Stroke management

Introduction Scope of the guidelines These National Clinical Guidelines for stroke cover the management of patients with acute stroke and the secondary prevention of stroke. Primary prevention of stroke, rehabilitation and subarachnoid hemorrhage are excluded from the scope of these guidelines. These guidelines cover the management of stroke in adults (over 18 years) from onset to chronic care and focus on patients with a new clinical event (first stroke or recurrent stroke). Goal and objectives of the guidelines The primary goal of the guidelines is to continuously improve the quality of care in patients with stroke nationally. Our intention is closing the gap between best practice and actual practice. The objective of the guidelines is to provide clinicians and administrators with explicit statements, where evidence is available, on the best way to manage specific problems. Local health service facilities (e.g. hospitals, nursing homes, etc.) will need to add detail. The guidelines are directed primarily at practising clinicians involved in management of patients with stroke. Their aim is to help clinicians, at any level – primary, secondary or tertiary - to make the best decisions for each patient, using the evidence currently available. The focus is on the more common clinical questions faced in day-to-day practice. The guidelines may be used by all health professionals or health care planners involved in the management of the patients with stroke. The secondary objectives of the guidelines are to identify areas where gaps in knowledge or lack of evidence exist and to stimulate research in each area. The guidelines are concerned with the management of patients who present with a new clinical event that might be stroke. Stroke in this context is defined as ‘a clinical syndrome characterized by rapidly developing signs and symptoms of focal or at times global loss (as in subarachnoid hemorrhage or brain stem involvement) of cerebral brain functions, lasting more than 24 hours or leading to death, with no apparent cause other than of vascular origin.’ While appraisal of evidence forms the basis of the development of these guidelines, we wish to clarify some points: Evidence related to drugs is generally stronger, because it is methodologically easier to study each intervention in contrast to studying complex intervention like occupational therapy, health education or nursing care. These do not necessarily mean that interventions with so called strong evidence are more important than those where the evidence is weak. We believe that highest level of evidence is not always required to make strong recommendation. If the intervention is safe, logic is strong and effect is obvious, the level of evidence desirable to make strong recommendation may be lower than the highest. We recognize that many areas of clinical importance may not have evidence available to construct guidelines, and the recommendations represent a consensus from the working group on such areas. The working group is aware of recent developments in evaluating levels of evidence and strength of recommendations, and also that the GRADE methodology has been adopted by more than 25 organizations around the world including the WHO. The group endorses the use of GRADE methodology (Guyatt and Oxman)1 for this purpose and will incorporate this in the next version of the guidelines. Context and use These guidelines should be taken as statements to inform the clinician, not as rigid rules. Practitioners may need to deviate from the guidelines in individual cases but such deviations should be justifiable and justified. The guidelines may be used to inform decisions on standards of good practice and are likely to be used for audit of stroke services. Before the guidelines are used as ‘standards’, it is important to ensure that the relevance and appropriateness of the guidelines are discussed in the context proposed. These guidelines do not cover specific management of associated illnesses like diabetes mellitus, cardiac problems and others as these may addressed by guidelines from related organizations or are generally expected from a physician. Guidelines for Organization of Services for Stroke Care Stroke care may be organized at three levels - a basic stroke care facility, a primary stroke care facility and a comprehensive stroke care facility. The basic stroke care facility should be the minimum setup at district hospitals; primary stroke care facility should be mandatory for all medical colleges and multispeciality hospitals; and well-equipped hospitals including some medical colleges should develop comprehensive stroke care facilities. The basic stroke facility may not have artificial ventilators, echocardiography and carotid Doppler facility, primary stroke care facilities may have these facilities but not neurosurgery, MRI or angiography. Comprehensive stroke care facilities should have all these facilities. Recommendations Patient care services Acute stroke team At a minimum, includes a physician and another health care professional (i.e., nurse, physician). In addition, a physiotherapist is essential for rehabilitation. Team personnel should have experience, expertise and special interest in diagnosis and treatment of stroke patients. Team should be available 24 × 7 and a member of the team should be at patient bedside within 15 minutes of being called. Written care protocols Protocols should be made available for rt-PA use in acute stroke. Protocols for emergency care, diagnostic tests, stabilization of vital functions and use of medication should be made available. Protocols should be reviewed and updated at least once a year. Emergency medical services (EMS) should be developed and upgraded for stroke care at the hospital or district level to include transport and triage of patients from peripheral medical centers. Emergency department ED personnel should be trained to diagnose and treat all types of stroke. ED should have good communication with the EMS and the acute stroke team ED personnel should undergo educational activities related to stroke diagnosis and management at least twice a year. Stroke unit Should consist of a hospital unit with specially trained staff and a multidisciplinary approach to treatment and care of stroke patients. Should be able to admit patients in the unstable phase, monitor the vital and neurological parameters, diagnose the etiology and subtype, treat and discharge patients with advice on physiotherapy and secondary prevention. Should transfer severely ill and stuporous patients including those with raised intracranial pressure (ICP) and with unstable cardiopulmonary status to intensive care. Should consider using telemedicine to improve access to treatment in rural and remote areas. Neurosurgical services Comprehensive stroke care facilities should have 24 × 7 on call neurosurgeon to evaluate and operate in cases requiring such consultation and neurosurgery. A primary stroke care facility should have neurosurgical care available as early as possible (<2 hours). The patient should either be transferred to a neurosurgical care facility or should be able to call in a neurosurgeon within 2 hours. A written protocol for transfer plan should be available. The hospital with neurosurgical facility should be having 24 hours operating facility and support personnel (anesthesia, radiology, laboratory services, etc.). Support services Neuroimaging: All levels of stroke care facilities should have the capability of performing or access to either a cranial computed tomography (CT scan) or magnetic resonance imaging (MRI) scan within 30 minutes of the order being written with experienced physicians or a radiologist to interpret the imaging reports. Laboratory services to perform routine blood tests, coagulation studies, ECG and chest roentgenograms with 24-hour services. The lab results should be available within 45 minutes of being ordered. Commitment and Support of the Organization/Institution should be available toward the stroke care facility and the stroke unit should have a designated medical director/incharge with expertise in stroke. Educational programs periodically and annual programs for the stroke team should be instituted and public education about prevention, recognition and management of stroke should be carried out. Evidence: Albers,2 Alberts,3 Audebert,4 Calvet,5 Evans,6 Intercollegiate Stroke Working Party,7 Katzan,8 Koton,9 LaMonte,10 Prabhakaran,11 Purroy,12 Ronning,13 Silva,14 Stavem,15 Stroke Unit Trialists’ Collaboration.16 Acute Phase Care Admission to hospital Most patients with stroke should be admitted to a hospital because their neurological condition may worsen over the first few days, they may develop non-neurological complications (e.g., aspiration pneumonia), and urgent investigations (like CT scan) may be required. Recommendations Patients with acute stroke (onset within last 72 hours or altered consciousness due to stroke) should be admitted to hospital for initial care and assessment. Circumstances where a physician might reasonably choose not to admit selected patients with stroke include the following: Individuals with severe pre-existing irreversible disability (e.g., severe untreatable dementia), or terminal illnesses (e.g., cancer), who have options to be cared at lower level health care facility. Alert patients with mild neurological deficits (not secondary to ruptured saccular aneurysm) who are identified more than 72 hours after onset of symptoms, who can be evaluated expeditiously as outpatients, and who are unlikely to require surgery, invasive radiological procedures or anticoagulation; Patients with mild neurological deficits in whom a history and examination is consistent with lacunar stroke syndrome, and a CT scan that either is normal or shows old lacunar infarcts. However, they should be evaluated expeditiously as outpatients. Diagnosis and management of resolved or rapidly resolving acute neurological event Patients who are first seen after fully resolved or rapidly resolving neurological symptoms need diagnosis to determine whether in fact the cause is vascular (about 50% are not) and then to identify treatable causes that can reduce the risk of stroke (greatest in first 7-14 days). Any patient who presents with transient symptoms suggestive of a cerebrovascular event should be considered to have had a transient ischemic attack (TIA), unless neuroimaging reveals an alternative diagnosis. All such patients except those with transient monocular blindness should have imaging of brain, either CT scan or MRI. Patients presenting with transient monocular blindness (amaurosis fugax) must have a complete ophthalmological examination to exclude primary disorders of the eye before diagnosis of TIA. Patients who have had a TIA should be assessed as soon as possible for their risk of subsequent stroke using a validated scoring system, such as ABCD2 (Refer to Appendix -1). All patients with history of TIA should be started on aspirin 150 or 300 mg daily or Clopidogrel (75 mg) once a day in case of aspirin allergy; and those at high risk of stroke (ABCD2 score of 4 or above) should be assessed at primary or comprehensive stroke care facility within 24 hours for further management (as indicated under heading ‘Secondary Prevention’). Those at lower risk should be assessed within 1 week of onset of symptoms. Patients with crescendo TIA (two or more TIAs in a week) should be treated as being at high risk of stroke, even though they may have ABCD2 score of 3 or below. Patients who have had a TIA but who present more than one week after their last symptom has resolved should be treated as those with ABCD2 score of 3 or below. All patients with TIA should be managed as indicated under the heading ‘Secondary Prevention’. FigureEvidence: Bray,17 Cucchiara,18 Lavallee,19 Rothwell.20 Diagnosis of acute persistent cerebrovascular event The aims of emergent evaluation are to: Separate stroke (a vascular event) from other causes of rapid onset neurological dysfunction (stroke mimics); Provide information about pathology (hemorrhage vs. ischemia); Give clues about the most likely etiology; Predict the likelihood of immediate complications; and Plan appropriate treatment. It should be recognized that ‘stroke’ is primarily a clinical diagnosis and that the diagnosis should be made with special care: In the young; If the sensorium is altered in presence of mild to moderate hemiparesis; If the history is uncertain; or If there are other unusual clinical features such as gradual over days, or examination and common investigations should should be to onset of symptoms, recent stroke, surgery, and use of history of risk and history of or recent and risk of examination should be on with special to of carotid peripheral cardiac evidence of or stroke like may be used to determine the of neurological All patients should have complete blood blood ECG and of cardiac patients may require tests, chest blood blood or All patients should have their clinical and any patient clinical is unusual for stroke should be for possible alternative diagnosis. imaging should be for patients with persistent neurological symptoms any of the for or early treatment. A A level of consciousness at onset of stroke symptoms. hemorrhage or Patients with acute stroke the for immediate brain should be within 24 hours after onset of symptoms. Evidence: Intercollegiate stroke working specific management of ischemic stroke All patients with acute ischemic stroke who can be treated within 3 hours hours as soon as by the after symptom onset should be evaluated to determine their for treatment with - for recommendation on All acute stroke patients should be at least 150 mg of aspirin after brain imaging has excluded intracranial hemorrhage patients with aspirin should be after the 24-hour In patients with aspirin may be or is made not to In aspirin may be by least 150 mg) should be 2 after the onset of stroke symptoms, at any or is started as indicated in Any patient with acute ischemic stroke who is to have with aspirin should be a in to aspirin FigureEvidence: - National for and Clinical for stroke Patients with cerebral who all of the should be considered for and within a of or below. score of in the level of consciousness to a score of 1 or more on of or score between and CT scan signs of an of at least 50% of the with or in the of or cerebral on the or MRI Patients with of and altered consciousness should be managed with should be treated with - and is not for the management of patients with acute ischemic stroke. is the of clinical Evidence: specific management of hemorrhage related to or related to rapid of by of with of to the last 30 to to for to to for is by not to of may also be used for related to use of Patients with related should be managed with and available complex mg should not be used because it at least hours to the is an way of but there is risk of and complex and complex require of than the but with risk of Patients with related to should be treated with of and as indicated in Evidence: Patients with a high risk of with may be at after onset of the Those with lower risk may be on Evidence: for Patients with hemorrhage in who are or who have signs of brain stem dysfunction should have and of Patients with with of consciousness or should have of within 72 hours of onset of symptoms, unless they on others for activities of daily to the event or their is this is because of Patients with who are from should undergo Evidence: Acute Any patient of having should be with appropriate imaging and with stroke secondary to should be treated with either or In selected may be Evidence: stroke Patients with ischemic stroke who are in should be treated with aspirin 300 mg for the first 2 before In patients with who have cerebral and who are at risk of hemorrhage treatment should be for one week and aspirin mg should be lack of within hours of onset of stroke, except in patients with Evidence: Intercollegiate Stroke Working Party,7 Intercollegiate Guidelines Patients to have stroke due to cerebral should be by not by CT Patients with stroke due to cerebral or or secondary cerebral should be and then unless there are Evidence: blood Patients should their Evidence: of should be 4 hours for at least first hours and as as the patient is in the should be treated with The for possible and should be should be as it can to and cardiac Evidence of blood pressure stroke In acute ischemic stroke, medication should be there is a emergency with one or more of the medical cardiac hemorrhage with blood pressure over medication should be in ischemic stroke patients unless is or the mean blood pressure is by the first 24 hours is in of blood pressure should be and with use of use of is not pressure to or lower should be considered in who are for hemorrhage If is or is or more minutes then blood pressure should be treated with (e.g., or If is or is to 150 then a is with rapidly or medication or should be or of Evidence: of blood The blood level should be between and blood should be managed with using the in the first week of stroke should be and should be Evidence: National for and Clinical and intracranial pressure more are available are not for the management of cerebral and stroke. In patients condition is secondary to including those with options and If CT scan (first or one after as the cause of then of can be care includes mild of of of the by to 30 and of that might (e.g. and of the by by but should be by another intervention to brain and can cause that might of mg may be used in patients condition is rapidly If mg may be for the first mg may be in those not to other treatment must be to over can be hours. If may be to 4 but then the pressure should be and between and to may be for Evidence: Care Patients should be to activities like or with patient, who on or should be patient should be to the risk of complications such as and pressure Evidence 3 for recommendation on bedside assessment. All patients should have of the to A at the bedside is (e.g. the is as a of Patients with normal should be assessed for the most and to Any patient with should be using a should be considered for patients who are to Patients with altered sensorium should be or normal for at least FigureEvidence: care All stroke patients should have an including signs of or soon after patients a or it should be they have the to and use the appropriate care protocol should be used for patient with stroke, including those who use The care protocol should areas including of care day or types of care and and specific management for patients with If are identified with health patients should be to a for consultation and management as soon as Evidence: for can be started the first 24 hours. All patients should be to a team as soon as within hours of The need in to and should be assessed within hours of Evidence: patient should have status using within hours of support should be considered in any Evidence: National for and Clinical of Patients with even should be treated with of by day for a of at least 3 If or may be should be treated as guidelines. At present there is to on the of to patients with recent stroke. Evidence: Patients with to ischemic stroke) should be or appropriate as to those who aspirin for treatment is of some In patients with to routine physiotherapy and early should be carried to and should be for all acute stroke patients. not support the routine use of for prevention of or appropriate as should be started is a complete blood and should be and a and should be of times the mg once should be started unless and the should be to a of should be Evidence: care should be as as possible and should be assessed daily and as soon as should be used for or The use of is as for Evidence: care Patient with should be assessed for other causes of including with Patients with severe should have a to use of be advice on and (as as be and be severe problems Evidence: of after stroke should a for or of is not should be early Evidence: should be as soon as a patient is Patients and should be and fully Care should all in for Patients should be information about discharge and the need for and of after Evidence: includes to reduce the risk of of stroke in patients who have had TIA or stroke. These guidelines to of patients with TIA or stroke, some of the recommendations may not be appropriate for those with unusual causes of stroke, like patient should be evaluated for risk within one week of those with stroke) or other cardiac In any patient where no risk is for for causes may be The investigations may include and Evidence: All patients with ischemic stroke or TIA should unless there is for or of aspirin mg) and mg) twice or (75 mg are all options for initial The should be by with the and of the In the of aspirin is as as is more than aspirin in vascular The of aspirin and the risk of hemorrhage and is not unless there is for this (i.e., or acute of should not be routine and should be considered there is or other risk of with Evidence: – should be started in patient with or unless they are likely to be with the required and are not at high risk for also some there are to the use of should be considered for all patients who have ischemic stroke associated with or within 3 of should not be started brain imaging has excluded and have from the onset of a ischemic stroke a is should not be used for patients in unless cardiac is is except for cardiac Evidence: Trialists’ pressure pressure treatment is for all patients with history of TIA or stroke. The to with or a history of The treatment should be to discharge from hospital in and at the of first medical in patients. for these patients is but for patients to have severe carotid of 150 may be The is uncertain; the available the use of or the of and an Evidence: Trialists’ – intervention Patients with TIA or stroke and carotid by imaging or on a should be carotid or within 2 of the event unless intervention is for selected patients with moderate in patients. should be on all patients who be considered for carotid or should be by a with a and of should be considered for patients who are not for or medical or expertise is not available. intervention is not for patients with mild All those with carotid should all secondary prevention whether or not they carotid Evidence: - All patients with history of TIA or ischemic stroke should be treated with a they have a of or The treatment should be a of and of for high risk with should be or used with in patients with history of stroke. Evidence: - All patients who should be to and to All patients who can do should be to do so for at least 30 minutes each should be to with and to moderate levels to All patients should be to use and on and and reduce of or should be and those who are or should be advice and support to All but those with should be to reduce their by not to using as as possible in and and Patients who should be to within recognized of no more than three day for and day for Evidence: