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Guideline Summary
Guideline Title
Acute medical and surgical management. In: Clinical guidelines for stroke management 2010.
Bibliographic Source(s)
Acute medical and surgical management. In: Clinical guidelines for stroke management 2010. Melbourne (Australia): National Stroke Foundation; 2010 Sep. p. 58-67.
Guideline Status

This is the current release of the guideline.

This guideline updates a previous version: Acute medical and surgical management. In: National Stroke Foundation. Clinical guidelines for acute stroke management. Melbourne (Australia): National Stroke Foundation; 2007 Oct. p. 22-9.

FDA Warning/Regulatory Alert

Note from the National Guideline Clearinghouse: This guideline references a drug(s) for which important revised regulatory and/or warning information has been released.

  • August 1, 2013 – Acetaminophen External Web Site Policy: The U.S. Food and Drug Administration (FDA) notified healthcare professionals and patients that acetaminophen has been associated with a risk of rare but serious skin reactions. Acetaminophen is a common active ingredient to treat pain and reduce fever; it is included in many prescription and over-the-counter (OTC) products. These skin reactions, known as Stevens-Johnson Syndrome (SJS), toxic epidermal necrolysis (TEN), and acute generalized exanthematous pustulosis (AGEP), can be fatal. These reactions can occur with first-time use of acetaminophen or at any time while it is being taken. Other drugs used to treat fever and pain/body aches (e.g., non-steroidal anti-inflammatory drugs, or NSAIDS, such as ibuprofen and naproxen) also carry the risk of causing serious skin reactions, which is already described in the warnings section of their drug labels.

Scope

Disease/Condition(s)
  • Stroke
  • Transient ischaemic attack (TIA)

Note: These guidelines do not cover:

  • Subarachnoid haemorrhage
  • Stroke in infants, children and youth (i.e. <18 years old), or
  • Primary prevention of stroke (refer to Guidelines for the assessment of absolute cardiovascular disease risk 2009.)
Guideline Category
Evaluation
Management
Treatment
Clinical Specialty
Critical Care
Emergency Medicine
Neurological Surgery
Neurology
Preventive Medicine
Pulmonary Medicine
Intended Users
Advanced Practice Nurses
Emergency Medical Technicians/Paramedics
Health Plans
Hospitals
Physician Assistants
Physicians
Guideline Objective(s)

To provide evidence-based recommendations related to recovery from stroke and transient ischaemic attack (TIA) to assist decision-making based on the best evidence available at the time of development

Target Population

Adults (18 years or older) with stroke or transient ischemic attack (TIA) symptoms

Interventions and Practices Considered

Management/Treatment

  1. Thrombolysis
    • Intravenous recombinant tissue plasminogen activator (rt-PA)
    • Intra-arterial (IA) thrombolysis
  2. Antithrombotic therapy (aspirin)
  3. Acute phase blood pressure lowering therapy
  4. Monitoring for neurological deterioration
  5. Surgery (decompressive hemicraniectomy)
  6. Management of cerebral oedema (osmotherapy, hyperventilation)
  7. Intracerebral hemorrhage management
    • Reverse anticoagulation (vitamin K, prothrombin complex)
    • Surgery for supratentorial haemorrhage
    • Surgical evacuation
  8. Physiologic monitoring (neurological status [e.g., Glasgow coma scale], vital signs, respiratory pattern)
  9. Oxygen therapy
  10. Glycaemic control
  11. Neuroprotector therapy (as part of randomised controlled trial only)
  12. Continuation of statin therapy for patients receiving statins prior to admission
  13. Antipyretic therapy
  14. Seizure management

Note: Corticosteroids and complementary alternative therapies were considered, but not recommended.

Major Outcomes Considered
  • Thrombolysis rates
  • Post-stroke seizures
  • Rate of perioperative stroke
  • Morbidity
  • Death and dependency
  • Functional outcome

Methodology

Methods Used to Collect/Select the Evidence
Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases
Description of Methods Used to Collect/Select the Evidence

Finding Relevant Studies

Systematic identification of relevant studies was conducted between May and August 2009. An external consultant undertook all the electronic database searches. EMBASE, Medline and Cochrane databases were used for all questions. CINAHL and PsycINFO databases were searched where relevant (e.g., questions relating to rehabilitation, discharge planning or long-term recovery). The PEDro database was used by the National Stroke Foundation (NSF) project team to check studies related to physical therapy. A second updated search of the literature up to February 19, 2010 using Medline and EMBASE databases was conducted. Updated Cochrane reviews were also searched and included.

Where the questions were the same as those used in the previous acute management guidelines (2007), the literature was searched from the beginning of 2007. Where the questions were the same as those used in the previous rehabilitation guidelines (2005), the literature was searched from the beginning of 2005. For topics not previously addressed, searches were carried out from 1966 onwards.

Searching of EMBASE, Medline and Cochrane libraries was conducted in four broad steps:

  1. Terms for the patient group were abridged from the Cochrane Collaboration's Stroke Group.
  2. A second search term specific to the particular question (i.e., specific terms relevant to an intervention or assessment) was added.
  3. Relevant evidence filters (Cochrane sensitive filter or Medline diagnostic filter) were applied.
  4. If the search was for an update to an authoritative meta-analysis (NSF or other), it was limited to the years after the relevant document was published.

Search strategies are available from the NSF. Table A2.1 in the original guideline document outlines the number of articles found for each of the nine broad topic areas.

A total of 39,930 potential articles were identified up until August 2009 and an additional 7337 at February 2010. Reference lists of identified articles and other guidelines were then used to identify further studies. Existing international guidelines identified and used included those published by the Scottish Intercollegiate Guidelines Network (SIGN), the National Institute for Health and Clinical Excellence UK, the Royal College of Physicians (London, UK), the Canadian Stroke Network and the Heart and Stroke Foundation of Canada, the American Heart/Stroke Association and the European Stroke Organisation. Correspondence with SIGN identified overlapping topics that had recently been systematically searched by SIGN and hence this information was kindly provided and used for several rehabilitation-related topics. A number of key journals were also searched by hand from October 2009 to March 2010: Stroke, Cerebrovascular Disease, Lancet (and Lancet Neurology), and Archives of Physical Medicine and Rehabilitation. Further, an internet search was undertaken (using the 'Google' search engine). Finally, where possible, experts in the field were contacted to review the identified studies and suggest other new studies not yet identified.

One reviewer initially scanned the titles and available abstracts of all studies identified by the searches and excluded any clearly irrelevant studies. Based on the titles and abstracts of the remaining studies, two reviewers assessed and selected potentially eligible studies using the following inclusion criteria:

  • Type of study. Relevant systematic reviews were first identified. Where no systematic review was found, randomized controlled trials (RCTs) were searched. If there was a sparsity of Level I or Level II evidence, the search was expanded to consider lower levels of evidence.
  • Type of participant. Initially only studies which included adults (>18 years) with stroke or transient ischaemic attack (TIA) were included. Studies in other related populations (e.g., general elderly population or those with traumatic brain injury) were then included if the particular intervention was deemed to be transferable to those with stroke.
  • Language. Only studies published in English were used.

Disagreements on inclusion of particular studies were resolved by consensus. If necessary a relevant member of the expert working group (EWG) provided a third and final vote.

In addition to the initial searches, economic literature was searched via the Australian Medical Index, Econlit, EMBASE, Medline, Health Technology Assessment, and National Health Service (NHS) Economic Evaluation Databases. Searches were carried out from the beginning of 2005 to identify papers published after the rehabilitation guidelines (2005). A total of 1033 references were retrieved after de-duplication (Table A2.2 in the original guideline document). One person initially reviewed all references and selected 44 potentially relevant articles. These abstracts were scrutinised by two people and 35 appropriate papers were retrieved and reviewed.

Number of Source Documents

35 appropriate papers were retrieved.

Methods Used to Assess the Quality and Strength of the Evidence
Expert Consensus
Weighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence

Designation of Levels of Evidence According to Type of Research Question

Level Intervention Diagnosis Prognosis Aetiology Screening
I A systematic review of Level II studies A systematic review of Level II studies A systematic review of Level II studies A systematic review of Level II studies A systematic review of Level II studies
II A randomised controlled trial A study of test accuracy with: an independent, blinded comparison with a valid reference standard, among consecutive patients with a defined clinical presentation A prospective cohort study A prospective cohort study A randomised controlled trial
III-1 A pseudo-randomised controlled trial (i.e., alternate allocation or some other method) A study of test accuracy with: an independent, blinded comparison with a valid reference standard, among consecutive patients with a defined clinical presentation All or none All or none A pseudo-randomised controlled trial (i.e., alternate allocation or some other method)
III-2 A comparative study with concurrent controls:
  • Non-randomised experimental trial
  • Cohort study
  • Case-control study
  • Interrupted time series without a parallel control group
A comparison with a reference standard that does not meet the criteria required for Level II and Level III-1 evidence Analysis of prognostic factors amongst untreated control patients in a randomised controlled trial A retrospective cohort study A comparative study with concurrent controls:
  • Nonrandomised, experimental trial
  • Cohort study
  • Case-control study
III-3 A comparative study without concurrent controls:
  • Historical control study
  • Two or more single arm studies
  • Interrupted time series without a parallel control group
Diagnostic case-control study A retrospective cohort study A case-control study A comparative study without concurrent controls:
  • Historical control study
  • Two or more single arm studies
IV Case series with either post-test or pre-test/post-test outcomes Study of diagnostic yield (no reference standard) Case series or cohort study of patients at different stages of disease A cross-sectional study Case series
Methods Used to Analyze the Evidence
Review of Published Meta-Analyses
Systematic Review with Evidence Tables
Description of the Methods Used to Analyze the Evidence

Appraising the Selected Studies

A standardised appraisal process was used based on forms adapted from the Guidelines International Network and Scottish Intercollegiate Guideline Network (SIGN). Where available, appraisals already undertaken by SIGN for the rehabilitation section were used to avoid duplication. The standardised appraisal form assesses the level of evidence (design and issues of quality), size of effect, relevance, applicability (benefits/harms) and generalisability of studies. Examples of completed checklists can be obtained from the National Stroke Foundation (NSF). Evidence for diagnostic and prognostic studies was also appraised using the SIGN methodology.

Summarising and Synthesising the Evidence

Details of relevant studies were summarised in evidence tables which form a supplement to this document and can be downloaded from the NSF website (www.strokefoundation.com.au External Web Site Policy).

To assist in the formulation of recommendations for each question, the National Health and Medical Research Council (NMHRC) Grades process (2008–2010) was applied. No pooling of data or meta-analysis was undertaken during the evidence synthesis process.

Methods Used to Formulate the Recommendations
Expert Consensus
Informal Consensus
Description of Methods Used to Formulate the Recommendations

These guidelines were developed according to standards outlined by the National Health and Medical Research Council (NHMRC).

Question Formulation

Clinical questions used for previous guidelines were reviewed and duplication removed. A draft set of questions was developed by the National Stroke Foundation (NSF) project team and circulated to the expert working group (EWG). The EWG agreed on one hundred and thirty-four (134) specific clinical questions addressing interventions relevant to stroke care. The questions generally queried the effects of a specific intervention and were developed in three parts: the intervention, the outcomes and the population, for example, 'What is the effect of anticonvulsant therapy on reducing seizures in people with post-stroke seizures?' In this example, anticonvulsant therapy is the intervention, reduction of post-stroke seizures is the outcome, and the population is people with post-stroke seizures. The list of questions is available from the NSF.

Summarising and Synthesising the Evidence

For each question, the NSF project team developed a draft recommendation based on the NHMRC matrix (Table A2.3 in the original guideline document). These recommendations were subsequently discussed and agreed on by the EWG. Final decisions were made by informal group processes after open discussion facilitated by the co-chairs. The recommended grading matrix was used to guide the strength or grading of the recommendation (Table A2.4 in the original guideline document).

Following agreement on recommendations, the NSF project team drafted the body of the guidelines which included a brief discussion of the evidence and other relevant factors such as the current gaps in practice as outlined in the most recent National Stroke Audits or considerations regarding implementation. Early drafts were circulated for comment by the EWG and amended before release for public consultation.

Rating Scheme for the Strength of the Recommendations

Grading of Recommendations

Grade Description
A Body of evidence can be trusted to guide practice
B Body of evidence can be trusted to guide practice in most situations
C Body of evidence provides some support for recommendation(s) but care should be taken in its application
D Body of evidence is weak and recommendation must be applied with caution
Good Practice Point (GPP) Recommended best practice based on clinical experience and expert opinion
Cost Analysis

Cost and Socioeconomic Implications

The lifetime costs of first-ever stroke have been recently estimated to be more than $2 billion in Australia (net present value 2004). Therefore, providing cost-effective stroke care (prevention management and treatment) is important to avoid unnecessary costs to society. This section presents an updated review of the cost and socioeconomic implications of providing evidence-based stroke care given the recommendations within these guidelines. The expert working group (EWG) (including a search specialist) conducted a separate systematic review for this section. A broad search strategy was used to search the following databases: Econlit, EMBASE, Medline, Health Technology Assessment, National Health Service (NHS) Evaluations and Australasian Medical Index (the search strategy used is available from the National Stroke Foundation). The search yielded 1033 abstracts which were reviewed by one member of the project team. Forty-four potential studies were selected for further consideration.

Staff at the National Stroke Research Institute, a subsidiary of Florey Neuroscience Institutes, scrutinised the 44 abstracts published between 2005 and 2009 for omissions and appropriate papers were retrieved and reviewed. As the breadth of topics was wide and the methods used quite disparate, a narrative review was deemed the most appropriate way to summarise the cost and socioeconomic evidence. There was also a preference to report evidence from studies undertaken in Australia. Therefore, if similar work had been undertaken elsewhere, this information was not included in the summary unless the results were relevant to the findings in Australia. This is because it is often difficult to extrapolate from international studies to the Australian context given differences in health services provision and funding, target populations and interventions such as drug dosages.

The discussion related to the cost-effectiveness evidence is presented to follow the structure of the guidelines document. It should be noted that these guidelines include several consensus recommendations or recommendations based on levels of evidence below Level II for a number of 'micro' clinical practice issues (e.g., physiological monitoring and oxygen therapy). As such, it is not possible to analyse the implications of these sorts of recommendations, as they in fact often form part of a larger package or program of care for which there is Level I evidence (for example, stroke units). Furthermore, there is limited cost-effectiveness evidence available for many acute stroke care interventions and often these types of studies have not been conducted. Therefore, evidence and discussion for the main (strongest) recommendations in these guidelines is provided. This review is also an extension of the summaries provided in the earlier versions of the stroke clinical guidelines.

Conclusions

There is good cost-effectiveness evidence for the most clinically effective stroke prevention and treatment strategies recommended in these guidelines. In particular, stroke unit care, thrombolysis, blood pressure lowering, warfarin for atrial fibrillation (AF), aspirin for stroke prevention and carotid endarterectomy were all determined to be worthwhile from an economic perspective. The findings for intravenous thrombolysis with recombinant tissue plasminogen activator (rt-PA) administered within three hours of acute ischaemic stroke were consistently found to be cost-saving from a lifetime perspective. However, there is limited evidence for the cost-effectiveness of rt-PA used up to 4.5 hours and further research is needed. There is sufficient evidence for the cost-effectiveness of antithrombotic therapy with dipyridamole plus aspirin compared to aspirin alone in secondary stroke prevention. There is also sufficient evidence for blood pressure lowering with angiotensin-converting enzyme (ACE) inhibitors in all stroke and transient ischaemic attack (TIA) patients, as recommended by these guidelines. This review also allowed the developers to identify a range of areas where additional cost-effectiveness studies would complement health outcome data, including an assessment of home-based stroke rehabilitation, rapid assessment clinics for TIA, carer training, the use of botulinum toxin A for stroke patients with persistent moderate to severe spasticity and imaging modalities for selecting patients for intravenous thrombolysis. One major factor that may influence the economic implications of interventions found to be cost-effective is access and population coverage. In a recent modelling exercise in the Australian setting, it was found that more widely accessible, evidence-based stroke care could produce substantial economic and health-related benefits and would require only modest investment. The authors suggested that if there was improved access to effective acute care (stroke units and intravenous thrombolysis) and secondary prevention (BP lowering, warfarin for AF, aspirin in ischaemic stroke and carotid endarterectomy) and improved management of BP and AF as primary prevention in the Australian population, then about $1.06 billion could be recovered as potential cost-offsets with recovery of more than 85,000 DALYs. Therefore, clinical guidelines such as these which promote improved treatment and prevention of stroke are an important contribution to achieving such increased access and cost-effective use of health resources in this country.

See Chapter 9 in the original guideline document for a full discussion of cost analysis.

Method of Guideline Validation
External Peer Review
Internal Peer Review
Description of Method of Guideline Validation

Consultation

Public consultation about the draft document was undertaken over one month from February to March 2010. A specific feedback form was circulated via the Australian Stroke Coalition and members of the expert working group (EWG) and advisory group to relevant professional bodies, stroke clinical networks, consumers and consumer organisations. A public notice was published in The Australian newspaper (1 February 2010) in line with National Health and Medical Research Council (NHMRC) requirements. The draft document was also posted on the National Stroke Foundation website.

Over 460 individual comments covering a wide range of topics were received from 77 individuals, groups or organisations. Feedback received was initially considered by the NSF project team with minor amendments such as formatting or spelling reviewed and actioned. Other feedback was forwarded to relevant members of the EWG depending on topic areas and suggested responses developed. All comments and suggested responses were collated and circulated to the full EWG for consideration and discussion, with several topics being further discussed during subsequent teleconferences. Informal consensus processes were used to modify any recommendations.

A significant number of the comments received during consultation related to the structure of the document, the size of some of the chapters and the ambiguity of some the recommendations. As a result of the feedback, significant structural changes to the order of contents of the guidelines were made. Other minor rewording and reformatting was also carried out. The sequencing of the recommendations was also reviewed and modified where appropriate.

Several topics received significantly more feedback than others and the EWG's responses are listed below:

  • Acute blood pressure therapy: recommendation specific to intracranial haemorrhage (ICH) added
  • Behavioural management: further section added to expand this information
  • Cognitive communication deficits: further section added to expand this information
  • Contracture: revision of preamble regarding prolonged stretches and relevant recommendation
  • Loss of sensation: revision of preamble and recommendations
  • Neurointervention: rewording of recommendation regarding mechanical retrieval devices
  • Spasticity: revision of preamble
  • Transient ischaemic attack (TIA) management: revision of both organisation and clinical management preambles and minor changes to recommendations

Minor changes were also made to aphasia, cognition, incontinence, thrombolysis and dysphagia. For other topics, apart from a change in order and minor wording changes, none of the recommendations were significantly changed after feedback from consultation. Five questions, modified from key questions included in the Guidelines Implementability Tool, were also included in the consultation feedback form to provide general feedback. This feedback was used by the National Stroke Foundation (NSF) project team when reviewing and updating the draft document. Recommendations that were unclear or ambiguous were reworded. A medical editor also reviewed the guidelines to ensure that there was consistency in the language used and the presentation of the evidence.

A letter of reply outlining the EWG's responses was sent to all individuals and organisations who provided feedback during the public consultation period. A list of individuals, groups or organisations who provided feedback during the consultation process can be obtained from the NSF.

The updated guideline document underwent one final round of peer review by international experts in the field of stroke and guideline development.

Feedback received was initially reviewed by the NSF project team and the EWG co-chairs and minor changes were made (slight wording changes to several recommendations). The final document was circulated to the EWG for sign-off and then submitted to the NHMRC for consideration of approval.

These guidelines were approved by the Chief Executive Officer of the NHMRC on 3rd August 2010, under Section 14A of the National Health and Medical Research Council Act 1992. In approving these guidelines the NHMRC considers that they meet the NHMRC standard for clinical practice guidelines.

Recommendations

Major Recommendations

The grades of recommendations (A-D and good practice point [GPP]) are defined at the end of the "Major Recommendations" field.

Thrombolysis

Intravenous recombinant tissue plasminogen activator (rt-PA) in acute ischaemic stroke should only be undertaken in patients satisfying specific inclusion and exclusion criteria. (Grade A [Wardlaw et al., 2009])

Intravenous rt-PA should be given as early as possible in carefully selected patients with acute ischaemic stroke as the effect size of thrombolysis is time-dependent. Where possible, therapy should commence in the first few hours but may be used up to 4.5 hours after stroke onset. (Grade A [Wardlaw et al., 2009; Lansberg et al., 2009])

Intravenous rt-PA should only be given under the authority of a physician trained and experienced in acute stroke management. (Grade B [Wardlaw et al., 2009])

Thrombolysis should only be undertaken in a hospital setting with appropriate infrastructure, facilities and network support including:

  • Access to an multidisciplinary acute care team with expert knowledge of stroke management who are trained in delivery and monitoring of patients receiving thrombolytic therapy (GPP)
  • Pathways and protocols available to guide medical, nursing and allied health acute phase management, in particular acute blood pressure management (Grade C [Graham, 2003; Ahmed et al., 2009; Butcher et al., 2010])
  • Immediate access to imaging facilities and staff trained to interpret images. (GPP)

A minimum set of de-identified data from all patients treated with thrombolysis should be recorded in a central register to allow monitoring, review, comparison and benchmarking of key outcomes measures over time. (Grade C [Wahlgren et al., 2007])

The commencement of aspirin for patients who have received thrombolysis should be delayed for 24 hours (usually after a follow-up scan has excluded significant bleeding). (GPP)

Neurointervention

Intra-arterial (IA) thrombolysis within six hours can be used in carefully selected patients. (Grade B [Wardlaw et al., 2009])

Each large tertiary centre should consider establishing facilities and systems for IA thrombolysis. (GPP)

There is insufficient evidence to recommend the use of mechanical clot removal in routine clinical practice. Consideration should be given to enrolling patients in a suitable clinical trial evaluating this intervention. (GPP)

Antithrombotic Therapy

Aspirin orally or via a nasogastric tube or suppository (for those with dysphagia) should be given as soon as possible after the onset of stroke symptoms (i.e., within 48 hours) if computed tomography/magnetic resonance imaging (CT/MRI) scans exclude haemorrhage. The first dose should be at least 150 to 300 mg. Dosage thereafter can be reduced (e.g., 100 mg daily). (Grade A [Sandercock et al., 2008])

The routine use of early anticoagulation in unselected patients following ischaemic stroke/transient ischaemic attack (TIA) is NOT recommended. (Grade A [Sandercock, Counsell, & Tseng, 2008])

Acute Phase Blood Pressure Lowering Therapy

In ischaemic stroke, if blood pressure is more than 220/120 mmHg, antihypertensive therapy can be started or increased, but blood pressure should be cautiously reduced (e.g., by no more than 10–20%) and the patient monitored for signs of neurological deterioration. (GPP)

In acute primary intracerebral haemorrhage where severe hypertension is observed on several occasions within the first 24 to 48 hours of stroke onset, antihypertensive therapy (that could include intravenous treatment) can be used to maintain a blood pressure below 180 mmHg systolic (mean arterial pressure of 130 mmHg). (GPP)

Pre-existing antihypertensive therapy can be continued (orally or via nasogastric tube) provided there is no symptomatic hypotension or other reason to withhold treatment. (GPP)

Surgery for Ischaemic Stroke and Management of Cerebral Oedema

Selected patients (18–60 years, where surgery can occur within 48 hours of symptom onset) and with large middle cerebral artery infarction should be urgently referred to a neurosurgeon for consideration of decompressive hemicraniectomy. (Grade A [Vahedi et al., 2007])

Corticosteroids are NOT recommended for management of patients with brain oedema and raised intracranial pressure. (Grade A [Qizilbash, Lewington, & Lopez-Arrieta, 2002])

Osmotherapy and hyperventilation can be trialled while a neurosurgical consultation is undertaken, or in patients whose condition is deteriorating due to raised intracranial pressure. (Grade C [Righetti et al., 2004; Hofmeijer, van der Worp, & Kappelle, 2003]).

Intracerebral Haemorrhage Management

The use of haemostatic drug treatment with recombinant activated factor VII (rFVIIa) is currently considered experimental and is NOT recommended for use outside a clinical trial. (Grade B [You & Al-Shahi, 2006])

In patients with intracerebral hemorrhage (ICH) who were receiving anticoagulation therapy prior to the stroke and who have elevated international normalised ratio (INR), therapy to reverse anticoagulation should be initiated rapidly (e.g., using a combination of prothrombin complex concentrate and vitamin K). (Grade D [Aguilar et al., 2007; Steiner, Rosand, & Diringer, 2006])

Patients with supratentorial ICH should be referred for neurosurgical review if they have hydrocephalus. (GPP)

Surgery for supratentorial haemorrhage can be considered in carefully selected patients. If undertaken, surgery should be performed within 72 hours. The strongest evidence for benefit with surgery is for patients aged <85, a Glasgow Coma Score of 5–15 having altered consciousness or severe neurological deficit and presenting within 24 hours. (Grade C [Prasad, Mendelow, & Gregson, 2008])

Surgical evacuation may be undertaken for cerebellar hemisphere haematomas >3 cm diameter in selected patients. (GPP)

Physiological Monitoring

Patients should have their neurological status (e.g., Glasgow Coma Scale), vital signs (including pulse, blood pressure, temperature, oxygen saturation, and glucose levels) and respiratory pattern monitored and documented regularly during the acute phase, the frequency of such observations being determined by the patient's status. (Grade C [Silva et al., 2005; Cavallini et al., 2003; Roquer et al., 2008; Sulter et al., 2003])

Oxygen Therapy

Patients who are hypoxic (i.e., <95% oxygen saturation) should be given supplemental oxygen. (GPP)

The routine use of supplemental oxygen is NOT recommended in acute stroke patients who are not hypoxic. (Grade C [Ronning & Guldvog, 1999])

Glycaemic Control

On admission, all patients should have their blood glucose level monitored and appropriate glycaemic therapy instituted to ensure euglycaemia, especially if the patient is diabetic. (GPP)

An early intensive approach to the maintenance of euglycaemia is currently NOT recommended. (Grade B [Gray et al., 2007])

Neuroprotection

Putative neuroprotectors (including hypothermic cooling) should only be used in a randomised controlled trial. (Grade A [Diener et al., 2008; Bath 2004; den Hertog et al., 2009; Doesborgh et al., 2004; Rose, Douglas, & Matyas, 2002])

Patients with acute ischaemic stroke who were receiving statins prior to admission can continue statin treatment. (Grade B [Blanco et al., 2007])

Pyrexia Management

Antipyretic therapy, comprising regular paracetamol and/or physical cooling measures, should be used routinely where fever occurs. (Grade C [den Hertog et al., 2009; Mayer et al., 2004])

Seizure Management

Anti-convulsant medication should be used for people with recurrent seizures after stroke. (GPP)

Complementary and Alternative Therapy

The routine use of the following complementary and alternative therapies is NOT recommended:

  • Acupuncture (Grade B [Zhang et al., 2005])
  • Traditional Chinese herbal medicines (Grade B [Li et al., 2009; Cao et al., 2008; Tan, Liu, & Wu, 2008; Zeng et al., 2005; Wu, Liu, & Zhang, 2007; Chen et al., 2008; Zhuo et al., 2008; Yan & Hui-Chan, 2009])

Health professionals should be aware of different forms of complementary and alternative therapies and be prepared to discuss these with stroke survivors and their families/carers. (GPP)

Definitions:

Grading of Recommendations

Grade Description
A Body of evidence can be trusted to guide practice
B Body of evidence can be trusted to guide practice in most situations
C Body of evidence provides some support for recommendation(s) but care should be taken in its application
D Body of evidence is weak and recommendation must be applied with caution
Good Practice Point (GPP) Recommended best practice based on clinical experience and expert opinion
Clinical Algorithm(s)

None provided

Evidence Supporting the Recommendations

References Supporting the Recommendations
Type of Evidence Supporting the Recommendations

The type of supporting evidence is identified and graded for each recommendation (see "Major Recommendations").

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits

Appropriate medical and surgical management of patients with acute stroke

Potential Harms
  • Acute blood pressure therapy (i.e., within first 48 hours) remains controversial with both high and low blood pressure found to negatively affect patient outcomes.
  • Thrombolysis is associated with a risk of intracerebral haemorrhage (ICH) at the end of three or six month follow-up.

Contraindications

Contraindications

Recombinant Tissue Plasminogen Activator (rt-PA)

ABSOLUTE contraindications: Do NOT administer rt-PA if any of these statements are true.

  1. Uncertainty about time of stroke onset (e.g., patients awaking from sleep).
  2. Coma or severe obtundation with fixed eye deviation and complete hemiplegia.
  3. Only minor stroke deficit which is rapidly improving.
  4. Seizure observed or known to have occurred at onset of stroke.
  5. Hypertension: systolic blood pressure ≥185 mmHg or diastolic blood pressure >110 mmHg on repeated measures prior to study.
  6. Clinical presentation suggestive of subarachnoid haemorrhage even if the computed tomography (CT) scan is normal.
  7. Presumed septic embolus.
  8. Patient has received heparin with the last 48 hours and has elevated partial thromboplastin time (PTT) or has a known hereditary or acquired haemorrhagic diathesis (e.g., partial thromboplastin [PT] or activated partial thromboplastin time [APTT] greater than normal).
  9. International normalized ratio (INR) >1.5.
  10. Platelet count <100,000/micro liters
  11. Serum glucose <2.8 mmol/l or >22.0 mmol/l

RELATIVE contraindications: If any of the following statements is true, use rt-PA with caution. In each situation the balance of the potential risks and benefits must be carefully considered.

  1. Severe neurological impairment with National Institutes of Health (NIH) Stroke Scale score >22.
  2. Age >80 years.
  3. CT evidence of extensive middle cerebral artery (MCA) territory infarction (sulcal effacement or blurring of grey-white junction in greater than 1/3 of MCA territory).
  4. Stroke or serious head trauma within the past three months where the risks of bleeding are considered to outweigh the benefits of therapy.
  5. Major surgery within the last 14 days.
  6. Patient has known history of intracranial haemorrhage, subarachnoid haemorrhage, known intracranial arteriovenous malformation or previously known intracranial neoplasm such that, in the opinion of the clinician, the increased risk of intracranial bleeding would outweigh the potential benefits of treatment.
  7. Suspected recent (within 30 days) myocardial infarction.
  8. Recent (within 30 days) biopsy of a parenchymal organ or surgery that, in the opinion of the responsible clinician, would increase the risk of unmanageable (e.g., uncontrolled by local pressure) bleeding.
  9. Recent (within 30 days) trauma with internal injuries or ulcerative wounds.
  10. Gastrointestinal or urinary tract haemorrhage within the last 30 days or any active or recent haemorrhage that, in the opinion of the responsible clinician, would increase the risk of unmanageable (e.g., by local pressure) bleeding.
  11. Arterial puncture at non-compressible site within the last seven days.
  12. Concomitant serious, advanced or terminal illness or any other condition that, in the opinion of the responsible clinician, would pose a risk to treatment.

Qualifying Statements

Qualifying Statements
  • This document is a general guide to appropriate practice, to be followed subject to the clinician's judgment and the patient's preference in each individual case. The guidelines are designed to provide information to assist decision-making and are based on the best evidence available at the time of development.
  • The guidelines should not be seen as an inflexible recipe for stroke care, sometimes rather disparagingly called 'cookbook medicine'; rather, they provide a general guide to appropriate practice to be followed subject to the clinician's judgment and the patient's preference.

Implementation of the Guideline

Description of Implementation Strategy

Using the Guidelines

The primary goal of these guidelines is to help healthcare workers improve the quality and effectiveness of the care they provide.

Guidelines differ from clinical or care pathways (also referred to as critical pathways, care paths, integrated care pathways, case management plans, clinical care pathways or care maps). Guidelines are an overview of the current best evidence translated into clinically relevant statements. Care pathways are based on best practice guidelines but provide a local link between the guidelines and their use.

In considering implementation of these guidelines at a local level, health professionals are encouraged to identify the barriers and facilitators to evidence-based care within their environment to determine the best strategy for local needs. Where change is required, initial and ongoing education is essential and is relevant to all recommendations in these guidelines.

Implementation

Reviewing the evidence and developing evidence-based recommendations for care are only the first steps to ensuring that evidence-based care is available. Following publication, the guidelines must be disseminated to all those involved in stroke care, who will then identify ways in which the guidelines may be taken up at a local level.

Strategies by which guidelines can be disseminated and implemented include:

  1. Distribution of education materials, for example, guidelines will be emailed to stroke clinicians via existing stroke networks. Concise guidelines for the majority of disciplines including general practitioners, nurses and doctors are planned. A link to the guidelines will be available on the National Stroke Foundation (NSF) website and will be sent to all appropriate universities, colleges, associations, societies and other professional organisations.
  2. Educational meetings, for example, interdisciplinary conferences or internet-based web conferences. Resources will be developed to aid workshop facilitators identify barriers and solutions in the implementation phase.
  3. Educational outreach visits. A peer support model using centres viewed as champions in aspects of acute stroke management may be used in collaboration with national audit results.
  4. Key opinion leaders. Educational resources will utilise key opinion leaders. It is also planned to have local champions facilitate workshops in their local areas.
  5. Audit and feedback. Data from the National Stroke Audits will be fundamental to the implementation of these guidelines. A copy of relevant indicators covering organisation of care and clinical care will be available from the NSF along with key audit reports (see Appendix 4 in the original guideline document).
  6. Reminders. Electronic reminders should be used once local teams have identified key areas of quality improvement activities and commenced planned strategies.

The NSF strongly recommends a systematic approach to identifying gaps in service delivery, understanding local barriers or enablers to reducing those gaps and developing a clear plan of action to improve stroke services. The NSF has developed a comprehensive quality improvement (QI) program (known as StrokeLink) offering outreach visits by NSF staff using interactive educational formats linked to audit and feedback and local consensus processes. Implementation issues also need to consider the barriers to delivering services to Aboriginal and Torres Strait Islander (ATSI) people and develop models of stroke care that address local cultural and geographical needs.

Existing resources and networks (see Appendix 2 in the original guideline document) can also support implementation of these stroke guidelines.

Implementation Tools
Foreign Language Translations
Patient Resources
Quick Reference Guides/Physician Guides
For information about availability, see the Availability of Companion Documents and Patient Resources fields below.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
Getting Better
IOM Domain
Effectiveness
Patient-centeredness
Timeliness

Identifying Information and Availability

Bibliographic Source(s)
Acute medical and surgical management. In: Clinical guidelines for stroke management 2010. Melbourne (Australia): National Stroke Foundation; 2010 Sep. p. 58-67.
Adaptation

Not applicable: The guideline was not adapted from another source.

Date Released
2007 Oct (revised 2010 Sep)
Guideline Developer(s)
National Stroke Foundation (Australia) - Nonprofit Organization
Source(s) of Funding

Australian Government Department of Health and Ageing

Guideline Committee

Expert Working Group

Composition of Group That Authored the Guideline

Group Members: Assoc Prof Louise Ada, Physiotherapist, University of Sydney; Dr Beata Bajorek, Pharmacist, University of Sydney and Royal North Shore Hospital; Prof Alan Barber, Neurologist, Auckland City Hospital; Dr Christopher Beer, Geriatrician/clinical pharmacologist, University of Western Australia, Royal Perth and Mercy Hospitals; Assoc Prof Julie Bernhardt (co-chair), Physiotherapist, National Stroke Research Institute; Dr Geoff Boddice, Clinical Neuropsychologist /Clinical Psychologist, University of Queensland and Ipswich Hospital; Ms Brenda Booth, Consumer, Working Aged Group with Stroke, NSW; Assoc Prof Sandy Brauer, Physiotherapist, University of Queensland; Ms Louise Corben, Occupational Therapist, Monash Medical Centre and Bruce Lefroy Centre (Murdoch Childrens Research Institute); Prof Maria Crotty, Rehabilitation Specialist, Repatriation General Hospital; Prof Tricia Desmond, Neuroradiologist, Royal Melbourne Hospital; Ms Cindy Dilworth, Speech Pathologist, Royal Brisbane Hospital; Dr Steven Faux, Rehabilitation Physician, St Vincent's Hospital, Sydney; Prof Jonathan Golledge, Vascular Surgeon, Townsville Hospital; Dr Louise Gustafsson, Occupational Therapist, University of Queensland; Dr Hugh Grantham, Medical Director, SA Ambulance Service; Dr Deborah Hersh, Speech Pathologist, Australian Aphasia Association; Ms Sue-Ellen Hogg, Speech Pathologist, Port Kembla Hospital; Mr Kelvin Hill, Manager, Guidelines Program, National Stroke Foundation; Ms Louise-Anne Jordan, Manager Clinical Service Delivery, Hunter Stroke Service; Assoc Prof Lynette Joubert, Social Worker, The University of Melbourne; Prof Justin Kenardy, Clinical Psychologist, University of Queensland; Dr Jonathan Knott, Emergency Physician, Royal Melbourne Hospital; Dr Erin Lalor, Chief Executive Officer, National Stroke Foundation; Dr Elaine Leung, General Practitioner, Adelaide; Prof Richard Lindley (co-chair), Geriatrician, University of Sydney; Ms Judy Martineau, Nutrition Consultant, Wesley Hospital; Prof Sandy Middleton, Director, Nursing Research Institute, St Vincent's & Mater Health Sydney, Australian Catholic University, Director, National Centre for Clinical Outcomes Research (NaCCOR), Nursing and Midwifery; Dr Ramu Nachiappan, General Practitioner, Broken Hill; Prof Mark Nelson, General Practitioner, University of Tasmania; Prof Lin Perry, Professor of Nursing Research and Practice Development, University of Technology, Prince of Wales Hospital and Sydney Eye Hospital; Ms Fiona Simpson, Dietitian and Senior Research Fellow, Royal North Shore Hospital; Ms Trish Spreadborough, Nurse Unit Manager, Rehabilitation, Redcliffe Hospital; Ms Leah Wright, Senior Project Officer, Guidelines Program, National Stroke Foundation

Financial Disclosures/Conflicts of Interest

All members of the Expert Working Group (EWG) completed and signed a declaration of potential conflicts of interest. Members also declared any potential conflicts at the beginning of each meeting throughout the development process. Most had no perceived conflicts. The reasons for potential conflicts primarily involved receiving money from non-commercial and commercial organisations specifically for undertaking clinical research. This was expected given the expertise of members in clinical research. Only a small number of members had received financial support from commercial companies for consultancy or lecturing. A policy of managing conflicts of interest was used during the process.

Guideline Endorser(s)
Australian and New Zealand Society for Geriatric Medicine - Medical Specialty Society
Australian College for Emergency Medicine - Medical Specialty Society
Australian College of Rural and Remote Medicine - Professional Association
Australian Physiotherapy Association - Medical Specialty Society
beyondblue: the national depression initiative - Nonprofit Organization
Carers Australia - Professional Association
Continence Foundation of Australia - Professional Association
Council of Ambulance Authorities (Australia) - Professional Association
Dietitians Association of Australia - Professional Association
Internal Medicine Society of Australia and New Zealand - Medical Specialty Society
Occupational Therapy Australia - Professional Association
Pharmacy Guild of Australia - For Profit Organization
Royal Australian and New Zealand College of Psychiatrists - Professional Association
Royal Australian College of General Practitioners - Professional Association
Royal College of Nursing, Australia - Professional Association
Speech Pathology Australia - Medical Specialty Society
Stroke Society of Australasia - Disease Specific Society
Guideline Status

This is the current release of the guideline.

This guideline updates a previous version: Acute medical and surgical management. In: National Stroke Foundation. Clinical guidelines for acute stroke management. Melbourne (Australia): National Stroke Foundation; 2007 Oct. p. 22-9.

Guideline Availability

Electronic copies: Available in Portable Document Format (PDF) from the National Stroke Foundation (Australia) Web site External Web Site Policy.

Print copies: Available from the National Stroke Foundation (Australia), Level 7, 461 Bourke Street, Melbourne Victoria 3000, Australia.

Availability of Companion Documents

The following are available:

  • Clinical guidelines for stroke management 2010 recommendations. Melbourne (Australia): National Stroke Foundation; 2010. 30 p.
  • Ten things to know about the clinical guidelines for stroke management 2010. Melbourne (Australia): National Stroke Foundation; 2010. 1 p.

Electronic copies: Available in Portable Document Format (PDF) from the National Stroke Foundation (Australia) Web site External Web Site Policy.

Also, the following concise guidelines are available:

  • Clinical guidelines for stroke management: A quick guide for general practitioners. 2010. 8 p.
  • Clinical guidelines for stroke management: A quick guide for occupational therapy. 2010. 10 p.
  • Clinical guidelines for stroke management: A quick guide for dietetics. 2010. 5 p.
  • Clinical guidelines for stroke management: A quick guide for physiotherapy. 2010. 8 p.
  • Clinical guidelines for stroke management: A quick guide for psychology. 2010. 8 p.
  • Clinical guidelines for stroke management: A quick guide for social work. 2010. 7 p.

Electronic copies: Available in Portable Document Format (PDF) from the National Stroke Foundation (Australia) Web site External Web Site Policy.

Print copies: Available from the National Stroke Foundation (Australia), Level 7, 461 Bourke Street, Melbourne Victoria 3000, Australia.

Patient Resources

The following is available:

  • All about stroke. Melbourne (Australia): National Stroke Foundation; 2010. 5 p. Available in Portable Document Format (PDF) in English, Vietnamese, Chinese, Arabic, Italian and Greek from the National Stroke Foundation (Australia) Web site External Web Site Policy.

Print copies: Available from the National Stroke Foundation (Australia), Level 7, 461 Bourke Street, Melbourne Victoria 3000, Australia.

Please note: This patient information is intended to provide health professionals with information to share with their patients to help them better understand their health and their diagnosed disorders. By providing access to this patient information, it is not the intention of NGC to provide specific medical advice for particular patients. Rather we urge patients and their representatives to review this material and then to consult with a licensed health professional for evaluation of treatment options suitable for them as well as for diagnosis and answers to their personal medical questions. This patient information has been derived and prepared from a guideline for health care professionals included on NGC by the authors or publishers of that original guideline. The patient information is not reviewed by NGC to establish whether or not it accurately reflects the original guideline's content.

NGC Status

This NGC summary was completed by ECRI Institute on November 26, 2008. The information was verified by the guideline developer on December 4, 2008. This NGC summary was update by ECRI Institute on January 24, 2011. This summary was updated by ECRI Institute on June 27, 2011 following the U.S. Food and Drug Administration advisory on Zocor (simvastatin). This summary was updated by ECRI Institute on October 28, 2013 following the U.S. Food and Drug Administration advisory on Acetaminophen.

Copyright Statement

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.

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