the ILAE consensus on the”recommendations for using structural MRI in the care of PWE” (strong recommendation)<\/p>\n

      –\u00a0\u00a0We recommend MRI\u00a0 for brain imaging in PWE (before the age of two years and in adults) (strong recommendation).<\/p>\n

      –\u00a0Any patient with focal onset on history, EEG, or examination (unless clear evidence of benign focal epilepsy) is indicated for MRI(strong recommendation).\u00a0<\/p>\n

      –\u00a0\u00a0We recommend Referral for neuropsychological for any PWE who is suffering from learning or occupational challenges and as a part of the pre-surgical evaluation (strong recommendation).<\/p>\n

      –\u00a0In adults, appropriate blood tests should be considered (complete blood count (CBC), glucose, calcium, thyroid-stimulating hormone (TSH), plasma electrolytes) to specify possible causes and\/or any significant comorbidity(strong recommendation).<\/p>\n

      –\u00a0\u00a0In adolescents and adults, urine toxicology screening should be done if addiction is suspected (strong recommendation).\u00a0<\/p>\n

      –\u00a0\u00a0We recommend lumbar puncture (LP) for a child <6 months, a patient who fails to return to baseline \/meningeal signs, or suspects high intracranial pressure (imaging before LP is mandatory) (strong recommendation).<\/p>\n

      –\u00a0\u00a0In children and young people, other investigations should be considered in special situations (including urine and blood biochemistry) to identify an underlying cause of epilepsy and exclude other diagnoses (strong recommendation)..<\/p>\n

      –\u00a0\u00a0In case of failure of the initial ASM (due to continued seizures or adverse effects), initiation of an additional drug should take place and then escalate up to an adequate or maximum tolerated dose (this drug may be an alternative first\u2010line or second\u2010line drug). Afterward, slow tapering off the first drug should be done and caution is needed during the changeover period (strong recommendation).<\/p>\n

      –\u00a0\u00a0In case the second drug is worthless, consider tapering of it or the first drug\u00a0 (conditional recommendation).<\/p>\n

      –\u00a0\u00a0We recommend combination therapy with the newer antiepipetic drugs in\u00a0 patients who do not achieve seizure freedom on monotherapy . (strong recommendation).<\/p>\n

      –\u00a0\u00a0We recommend Drug withdrawal\u00a0 after a minimum of 2-5 years without a seizure based on risk of seizure recurrence. Gradual withdrawal over 2-6 months is recommended.<\/p>\n

      If seizures recur, the effective well tolerated drug previously used should be restarted using the last effective dose . (strong recommendation).<\/p>\n

      –\u00a0\u00a0In self-limited epilepsy with centrotemporal spikes first line are carbamazepine, oxcarbazepine, valproate. And adjuvant therapy are eslicarpazepine, lacozamide, lamotrigine, levetiracetam, zonisamide\u00a0<\/span>(strong recommendation)\u00a0\u00a0<\/span>.\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<\/p>\n

      –\u00a0\u00a0In self-limited epilepsy with autonomic seizures first line are carbamazepine, sodium valproate. And adjuvant therapy are eslicarpazepine, lacozamide, lamotrigine, levetiracetam, zonisamide\u00a0<\/span>(conditional recommendation)\u00a0\u00a0<\/span>.<\/p>\n

      –\u00a0\u00a0In childhood occipital visual epilepsy first line are carbamazepine, lamotrigine, levetiracetam, oxcarbazepine, valproate. And adjuvant therapy are eslicarpazepine, lacozamide, lamotrigine, levetiracetam, zonisamide\u00a0<\/span>(strong recommendation)\u00a0\u00a0<\/span>.<\/p>\n

      –\u00a0\u00a0In photosensitive occipital lobe epilepsy first line is avoid factors that provoke seizures, valproate and adjuvant therapy are benzodiazepines, levetiracetam\u00a0<\/span>(strong recommendation)\u00a0\u00a0<\/span>.<\/p>\n

      –\u00a0\u00a0In childhood absence epilepsy first line are ethosuximide, valproic acid. And adjuvant therapy are a combination of ethosuximide and valproic acid or lamotrigine\u00a0<\/span>(strong recommendation)\u00a0 .<\/p>\n

      –\u00a0\u00a0In epilepsy with myoclonic absence first line are ethosuximide, valproic acid.and adjuvant therapyare a combination of ethosuximide and valproic acid. other options are lamotrigine (strong recommendation)\u00a0<\/span>.<\/p>\n

      –\u00a0\u00a0In epilepsy with eyelid myoclonia first line are ethosuximide, valproic acid.and adjuvant therapy are clonazepam, ethosuximide, valproic acid\u00a0<\/span>(conditional recommendation)\u00a0\u00a0<\/span>.<\/p>\n

      –\u00a0\u00a0In myoclonic atonic epilepsy first line are valproate in GTCS, ethosuximide in absence seizures, steroids in the periods with multiple atonic seizures, and frequent, prolonged episodes of nonconvulsive status.\u00a0<\/span>and adjuvant therapy are\u00a0<\/span>lamotrigine, ketogenic diet\u00a0<\/span>(conditional recommendation)\u00a0\u00a0<\/span>.<\/p>\n

      –\u00a0\u00a0In lennox-gastaut syndrome first line are lamotrigine, topiramate, valproate.and adjuvant therapy are lamotrigine, topiramate, valproate, rufinamide\u00a0<\/span>(strong recommendation)\u00a0\u00a0<\/span>.<\/p>\n

      –\u00a0\u00a0In developmental and\/or epileptic encephalopathy with spike-wave activation during sleep first line are standard ASMs, VPA, benzodiazepines, ethosuximide, ACTH or prednisone, high-dose benzodiazepines, intravenous immunoglobulins, epilepsy surgery.other options: acetazolamide, clobazam, lacozamide, lamotrigine, levetiracetam\u00a0<\/b>(conditional recommendation)\u00a0\u00a0<\/span>.<\/p>\n

      –\u00a0\u00a0IN Febrile infection-related epilepsy syndrome First line ARE benzodiazepines and barbiturates for treatment of the acute event.And adjuvant therapy is ketogenic diet.other options: IVIG, cannabidiol, anakinra, immunomodulation such as tocilizumab or canakinumab, epilepsy surgery\u00a0\u00a0<\/span>(strong recommendation).<\/p>\n

      –\u00a0\u00a0In hemiconvulsion, hemiplegia epilepsy syndrome first line are Steroids, NMDA receptor blocker as memantine, amantadine.and adjuvant therapy are carbamazepine, phenytoin in cases of persistent seizures.other options: lamotrigine, perampanel, rufinamide, topiramate, valproate, epilepsy surgery\u00a0<\/span>(conditional recommendation)\u00a0\u00a0\u00a0<\/span>.<\/p>\n

      –\u00a0\u00a0In juvenile absence epilepsy (JAE) first line are ethosuximide, lamotrigine, sodium valproate.and adjuvant therapy are a combination of any of the first lines\u00a0<\/span>(strong recommendation)\u00a0<\/span>.<\/p>\n

      –\u00a0\u00a0In juvenile myoclonic epilepsy (JME) first line aresodium valproate, topiramate.and adjuvant therapy are acetazolamide, lamotrigine, levetiracetam .\u00a0\u00a0<\/span>(strong recommendation).\u00a0<\/span>.<\/p>\n

      –\u00a0\u00a0In idiopathic generalized tonic\u2013clonic seizures first line are lamotrigine, sodium valproate. And adjuvant therapy are consider carbamazepine, oxcarbazepine (exacerbating myoclonic and absence seizures) (strong recommendation).\u00a0<\/span>.<\/p>\n

      –\u00a0In focal aware and impaired awareness seizures first line are carbamazepine, eslicarpazepine acetate, lacozamide, lamotrigine, levetiracetam, oxcarbazepine, sodium valproate.and adjuvant\/ add-on: lamotrigine, phenobarbital, phenytoin, topiramate, vigabatrin, zonisamide\u00a0<\/span>(strong recommendation).<\/p>\n

      –\u00a0\u00a0In focal to bilateral tonic-clonic seizure and generalized onset tonic-clonic seizure first line; lamotrigine, sodium valproate.and adjuvant\/ add-on: levetiracetam, topiramate\u00a0<\/span>(strong recommendation).\u00a0<\/span>.<\/p>\n

      –\u00a0In generalized non-motor (Absence) seizures first line: ethosuximide, sodium valproate,and adjuvant: clonazepam, lamotrigine, levetiracetam, topiramate, zonisamide\u00a0<\/span>(strong recommendation) .<\/p>\n

      –\u00a0In myoclonic seizures first line: levetiracetam, sodium valproate, topiramate.and adjuvant are clonazepam, levetiracetam, piracetam\u00a0<\/span>(strong recommendation).\u00a0<\/span>\u00a0.<\/p>\n

      –\u00a0In tonic & atonic seizures first line: sodium valproateand adjuvant: lamotrigine, topiramate(strong recommendation)\u00a0<\/span>.<\/p>\n

      –\u00a0\u00a0<\/span>\u00a0In status Epilepticus (SE) the diagnostic evaluation begins in parallel with emergent Initial Therapy\u00a0:<\/span><\/p>\n

      o\u00a0\u00a0\u00a0For diagnosis, finger stick glucose should be checked, pulse oximeter and cardiac monitoring should be started as soon as possible. Blood and serum laboratory evaluation typically includes a CBC, basic metabolic panel, calcium and magnesium determinations (conditional recommendation)\u00a0.<\/span><\/p>\n

      o\u00a0\u00a0\u00a0In the case of febrile patients or if there is a suspected subarachnoid haemorrhage or central nervous system infection, LP should be performed, preferably after obtaining the CT scan. Non-contrast CT of the brain is the first imaging study to be considered in the Emergency Department (ED) if MRI is not feasible (conditional recommendation) .<\/p>\n

      o\u00a0\u00a0\u00a0Emergent prehospital treatment with benzodiazepines is needed and assess any abnormalities (hypoxia, hypoglycemia, or hypotension must be managed accordingly) (strong recommendation)\u00a0 .<\/p>\n

      o\u00a0\u00a0\u00a0If benzodiazepines are not administered to the patient before ED arrival and are still seizing, IV benzodiazepines should be included in the initial dosing when IV access is immediately available (strong recommendation)\u00a0 .<\/p>\n

      o\u00a0\u00a0\u00a0When IV access is not available, IM, per rectum (PR), buccal, or intranasal benzodiazepines should be administered together with IV placement (strong recommendation)\u00a0\u00a0 .<\/p>\n

      o\u00a0\u00a0\u00a0Unless IV access is immediately available, initiate IM. In adults or children over 40 kg, IM midazolam 10 mg. In children 13\u201340 kg, the IM midazolam dose is 5 mg, and in children <13 kg, the IM midazolam dose is 0.2 mg\/ kg\u00a0 (strong recommendation)\u00a0 .<\/p>\n

      o\u00a0\u00a0\u00a0Among second-line ASMs, the first-line choice will be either phenytoin or levetiracetam in their standard loading doses. Also lacosamide can be used if the previous ASM failed or is unavailable. It would be better to start the second line simultaneously with the initial benzodiazepine rather than waiting for a response for benzodiazepine (strong recommendation)\u00a0 .<\/p>\n

      o\u00a0\u00a0\u00a0If seizures have stopped after the initial ASM, and the patient had awakened, a maintenance dose of loading ASMs should be started if indicated and can be given either orally or intravenously\u00a0 (strong recommendation)\u00a0 .<\/p>\n

      l\u00a0\u00a0For treatment of Refractory SE early (within one hour) drug-induced coma with continuous IV infusion of an anaesthetic drug is recommended for RSE with EEG target of burst suppression (strong recommendation)\u00a0\u00a0 .<\/p>\n

      l\u00a0\u00a0The recommended loading dose of IV midazolam infusion is 0.2 mg\/kg at 2 mg\/min. Then, repeated boluses every 5 min of 0.2\u20130.4 mg\/kg should be administered until the seizures stop, up to a maximum loading dose of 2 mg\/kg. Then, a continuous infusion at 0.05\u20132 mg\/kg\/h should be started (strong recommendation)\u00a0\u00a0 .<\/p>\n

      –\u00a0\u00a0Propofol IV infusions are an alternative at 1\u20132 mg\/kg IV over 3\u20135 min as a loading dose and then repeated boluses every 3\u20135 min of the same amount until the seizures stop\u00a0 (strong recommendation).<\/p>\n

      –\u00a0\u00a0\u00a0The propofol infusion at a rate of 30\u2013200 mcg\/kg\/min should then be maintained .Pentobarbital at 5 mg\/kg as a loading dose, which is followed by a maintenance infusion of 1\u20133 mg\/ kg may be used in children with refractory SE more frequently because of adverse effects with propofol (strong recommendation)\u00a0\u00a0 .<\/p>\n

      –\u00a0\u00a0For treatment of Super-Refractory SE Thiopental should be initiated in the recommended dose with progressive weaning of the previous anesthetic over the following 24 hours (conditional recommendation).<\/p>\n

      –\u00a0\u00a0If a burst-suppression EEG pattern without epileptic activity has been achieved during 24 hours under thiopental and SE recurs after thiopental weaning, adding phenobarbital should be considered in therapeutic dose for at least 24 hours, after which weaning should again be tried .thiopental anesthesia (epileptiform discharges), then ketamine in the recommended dose should be associated with thiopental (conditional recommendation)\u00a0\u00a0 .<\/p>\n

      –\u00a0\u00a0In case of persistence or recurrence of SRSE despite the adoption of all previous recommendations and the patient in burst suppression so should be maintained under combined anesthesia with thiopental and ketamine, and all of the following therapeutics should be considered (according to availability and applicability):<\/p>\n

      A. magnesium sulfate \u2013 intravenous bolus (4 g) followed by a continuous infusion (2 – 6 g\/h) aiming for plasma levels of 3.5 mmol\/L (conditional recommendation).<\/p>\n

      B. Immunotherapy (conditional recommendation)\u00a0\u00a0 .<\/p>\n

      C. Ketogenic diet (conditional recommendation)\u00a0 .<\/p>\n

      D. Vagus nerve stimulation (conditional recommendation)\u00a0\u00a0 .<\/p>\n

      F. Epilepsy surgery (conditional recommendation)\u00a0\u00a0 .<\/p>\n

      G. electroconvulsive therapy (conditional recommendation)\u00a0\u00a0 .<\/p>\n

      –\u00a0\u00a0Patients with focal Drug resistant epilepsy should be referred for evaluation in a specialized\/tertiary epilepsy care facility. The expertise of multidisciplinary teams should include psychology, psychiatry, neuroradiology, social work, counseling, clinical nurse specialists, occupational therapy, neurology, neuroanesthesia, neurophysiology, and neurosurgery\u00a0 (conditional recommendation)\u00a0 .<\/p>\n

      –\u00a0\u00a0Once referred to a specialized\/tertiary epilepsy facility the patient should undergo :<\/p>\n

      A.\u00a0\u00a0\u00a0\u00a0Video-EEG to characterize the epilepsy types and rule out PNES (conditional recommendation)\u00a0 .<\/p>\n

      B.\u00a0\u00a0\u00a0\u00a0Imaging (MRI- HARNESS protocol) studies must be scrutinized once epilepsy diagnosis is confirmed to ascertain the presence of an epileptogenic focus and facilitate a possible surgical work-up\u00a0 (conditional recommendation)\u00a0 .<\/p>\n

      C.\u00a0\u00a0\u00a0\u00a0In presence of high suspicion of focal seizures; if no epileptogenic lesion is found on MRI, other ancillary tests include:<\/p>\n

      1.\u00a0\u00a0\u00a0\u00a0\u00a0Ictal single-photon emission computed tomography (SPECT) (conditional recommendation)\u00a0 .<\/p>\n

      2.\u00a0\u00a0\u00a0\u00a0\u00a0Positron emission tomography (PET) (strong recommendation)\u00a0 .<\/p>\n

      3.\u00a0\u00a0\u00a0\u00a0\u00a0Functional MRI for eloquent regions of the brain (strong recommendation)\u00a0 .<\/p>\n

      4.\u00a0\u00a0\u00a0\u00a0\u00a0Invasive EEG can be considered in case of unclear localization, or in case a more precise definition of the relationship of the eloquent cortex to the epileptic cortex is needed (strong recommendation)\u00a0\u00a0 .<\/p>\n

      l\u00a0\u00a0In case of the localized epileptogenic zone (i.e. for lesional focal epilepsy in concordance with semiology and EEG, or non-lesional focal epilepsy with the localized epileptogenic zone); For extra-temporal lobe epilepsy related to eloquent areas but not included in the epileptogenic zone; awake craniotomy, mapping techniques, and ECoG guided resection should be applied (conditional recommendation) .<\/p>\n

      \u00a0<\/p>\n

      –\u00a0\u00a0In case of the localized epileptogenic zone (i.e. for lesional focal epilepsy in concordance with semiology and EEG, or non-lesional focal epilepsy with the localized epileptogenic zone); For extra-temporal lobe epilepsy with eloquent areas included in the epileptogenic zone; implementation of procedure such as MST, VNS, or RNS should be applied (strong recommendation).<\/p>\n

      –\u00a0\u00a0In case of the localized epileptogenic zone (i.e. for lesional focal epilepsy in concordance with semiology and EEG, or non-lesional focal epilepsy with the localized epileptogenic zone); For unilateral temporal lobe epilepsy with lateral temporal involvement, ATL should be applied (strong recommendation).<\/p>\n

      –\u00a0\u00a0In case of the localized epileptogenic zone (i.e. for lesional focal epilepsy in concordance with semiology and EEG, or non-lesional focal epilepsy with the localized epileptogenic zone); For unilateral temporal lobe epilepsy with no lateral temporal involvement, either surgical procedures (ATL or SAH) or minimally invasive procedures (LITT or SRS) should be applied\u00a0\u00a0<\/b>(strong recommendation).<\/p>\n

      –\u00a0\u00a0In the case of the localized epileptogenic zone (i.e. for lesional focal epilepsy in concordance with semiology and EEG, or non-lesional focal epilepsy with the localized epileptogenic zone); For bilateral temporal lobe epilepsy, either VNS or RNS should be applied (conditional recommendation)\u00a0 .<\/p>\n

      –\u00a0\u00a0In the case of hemispheric generalized or multifocal epilepsy, either hemispherectomy (anatomical or functional) or VNS should be applied (conditional recommendation)\u00a0 .<\/p>\n

      –\u00a0\u00a0In the case of generalized poorly localized epilepsy with mostly atonic attacks, palliative management with corpus callosotomy should be applied (conditional recommendation) .<\/p>\n

      –\u00a0In case of generalized poorly localized epilepsy with minor atonic attacks, palliative management with VNS or DBS of the anterior nucleus of the thalamus should be applied (strong recommendation) .<\/p>\n

      \u00a0<\/b><\/p>\n

      \u00a0<\/b><\/p>\n
      \n

      \u00a0<\/p>\n<\/div>\n<\/div>\n

      \n
      \n
      \n
      \u00a0<\/div>\n<\/div>\n
      \n
      \n
      \u00a0<\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div> <\/div>\n\n <\/div>\n
      \n\n
      \n\n \n\n \n <\/path><\/svg> <\/span>\n\n \n <\/path><\/svg> <\/span>\n \n <\/span>\n \n \n Endovascular Intervention <\/span>\n\n <\/h5>\n\n
      \n
      \n
      \n
      \n
      “last update: 27 July \u00a02025”\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0\u00a0\u00a0<\/strong>\u00a0Download Guideline<\/u><\/a><\/strong>
      <\/u><\/h5>\n<\/div>\n<\/div>\n<\/div>\n
      \n
      \n
      \n
      \u00a0<\/div>\n<\/div>\n<\/div>\n<\/div>\n
      \n

      – Executive Summary<\/h3>\n
      \n

      \u00a0<\/p>\n\n\n\n
      \n

      \u00a0<\/p>\n<\/td>\n

      		\n
      \n

      These guidelines are concerned with clinical practice standards of endovascular intervention neurology procedures. It will discuss practicing physician qualifications, specific requirement for treating centers and specific pre & postoperative care and indications of different endovascular intervention neurology procedures.<\/h4>\n


      I)\u00a0\u00a0<\/b>PHYSICIAN QUALIFICATIONS<\/b><\/u><\/h4>\n<\/div>\n

      1-\u00a0\u00a0\u00a0\u00a0Practicing physician must have a valid license to practice medicine within their respective countries.<\/p>\n

      2-\u00a0\u00a0\u00a0\u00a0Practicing physician specialization criteria should be defined at a national level according to national medical regulations. They must have accomplished training in one of the following medical specialties: Neurology, Neurosurgery, Intervention radiology.<\/p>\n

      3-\u00a0\u00a0\u00a0\u00a0Practicing physician must have completed an accredited post graduate dedicated training in intervention neurology subspecialty. This program should have not less than 24 months mandatory dedicated training in intervention neurology.<\/p>\n

      Good practice statement.<\/i><\/b><\/p>\n

      II)\u00a0\u00a0\u00a0<\/b>REQUIREMENTS FOR PRACTICING INSTITUTIONS\/DEPARTMENTS<\/b><\/h4>\n

      1-\u00a0Intervention neurology practicing must take place in institutions\/departments operating in accordance with the national standards of medical service providence.<\/p>\n

      2-\u00a0All patients would be treated at a center offering a full spectrum of neuroendovascular care.<\/p>\n

      3-\u00a0Treating centers should have the following requirements at least to provide safe and efficient intervention neurology services:<\/p>\n

      a.\u00a0Offers full spectrum of neuroendovascular therapy (including aneurysm treatment, surgical and endovascular, arteriovenous malformations, arteriovenous fistulas, etc.)<\/p>\n

      b.\u00a0At least 250 case per year of stroke patients\u2019 management in a dedicated neuroscience department.<\/p>\n

      c.\u00a0Dedicated intensive care unit\/stroke unit to manage pre- and post-operative patients.<\/p>\n

      d.Standardized care pathways should be implemented with clinical practice guidelines, order sets, and other tools to ensure consistent care delivery and minimize practice variability. This should apply to\u00a0providers, and\u00a0nursing and ancillary staff.<\/p>\n

      Strong recommendation<\/i><\/b><\/p>\n

      \n

      III)\u00a0<\/b>PREPROCEDURE PATIENT CARE<\/b><\/h4>\n<\/div>\n

      1-\u00a0\u00a0\u00a0\u00a0Preprocedural documentation for elective diagnostic cervicocerebral\/spinal catheter angiography, must contain the following:<\/p>\n

      a.\u00a0\u00a0Clinically significant history, including indications for the procedure.<\/p>\n

      b.\u00a0\u00a0Clinically significant physical examination and diagnostic imaging findings, including neurological and vascular examinations appropriate to the procedure performed, and a general examination of relevant organ systems.<\/p>\n

      c.\u00a0\u00a0Laboratory evaluation as appropriate, including but not limited to measurement of hemoglobin, hematocrit, creatinine, electrolytes, and coagulation parameters.<\/p>\n

      d.\u00a0\u00a0Informed consent must be in compliance with all local laws and policies.<\/p>\n

      Strong recommendation<\/i><\/b><\/p>\n

      \n

      IV)<\/b>PATIENT SELECTION, INDICATIONS AND OUTCOMES<\/b><\/h4>\n<\/div>\n
      \n

      A.\u00a0<\/b>Diagnostic Angiography<\/u><\/b><\/h4>\n<\/div>\n

      1-\u00a0Diagnostic cervicocerebral\/spinal catheter angiography is a proven, safe, and effective procedure for evaluating many intracranial and extracranial disorders, especially vascular abnormalities of the head, neck, and brain.\u00a0Strong recommendation<\/i><\/b><\/p>\n

      2-\u00a0Diagnostic cervicocerebral\/spinal catheter angiography has been considered the gold standard for judging the accuracy of other intracranial or extracranial vascular imaging modalities.\u00a0Strong recommendation<\/i><\/b><\/p>\n

      3-The following list of indications helps to focus on the primary indications for diagnostic cervicocerebral\/spinal catheter angiography and therefore helps to avoid unnecessary testing:<\/p>\n

      a.\u00a0Definition of the presence and extent of atherosclerotic occlusive disease and thromboembolic phenomena and as an aid in planning intervention.<\/p>\n

      b.\u00a0Definition of the etiology of cervicocerebral\/spinal hemorrhage.<\/p>\n

      c.\u00a0\u00a0Definition of the presence, location, and anatomy of extra- or intracranial and spinal aneurysms and vascular malformations.<\/p>\n

      d.\u00a0Evaluation of vasospasm related to subarachnoid hemorrhage or drug-induced vasculopathy.<\/p>\n

      e.\u00a0Definition of the vascular supply to cervicocerebral\/spinal tumors.<\/p>\n

      f.\u00a0\u00a0\u00a0Diagnosis and definition of the nature and extent of cervicocerebral\/spinal congenital or acquired vascular abnormalities.<\/p>\n

      g.\u00a0Definition of the presence of venous occlusive disease.<\/p>\n

      h.\u00a0Definition of the relevant vascular anatomy for planning or evaluating a therapeutic intervention.<\/p>\n

      Strong recommendation<\/i><\/b><\/p>\n

      4-\u00a0\u00a0\u00a0\u00a0The threshold for these indications is 99%. When fewer than 99% of the procedures are for these indications, the institution should review the process of patient selection.\u00a0Strong recommendation<\/i><\/b><\/p>\n

      5-\u00a0\u00a0\u00a0\u00a0There are no absolute contraindications to diagnostic cervicocerebral catheter angiography. Relative contraindications include hypotension, severe hypertension, and coagulopathy, clinically significant sensitivity to iodinated contrast material, renal insufficiency, and congestive heart failure.\u00a0Strong recommendation<\/i><\/b><\/p>\n

      6-\u00a0\u00a0\u00a0\u00a0Patient management should address these relative contraindications prior to the procedure. When possible, every effort should be made to correct or control these clinical situations before the procedure.\u00a0Strong recommendation<\/i><\/b><\/p>\n

      7-\u00a0\u00a0\u00a0\u00a0Diagnostic cervicocerebral\/spinal catheter angiographic examinations must be performed by or under the supervision of and interpreted by a physician who has the appropriate qualification and training in the field of cervicocerebral\/spinal catheter angiography.\u00a0Strong recommendation<\/i><\/b><\/p>\n

      \u00a0<\/p>\n

      B.\u00a0<\/b>Acute\u00a0Ischemic Stroke<\/a>\u00a0(Mechanical Thrombectomy)
      <\/u><\/b>From 0 to 6 hours From Onset:<\/b><\/h4>\n

      1-\u00a0\u00a0\u00a0\u00a0Patients should receive mechanical thrombectomy with a stent retriever if they meet all the following criteria: (1) pre stroke mRS score of 0 to 1; (2) causative occlusion of the internal carotid artery or MCA segment 1 (M1); (3) age \u226518 years; (4) NIHSS score of \u22656; (5) ASPECTS of \u22656; and (6), treatment can be initiated (groin puncture) within 6 hours of symptom onset.\u00a0Strong recommendation<\/i><\/b><\/p>\n

      2-\u00a0\u00a0Although the benefits are uncertain, the use of mechanical thrombectomy with stent retrievers may be reasonable for carefully selected patients with AIS in whom treatment can be initiated (groin puncture) within 6 hours of symptom onset and who have causative occlusion of the MCA segment 2 (M2) or MCA segment 3 (M3) portion of the MCAs.\u00a0Conditional recommendation<\/i><\/b><\/p>\n

      3-\u00a0\u00a0Although its benefits are uncertain, the use of mechanical thrombectomy with stent retrievers may be reasonable for patients with AIS in whom treatment can be initiated (groin puncture) within 6 hours of symptom onset and who have pre stroke mRS score >1, ASPECTS <6, or NIHSS score<6, and causative occlusion of the internal carotid artery (ICA) or proximal MCA (M1).\u00a0Conditional recommendation<\/i><\/b><\/p>\n

      4-\u00a0\u00a0Although the benefits are uncertain, the use of mechanical thrombectomy with stent retrievers may be reasonable for carefully selected patients with AIS in whom treatment can be initiated (groin puncture) within 6 hours of symptom onset and who have causative occlusion of the anterior cerebral arteries, vertebral arteries, basilar artery, or posterior cerebral arteries.\u00a0Conditional recommendation<\/i><\/b><\/p>\n

      From 6 to 24 hours From Onset:<\/b><\/h4>\n

      1-\u00a0In selected patients with AIS within 6 to 16 hours of last known normal who have LVO in the anterior circulation and meet other DAWN or DEFUSE 3 eligibility criteria, mechanical thrombectomy is recommended.\u00a0Strong recommendation<\/i><\/b><\/p>\n

      2-\u00a0In selected patients with AIS within 16 to 24 hours of last known normal who have LVO in the anterior circulation and meet other DAWN eligibility criteria, mechanical thrombectomy is reasonable.\u00a0Conditional recommendation<\/i><\/b><\/p>\n

      Thrombectomy Technique:<\/b><\/h4>\n

      1-\u00a0The use of stent retrievers is indicated in preference to the Mechanical Embolus Removal in Cerebral Ischemia (MERCI) device.\u00a0Strong recommendation<\/i><\/b><\/p>\n

      2-\u00a0The use of mechanical thrombectomy devices other than stent retrievers as first-line devices for mechanical thrombectomy may be reasonable in some circumstances, but stent retrievers remain the first choice.\u00a0Conditional recommendation<\/i><\/b><\/p>\n

      3-\u00a0The use of a proximal balloon guide catheter or a large-bore distal-access catheter, rather than a cervical guide catheter alone, in conjunction with stent retrievers may be beneficial.\u00a0Conditional recommendation<\/i><\/b><\/p>\n

      4-\u00a0The technical goal of the thrombectomy procedure should be reperfusion to a modified Thrombolysis in Cerebral Infarction (mTICI) grade 2b\/3 angiographic result to maximize the probability of a good functional clinical outcome.\u00a0Strong recommendation<\/i><\/b><\/p>\n

      5-\u00a0To ensure benefit, reperfusion to mTICI grade 2b\/3 should be achieved as early as possible within the therapeutic window.\u00a0Strong recommendation<\/i><\/b><\/p>\n

      6-\u00a0Use of salvage technical adjuncts including intra-arterial thrombolysis may be reasonable to achieve mTICI 2b\/3 angiographic results.\u00a0Conditional recommendation<\/i><\/b><\/p>\n

      7-\u00a0In the 6- to 24-hour thrombectomy window evaluation and treatment should proceed as rapidly as possible to ensure access to treatment for the greatest proportion of patients.\u00a0Strong recommendation<\/i><\/b><\/p>\n

      8-\u00a0Direct aspiration thrombectomy as first-pass mechanical thrombectomy is recommended as noninferior to stent retriever for patients who meet all the following criteria: (1) pre-stroke mRS score of 0 to 1; (2) causative occlusion of the internal carotid artery or M1; (3) age \u226518 years; (4) NIHSS score of \u22656; (5) ASPECTS \u22656; and (6) treatment initiation (groin puncture) within 6 hours of symptom onset.\u00a0Strong recommendation<\/i><\/b><\/p>\n

      9-\u00a0It is reasonable to select an anesthetic technique during EVT for AIS on the basis of individualized assessment of patient risk factors, technical performance of the procedure, and other clinical characteristics.\u00a0Conditional recommendation<\/i><\/b><\/p>\n

      10-\u00a0Treatment of tandem occlusions (both extracranial and intracranial occlusions) when performing mechanical thrombectomy may be reasonable.\u00a0Conditional recommendation<\/i><\/b><\/p>\n

      11-\u00a0The safety and efficacy of IV glycoprotein IIb\/IIIa inhibitors administered during endovascular stroke treatment are uncertain.\u00a0Conditional recommendation<\/i><\/b><\/p>\n

      Other Endovascular Therapies:<\/b><\/h4>\n

      1-\u00a0\u00a0\u00a0\u00a0Mechanical thrombectomy with stent retrievers is recommended over intra-arterial fibrinolysis as first-line therapy.\u00a0Strong recommendation<\/i><\/b><\/p>\n

      2-\u00a0\u00a0\u00a0\u00a0Intra-arterial fibrinolysis initiated within 6 hours of stroke onset in carefully selected patients who have contraindications to the use of IV alteplase might be considered, but the consequences are unknown.\u00a0Conditional recommendation<\/i><\/b><\/p>\n

      C.\u00a0<\/b>Endovascular Management For Secondary Prevention Of\u00a0Ischemic Stroke<\/a><\/u><\/b><\/h4>\n

      Intracranial Large Artery Atherosclerosis<\/b><\/p>\n

      1-\u00a0\u00a0In patients with severe stenosis (70%-99%) of a major intracranial artery and actively progressing symptoms or so-called medical failures; recurrent TIA or stroke after institution of aspirin and clopidogrel therapy, achievement of SBP< 140 mmHg, and high-intensity statin therapy, the usefulness of angioplasty alone or stent placement to prevent\u00a0ischemic stroke<\/a>\u00a0in the territory of the stenotic artery is recommended.\u00a0Strong recommendation<\/i><\/b><\/p>\n

      2-\u00a0\u00a0In patients with stroke or TIA attributable to severe stenosis (70%\u201399%) of a major intracranial artery, angioplasty, and stenting should not be performed as an initial treatment, even for patients who were taking an antithrombotic agent at the time of the stroke or TIA.\u00a0Conditional recommendation<\/i><\/b><\/p>\n

      3-\u00a0In patients with a stroke or TIA attributable to moderate stenosis (50%\u201369%) of a major intracranial artery, angioplasty or stenting is associated with excess morbidity and mortality compared with medical management alone.\u00a0Conditional recommendation<\/i><\/b><\/p>\n

      4-\u00a0In patients with stroke or TIA attributable to 50% to 99% stenosis or occlusion of a major intracranial artery, extracranial-intracranial bypass surgery may be considered when indicated.\u00a0Conditional recommendation<\/i><\/b><\/p>\n

      Extracranial Carotid stenosis<\/b><\/p>\n

      1-\u00a0In patients with a TIA or non-disabling\u00a0ischemic stroke<\/a>\u00a0within the past 6 months and ipsilateral severe (70%\u201399%) carotid artery stenosis, carotid endarterectomy (CEA) is recommended to reduce the risk of future stroke, provided that perioperative morbidity and mortality risk is estimated to be<6%.\u00a0Strong recommendation<\/i><\/b><\/p>\n

      2-\u00a0In patients with\u00a0ischemic stroke<\/a>\u00a0or TIA and symptomatic extracranial carotid stenosis who are scheduled for carotid artery stenting (CAS) or CEA, procedures should be performed by operators with established periprocedural stroke and mortality rates of<6%.\u00a0Strong recommendation<\/i><\/b><\/p>\n

      3-\u00a0In patients with carotid artery stenosis and a TIA or stroke, intensive medical therapy, with antiplatelet therapy, lipid lowering therapy, and treatment of hypertension, is recommended to reduce stroke risk.\u00a0Strong recommendation<\/i><\/b><\/p>\n

      4-\u00a0In patients with recent TIA or\u00a0ischemic stroke<\/a>\u00a0and ipsilateral moderate (50%\u201369%) carotid stenosis as documented by catheter-based imaging or noninvasive imaging, CEA is recommended to reduce the risk of future stroke, depending on patient-specific factors such as age, sex, and comorbidities, if the perioperative morbidity and mortality risk is estimated to be<6%.\u00a0Strong recommendation<\/i><\/b><\/p>\n

      5-\u00a0In patients \u226570 years of age with stroke or TIA in whom carotid revascularization is being considered, it is reasonable to select CEA over CAS to reduce the periprocedural stroke rate.\u00a0Conditional recommendation<\/i><\/b><\/p>\n

      6-\u00a0In patients in whom revascularization is planned within 1 week of the index stroke, it is reasonable to choose CEA over CAS to reduce the periprocedural stroke rate.\u00a0Conditional recommendation<\/i><\/b><\/p>\n

      7-\u00a0In patients with TIA or nondisabling stroke, when revascularization is indicated, it is reasonable to perform the procedure within 2 weeks of the index event rather than delay surgery to increase the likelihood of stroke-free outcome.\u00a0Conditional recommendation<\/i><\/b><\/p>\n

      8-\u00a0In patients with symptomatic severe stenosis (\u226570%) in whom anatomic or medical conditions are present that increase the risk for surgery (such as radiation-induced stenosis or restenosis after CEA) it is reasonable to choose CAS to reduce the periprocedural complication rate.\u00a0Conditional recommendation<\/i><\/b><\/p>\n

      9-\u00a0In symptomatic patients at average or low risk of complications associated with endovascular intervention, when the ICA stenosis is \u226570% by noninvasive imaging or >50% by catheter-based imaging and the anticipated rate of periprocedural stroke or death is<6%. CAS may be considered as an alternative to CEA for stroke prevention, particularly in patients with significant cardiovascular comorbidities predisposing to cardiovascular complications with endarterectomy.\u00a0Conditional recommendation<\/i><\/b><\/p>\n

      10-\u00a0In patients with a recent stroke or TIA (past 6 months), the usefulness of trans carotid artery revascularization (TCAR) for the prevention of recurrent stroke and TIA is uncertain.\u00a0Conditional recommendation<\/i><\/b><\/p>\n

      11-\u00a0In patients with recent TIA or\u00a0ischemic stroke<\/a>\u00a0and when the degree of stenosis is< 50%, revascularization with CEA or CAS to reduce the risk of future stroke is not recommended.\u00a0Conditional recommendation<\/i><\/b><\/p>\n

      12-\u00a0In patients with a recent (within 120 days) TIA or\u00a0ischemic stroke<\/a>\u00a0ipsilateral to atherosclerotic stenosis or occlusion of the middle cerebral or carotid artery, extracranial intracranial bypass surgery is not recommended\u00a0Conditional recommendation<\/i><\/b><\/p>\n

      Extracranial Vertebral artery stenosis<\/b><\/p>\n

      1-\u00a0\u00a0In patients with recently symptomatic extracranial vertebral artery stenosis, intensive medical therapy (antiplatelet therapy, lipid-lowering, BP control) is recommended to reduce stroke risk.\u00a0Strong recommendation<\/i><\/b><\/p>\n

      2-\u00a0In patients with\u00a0ischemic stroke<\/a>\u00a0or TIA and extracranial vertebral artery stenosis who are having symptoms despite optimal medical treatment, the usefulness of stenting is not well established.\u00a0Conditional recommendation<\/i><\/b><\/p>\n

      3-\u00a0In patients with\u00a0ischemic stroke<\/a>\u00a0or TIA and extracranial vertebral artery stenosis who are having symptoms despite optimal medical treatment, the usefulness of open surgical procedures, including vertebral endarterectomy and vertebral artery transposition, is not well-established.\u00a0Conditional recommendation<\/i><\/b><\/p>\n

      Moyamoya Disease<\/b><\/p>\n

      1-\u00a0In patients with Moyamoya disease and a history of\u00a0ischemic stroke<\/a>\u00a0or TIA, surgical revascularization with direct or indirect extracranial-intracranial bypass can be beneficial for the prevention of\u00a0ischemic stroke<\/a>\u00a0or TIA.\u00a0Conditional recommendation<\/i><\/b><\/p>\n

      2-\u00a0Inpatients with moyamoya disease and a history of\u00a0ischemic stroke<\/a>\u00a0or TIA, the use of antiplatelet therapy, typically aspirin monotherapy, for the prevention of\u00a0ischemic stroke<\/a>\u00a0or TIA may be reasonable.\u00a0Conditional recommendation<\/i><\/b><\/p>\n

      Carotid Web<\/b><\/p>\n

      1-\u00a0In patients with carotid web in the distribution of\u00a0ischemic stroke<\/a>\u00a0and TIA, without other attributable causes of stroke, antiplatelet therapy is recommended to prevent recurrent\u00a0ischemic stroke<\/a>\u00a0or TIA.\u00a0Strong recommendation<\/i><\/b><\/p>\n

      2-\u00a0In patients with carotid web in the distribution of\u00a0ischemic stroke<\/a>\u00a0refractory to medical management, with no other attributable cause of stroke despite comprehensive workup, carotid stenting or CEA may be considered to prevent recurrent\u00a0ischemic stroke<\/a>.\u00a0Conditional recommendation<\/i><\/b><\/p>\n

      Fibromuscular Dysplasia<\/b><\/p>\n

      1-\u00a0In patients with fibromuscular dysplasia (FMD) and a history of\u00a0ischemic stroke<\/a>\u00a0or TIA without other attributable causes, antiplatelet therapy, BP control, and lifestyle modification are recommended for the prevention of future ischemic events.\u00a0Strong recommendation<\/i><\/b><\/p>\n

      2-\u00a0In patients with a history of\u00a0ischemic stroke<\/a>\u00a0or TIA attributable to dissection, with FMD, and no evidence of intraluminal thrombus, it is reasonable to administer antiplatelet therapy for the prevention of future ischemic events.\u00a0Conditional recommendation<\/i><\/b><\/p>\n

      3-\u00a0In patients with cervical carotid artery FMD and recurrent\u00a0ischemic stroke<\/a>\u00a0without other attributable causes despite optimal medical management, carotid angioplasty with or without stenting may be reasonable to prevent ischemic stroke.\u00a0Conditional recommendation<\/i><\/b><\/p>\n

      Dolichoectasia<\/b><\/p>\n

      1-\u00a0In patients with vertebrobasilar dolichoectasia and a history of\u00a0ischemic stroke<\/a>\u00a0or TIA without other attributable causes, the use of antiplatelet or anticoagulant therapy is reasonable for the prevention of recurrent ischemic events according to proposed pathogenesis of ischemic event.\u00a0Conditional recommendation<\/i><\/b><\/p>\n

      D.\u00a0<\/b>Endovascular Management Of Aneurysmal<\/u><\/b>\u00a0Subarachnoid Hemorrhage<\/b><\/h4>\n

      1-\u00a0\u00a0\u00a0\u00a0In patients with spontaneous SAH with high level of concern for aneurysmal source and a negative or CT angiography, digital subtraction angiography is indicated to diagnose\/ exclude cerebral aneurysm(s).\u00a0Strong recommendation<\/i><\/b><\/p>\n

      2-\u00a0In patients with SAH from confirmed cerebral aneurysm(s), DSA can be useful to determine optimal strategy for aneurysm intervention.\u00a0Conditioned recommendation<\/i><\/b><\/p>\n

      3-\u00a0For patients with aSAH, timely transfer from hospitals with low case volume to higher-volume centers with multidisciplinary neurointensive care services, comprehensive stroke center capabilities, and experienced cerebrovascular surgeons\/ neuroendovascular interventionalists is recommended to improve outcomes.\u00a0Strong recommendation<\/i><\/b><\/p>\n

      4-\u00a0For patients with aSAH, surgical or endovascular treatment of the ruptured aneurysm should be performed as early as feasible after presentation, preferably within 24 hours of onset, to improve outcome.\u00a0Strong recommendation<\/i><\/b><\/p>\n

      5-\u00a0For patients with aSAH, the ruptured aneurysm should be evaluated by specialist(s) with endovascular and surgical expertise to determine the relative risks and benefits of surgical or endovascular treatment according to patient and aneurysm characteristics.\u00a0Strong recommendation<\/i><\/b><\/p>\n

      6-\u00a0For patients with aSAH, complete obliteration of the ruptured aneurysm is indicated whenever to reduce the risk of rebleeding and retreatment.\u00a0Strong recommendation<\/i><\/b><\/p>\n

      7-\u00a0For patients with aSAH in whom complete obliteration of the ruptured aneurysm by either clipping or primary coiling treatment is not feasible in the acute phase, partial obliteration to secure the rupture site and retreatment in a delayed fashion in those with functional recovery are reasonable to prevent rebleeding.\u00a0Conditioned recommendation<\/i><\/b><\/p>\n

      8-\u00a0For patients with aSAH from ruptured aneurysms of the posterior circulation that are amenable to coiling, coiling is indicated in preference to clipping to improve outcome.\u00a0Strong recommendation<\/i><\/b><\/p>\n

      9-\u00a0For patients >70 years of age with aSAH, the superiority of coiling or clipping to improve outcome is not well established.\u00a0Conditioned recommendation<\/i><\/b><\/p>\n

      10-\u00a0For patients <40 years of age with aSAH, clipping of the ruptured aneurysm might be considered the preferred mode of treatment to improve durability of the treatment and outcome.\u00a0Conditioned recommendation<\/i><\/b>\u00a0<\/i><\/b><\/p>\n

      11-\u00a0For patients with aSAH from ruptured wide-neck aneurysms not amenable to surgical clipping or primary coiling, endovascular treatment with stent-assisted coiling or flow diverters is reasonable to reduce the risk of rebleed.\u00a0Conditioned recommendation<\/i><\/b><\/p>\n

      12-\u00a0For patients with aSAH from ruptured fusiform\/blister aneurysms, the use of flow diverters is reasonable to reduce mortality.\u00a0Conditioned recommendation<\/i><\/b><\/p>\n

      13-\u00a0In patients with aSAH and severe vasospasm, use of intra-arterial vasodilator therapy may be reasonable to reverse cerebral vasospasm and reduce the progression and severity of DCI.\u00a0Conditioned recommendation<\/i><\/b><\/p>\n

      14-\u00a0In patients with aSAH and severe vasospasm, cerebral angioplasty may be reasonable to reverse cerebral vasospasm and reduce the progression and severity of DCI.\u00a0Conditioned recommendation<\/i><\/b><\/p>\n

      E.\u00a0<\/b>Brain Arteriovenous Fistula And Malformation Embolization<\/u><\/b><\/h4>\n

      1.\u00a0\u00a0\u00a0\u00a0\u00a0Digital subtraction catheter cerebral angiography (DSA)\u2014including 2D, 3D, and reformatted cross-sectional views when appropriate\u2014is recommended in the pre-treatment assessment of cerebral AVMs.\u00a0Strong recommendation\u00a0<\/i><\/b>It is recommended that endovascular embolization of cerebral AVMs be performed in the context of a complete multidisciplinary treatment plan aiming for obliteration of the AVM and cure.\u00a0Strong recommendation<\/i><\/b><\/p>\n

      2.\u00a0\u00a0\u00a0\u00a0\u00a0Embolization of brain AVMs before surgical resection can be useful to reduce intraoperative blood loss, morbidity, and surgical complexity.\u00a0Conditioned recommendation<\/i><\/b><\/p>\n

      3.\u00a0\u00a0\u00a0\u00a0\u00a0The role of primary curative embolization of cerebral AVMs is uncertain, particularly as compared to microsurgery and radiosurgery with or without adjunctive embolization. Further research is needed, particularly with regard to risk for AVM recurrence.\u00a0Conditioned recommendation<\/i><\/b><\/p>\n

      4.\u00a0\u00a0\u00a0\u00a0\u00a0Targeted embolization of high-risk features of ruptured brain AVMs may be considered to reduce the risk for recurrent hemorrhage.\u00a0Conditioned recommendation<\/i><\/b><\/p>\n

      5.\u00a0\u00a0\u00a0\u00a0\u00a0Palliative embolization may be useful to treat symptomatic AVMs in which curative therapy is otherwise not possible.\u00a0Conditioned recommendation<\/i><\/b><\/p>\n

      6.\u00a0\u00a0\u00a0\u00a0\u00a0Imaging follow-up after apparent cure of brain AVMs is recommended to assess for recurrence. Although non-invasive imaging may be used for longitudinal follow-up, DSA remains the gold standard for residual or recurrent AVM detection in patients with concerning imaging and\/or clinical findings.\u00a0Strong recommendation<\/i><\/b><\/p>\n

      7.\u00a0\u00a0\u00a0\u00a0\u00a0Improved national and international reporting of patients of all ages with brain AVMs, their treatments, side effects from treatment, and their long-term outcomes would enhance the ability to perform clinical trials and improve the rigor of research into this rare condition.\u00a0Strong recommendation<\/i><\/b><\/p>\n

      F.\u00a0\u00a0<\/b>Spinal Arteriovenous Fistula And Malformation Embolization<\/u><\/b><\/h4>\n

      1-\u00a0Digital subtraction angiography (DSA), given its higher spatial and temporal resolution, remains superior to non-invasive modalities in identifying relevant dural AVF or AVM angioarchitecture features as compared with non-invasive modalities.\u00a0Strong recommendation<\/i><\/b><\/p>\n

      2-\u00a0Angioarchitecture features, including feeding artery aneurysms, nidus aneurysms, large-caliber arteriovenous fistulous connections, and venous outflow stenoses, can be visualized to lesser or greater degrees by non-invasive imaging such as MR angiography (MRA) and CT angiography (CTA).\u00a0Conditioned recommendation<\/i><\/b><\/p>\n

      3-\u00a0The presence of spinal dural AVF is an indication for treatment in all patients; embolization maybe contraindicated in those patients in whom the anterior spinal artery originates from the same pedicle as the spinal dural AVF.\u00a0Conditioned recommendation<\/i><\/b><\/p>\n

      4-\u00a0The indications for embolization of spinal cord AVMs include all symptomatic patients with lesions that can be cured; adjuvant therapy before surgery\/radiosurgery; and palliative therapy when total obliteration is not practical and the patient suffers from progressive neurologic deficit or high risk of hemorrhage (associated aneurysm or pseudoaneurysm, previous hemorrhage) or when partial embolization is thought to be of benefit (presence of AVF, outflow restriction with venous ectasia).\u00a0Strong recommendation<\/i><\/b><\/p>\n

      G.\u00a0\u00a0<\/b>Head, Neck And Brain Tumor Embolization<\/u><\/b><\/h4>\n

      1-\u00a0\u00a0\u00a0\u00a0Endovascular embolization of highly vascular head, neck and brain tumors is undertaken to devascularise the lesion with the goal of minimizing blood loss and decreasing operating time.\u00a0Conditioned recommendation<\/i><\/b><\/p>\n

      2-\u00a0\u00a0\u00a0\u00a0In certain instances, embolization may be used as the sole treatment for palliation by decreasing the size of the tumor and reducing pain in patients who are deemed non-operable candidates.\u00a0Conditioned recommendation<\/i><\/b><\/p>\n

      3-\u00a0\u00a0\u00a0\u00a0The following list summarizes vascular tumors that are commonly treated with adjunct embolization prior to operative resection:<\/p>\n

      a.\u00a0Juvenile nasopharyngeal angiofibroma (JNA)<\/p>\n

      b.\u00a0Hemangiopericytoma<\/p>\n

      c.\u00a0Glomus jugulare and other paragangliomas<\/p>\n

      d.\u00a0Meningiomas<\/p>\n

      e.\u00a0Hemangioblastoma<\/p>\n

      Conditioned recommendation<\/i><\/b><\/p>\n

      4-\u00a0Digital subtraction angiography may provide additional information to supplement the clinical examination and findings on CT or MRI imaging. Angiography allows identification of displaced feeders to the tumor, facilitating their localization and ligation during surgery. In addition, the extent of tumor growth around the internal carotid, as well as the presence of collateral flow distal to the involved carotid, are important pieces of information.\u00a0Conditioned recommendation<\/i><\/b><\/p>\n

      5-\u00a0\u00a0\u00a0\u00a0Combined with a balloon occlusion test, catheter angiography can help determine the feasibility of carotid sacrifice during surgery if needed.\u00a0Conditioned recommendation<\/i><\/b><\/p>\n

      6-\u00a0\u00a0\u00a0\u00a0The goal of embolization should be to reduce the amount of tumor blush by approximately 80% or more.\u00a0Conditioned recommendation<\/i><\/b><\/p>\n

      7-\u00a0\u00a0\u00a0\u00a0Despite added resources used for embolization procedures compared with resection alone, the benefits of embolization may still be cost-effective.\u00a0Conditioned recommendation<\/i><\/b><\/p>\n

      8-\u00a0\u00a0\u00a0\u00a0Surgical resection should be carried out 1-8 days after embolization in order to maximize the benefits of the embolization procedure.\u00a0Conditioned recommendation<\/i><\/b><\/p>\n

      9-\u00a0\u00a0\u00a0\u00a0Major complications are rare with extracranial tumor embolization. However, stroke and intracerebral hemorrhage have been reported in up to 3-6% during intracranial embolization.\u00a0Conditioned recommendation<\/i><\/b><\/p>\n

      H.\u00a0\u00a0<\/b>Venous Sinus Stenting Procedure<\/u><\/b><\/h4>\n

      1-\u00a0\u00a0\u00a0\u00a0Idiopathic intracranial hypertension may be caused by significant bilateral venous sinus stenoses shown by MRV studies.\u00a0Conditioned recommendation<\/i><\/b><\/p>\n

      2-\u00a0\u00a0\u00a0\u00a0Endovascular venous stenting may improve visual deficits. There is insufficient evidence to determine role of endovascular approach in restoration of venous outflow in cerebral venous stenosis.\u00a0Conditioned recommendation<\/i><\/b><\/p>\n

      3-\u00a0\u00a0\u00a0\u00a0Endovascular therapy may be considered in patients with clinical deterioration or persistent symptoms despite adequate medical therapy.\u00a0Conditioned recommendation<\/i><\/b><\/p>\n

      \n

      V)\u00a0<\/b>POSTPROCEDURE CARE:<\/b><\/h4>\n<\/div>\n

      1-\u00a0\u00a0\u00a0\u00a0A procedure note should be completed for all patients. It should summarize the findings of the study, its major technical aspects, and any immediate complications. The report should be available for review by the referring physician in a timely manner.\u00a0Strong recommendation<\/i><\/b><\/p>\n

      2-\u00a0\u00a0\u00a0\u00a0All patients should be at bed rest and observed for indicators of procedural complications in the initial postprocedural period.\u00a0Strong recommendation<\/i><\/b><\/p>\n

      3-\u00a0\u00a0\u00a0\u00a0During the initial postprocedural period an experienced licensed provider should periodically monitor the puncture site and the status of the distal vascular distribution.\u00a0Strong recommendation<\/i><\/b><\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

      \u00a0<\/h2>\n

      \u00a0<\/p>\n<\/div>\n<\/div>\n

      \n
      \n
      \n
      \u00a0<\/div>\n<\/div>\n
      \n
      \n
      \u00a0<\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div> <\/div>\n\n <\/div>\n <\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"

      \u0637\u0628 \u0627\u0644\u0645\u062e \u0648\u0627\u0644\u0623\u0639\u0635\u0627\u0628 Ischemic Stroke “last update: 25 Feb, 2025”\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 […]<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-7430","page","type-page","status-publish","hentry"],"aioseo_notices":[],"_links":{"self":[{"href":"https:\/\/gothi.gov.eg\/index.php?rest_route=\/wp\/v2\/pages\/7430","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/gothi.gov.eg\/index.php?rest_route=\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/gothi.gov.eg\/index.php?rest_route=\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/gothi.gov.eg\/index.php?rest_route=\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/gothi.gov.eg\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=7430"}],"version-history":[{"count":4,"href":"https:\/\/gothi.gov.eg\/index.php?rest_route=\/wp\/v2\/pages\/7430\/revisions"}],"predecessor-version":[{"id":7435,"href":"https:\/\/gothi.gov.eg\/index.php?rest_route=\/wp\/v2\/pages\/7430\/revisions\/7435"}],"wp:attachment":[{"href":"https:\/\/gothi.gov.eg\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=7430"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}