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Guideline Summary
Guideline Title
Hyperacute stroke management. In: Canadian best practice recommendations for stroke care.
Bibliographic Source(s)
Hyperacute stroke management. In: Lindsay MP, Gubitz G, Bayley M, Hill MD, Davies-Schinkel C, Singh S, Phillips S, Canadian Stroke Strategy Best Practices and Standards Writing Group. Canadian best practice recommendations for stroke care. Ottawa (ON): Canadian Stroke Network; 2010 Dec 8. p. 55-84.
Guideline Status

This is the current release of the guideline.

This guideline updates a previous version: Lindsay P, Bayley M, Hellings C, Hill M, Woodbury E, Phillips S. Canadian best practice recommendations for stroke care. CMAJ 2008 Dec 2;179(12 Suppl).

The Canadian Best Practice Recommendations for Stroke Care include an ongoing plan to formally update the recommendations every 2 years to ensure that the best practice recommendations remain current and are coordinated with other similar initiatives nationally and internationally.

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.

  • November 6, 2013 – Low Molecular Weight Heparins External Web Site Policy: The U.S. Food and Drug Administration (FDA) is recommending that health care professionals carefully consider the timing of spinal catheter placement and removal in patients taking anticoagulant drugs, such as enoxaparin, and delay dosing of anticoagulant medications for some time interval after catheter removal to decrease the risk of spinal column bleeding and subsequent paralysis after spinal injections, including epidural procedures and lumbar punctures. These new timing recommendations, which can decrease the risk of epidural or spinal hematoma, will be added to the labels of anticoagulant drugs known as low molecular weight heparins, including Lovenox and generic enoxaparin products and similar products.

Scope

Disease/Condition(s)
  • Ischemic stroke
  • Transient ischemic attack
  • Subarachnoid or intracerebral hemorrhage
Guideline Category
Diagnosis
Evaluation
Management
Prevention
Risk Assessment
Treatment
Clinical Specialty
Cardiology
Critical Care
Emergency Medicine
Geriatrics
Internal Medicine
Neurological Surgery
Neurology
Nursing
Pediatrics
Preventive Medicine
Intended Users
Advanced Practice Nurses
Allied Health Personnel
Emergency Medical Technicians/Paramedics
Health Care Providers
Hospitals
Nurses
Patients
Physician Assistants
Physicians
Utilization Management
Guideline Objective(s)

To provide a synthesis of best practices in stroke care across the continuum of care and serve as a framework for Canadian provinces and territories as they develop and implement stroke strategies

Target Population

All patients who present with symptoms suggestive of ischemic stroke, transient ischemic attack, acute subarachnoid hemorrhage, and intracerebral hemorrhage

Interventions and Practices Considered

Diagnosis/Evaluation

  1. Clinical evaluation
  2. Electrocardiogram
  3. Brain imaging, including computed tomography (CT), magnetic resonance imaging (MRI)
  4. Neurovascular imaging, including CT angiography, carotid duplex ultrasound, magnetic resonance angiography (MRA), catheter angiography
  5. Emergency department rapid evaluation and acute phase monitoring, including airway, breathing, circulation, heart rate and rhythm, blood pressure, temperature, oxygen saturation, hydration, swallowing ability, and presence of seizure activity, neurological exam, standardized stroke scale
  6. Investigations, including routine chemistry, electrolytes, coagulation, renal function, creatine kinase, fasting lipid profile, fasting glucose level and A1c, and thyroid-stimulating hormone, electrocardiography, chest X-ray, neurological
  7. Outpatient assessment for functional impairment, including cognitive evaluation, screening for depression, screening of fitness to drive, and functional assessments for potential rehabilitation treatment

Management/Treatment

  1. Antiplatelet therapy (aspirin, clopidogrel)
  2. Anticoagulation therapy (warfarin)
  3. Antithrombolytic therapy (intravenous alteplase)
  4. Carotid endarterectomy
  5. Management of patient by emergency medical service, including prioritization of patients with hyperacute stroke, standardized screening tool, Direct Transport Protocol, notification of receiving facility, patient medical and drug history
  6. Cardiovascular investigations, including serial electrocardiograms, Holter monitor, echocardiography
  7. Acute blood pressure management
  8. Management of blood glucose abnormalities
  9. Other investigations, including blood cultures, fasting lipid profile, investigations for hypercoagulability and vasculitis
  10. Management of acute subarachnoid hemorrhage, including brain vascular imaging, lumbar puncture, consultation with neurosurgeon, placement of external ventricular drain, aneurysm management, venous thromboembolism prophylaxis
  11. Management of intracerebral hemorrhage, including brain imaging, neurosurgical consultation, neurosurgical evacuation of hemorrhage
Major Outcomes Considered
  • Functional impairment and functional status
  • Sensitivity and specificity of diagnostic tests and screening tools
  • Incidence of recurrent stroke
  • Rate of symptomatic intracranial hemorrhage
  • Rebleeding from the treated aneurysm

Methodology

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

Literature Search

MEDLINE, EMBASE and the Cochrane Library databases were rigorously searched. Also, the grey literature and websites of other best practice recommendation developers were searched for relevant material that may not have been published in an academic journal.

The time frame of each literature search ran from the time the best practice recommendation was last updated (2008) up until September, 2010. Unless invalid, the literature from the previously reviewed recommendations, completed in 2006 and 2008, was included. For new recommendations, the literature search time frame was from 1990 until September, 2010.

The following studies were included during the search: randomized controlled clinical trials (double-blinded or nonblinded); meta-analyses of randomized studies; nonrandomized controlled clinical trials and case series; population-based, consecutive series; consecutive cases (not population-based); or, non-consecutive cases. Included articles were published in English and were based on human studies.

All terms used were particular to stroke and the topic being searched. A total of 35 different topics were explored. Specific drug names, treatment names, and therapy names were used to create an inclusive database for each topic. This resulted in a total of 699 references included in the Canadian Stroke Best Practice Recommendations 2010 update.

Number of Source Documents

A total of 699 studies were included.

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

Summary of Definitions for Levels of Evidence*

Grade Criteria
A Strong recommendation. Evidence from randomized controlled trials or meta-analyses of randomized controlled trials. Desirable effects clearly outweigh undesirable effects, or vice versa.
B Single randomized controlled trial or well-designed observational study with strong evidence; or well-designed cohort or case–control analytic study; or multiple time series or dramatic results of uncontrolled experiment. Desirable effects closely balanced with undesirable effects.
C At least one well-designed, nonexperimental descriptive study (e.g., comparative studies, correlation studies, case studies) or expert committee reports, opinions and/or experience of respected authorities, including consensus from development and/or reviewer groups.

*Based on Guyatt GH, Cook DJ, Jaeschke R, et al. Grades of recommendation for antithrombotic agents: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th edition). [published erratum in Chest 2008;34:47]. Chest 2008;133(6 Suppl):123S-131S.

Methods Used to Analyze the Evidence
Review of Published Meta-Analyses
Systematic Review
Description of the Methods Used to Analyze the Evidence

Evaluating the Evidence

A Stroke Best Practices Recommendations Matrix was developed that mapped other existing stroke-related recommendations and their levels of evidence onto topic areas identified as relevant to optimal stroke care in Canada (i.e., blood pressure management, organization of care).

A list of topics was generated by identifying recommendations with the highest levels of evidence in each of the reference guidelines. Where similar or related recommendations on a particular topic appeared in more than two guidelines, it was added to the topic list. The final list of topics was then cross-referenced with the Stroke Canada Optimization of Rehabilitation through Evidence (SCORE) and the Canadian Stroke Quality of Care Study (CSQCS) studies.

The Best Practices Recommendations Matrix was created through an iterative process of review and discussion among the members of the sub-group and the Best Practices and Standards Working Group (BPS-WG) as a whole.

Evaluation of Levels of Evidence

Each recommendation included in this document was evaluated against several criteria: strength of the available research evidence to support the recommendation; degree to which the recommendation drives system change or processes of care delivery; overall validity and relevance as a core recommendation for stroke care along the continuum of care. The levels of evidence included in this document are determined through a structured ranking system which measures the strength of the results in a clinical trial or research study. The design of the study (such as a case report for an individual patient or a randomized double-blinded controlled clinical trial) and the endpoints measured (such as survival or quality of life) affect the strength of the evidence.

The various types of study designs, in descending order of strength, include:

  • Randomized controlled clinical trials (double-blinded or non-blinded) are considered the gold standard of study design.
  • Meta-analyses of randomized studies offer a quantitative synthesis of previously conducted studies. The strength of evidence from a meta-analysis is based on the quality of the conduct of individual studies. Meta-analyses of randomized studies are placed in the same category of strength of evidence as are randomized studies.
  • Nonrandomized controlled clinical trials
  • Case series: Population-based, consecutive series, consecutive cases (not population-based) or nonconsecutive cases. These clinical experiences are the weakest form of study design, but often they are the only available or practical information.

Several rating systems are used by guideline developers to evaluate the strength of the evidence for their recommendations. These systems vary in the nomenclature used (alphabetical versus numeric), but there is usually reasonable equivalence in the definitions across the levels of evidence. Each recommendation in this document provides the level of evidence for the recommendation (see the "Rating Scheme for the Strength of the Evidence" field), as well as the reference for the Primary Guideline(s) that were adapted or contributed most to the wording of the recommendation.

Methods Used to Formulate the Recommendations
Expert Consensus (Consensus Development Conference)
Description of Methods Used to Formulate the Recommendations

Stroke Guideline Development Framework

The conceptual framework used to guide the identification, selection, development and updating of the Canadian best practice recommendations was the Practice Guideline Evaluation and Adaptation Cycle of Graham and colleagues. This cycle involves a number of steps that are integral to the guideline development process:

  1. Establishing an interdisciplinary guideline development team
  2. Establishing a guideline appraisal process using a validated tool
  3. Systematic searching for existing practice guidelines
  4. Appraising the quality, currency and content of guideline recommendations
  5. Adopting or adapting guidelines for local use
  6. Obtaining external expert feedback on the proposed recommendations
  7. Selecting final recommendations
  8. Obtaining official endorsement
  9. Establishing an ongoing review and update process

The methodology for the first edition of the Canadian Best Practice Recommendations for Stroke Care (2006) was based on this framework, and it is applied, with some enhancements, to develop each update. The key activities undertaken in the guideline development process are highlighted below.

Leadership and Participants

The Canadian Stroke Strategy (CSS) Best Practices and Standards Working Group has overall responsibility for the development and update process. The 2010 update cycle was led by a subgroup of the Working Group and managed by the Director of Performance and Standards at the Canadian Stroke Network (CSN).

An interprofessional group of experts in stroke care participated in topic-specific task groups convened to review, draft, and revise recommendation statements for their topic. Recognized experts within the topic area chaired each task group, and members included stroke neurologists, physiatrists, nurses, emergency physicians, paramedics, physical therapists, occupational therapists, dietitians, speech–language pathologists, pharmacists, stroke survivors, education experts, and professionals from other disciplines as required. This interprofessional approach ensured that all relevant health disciplines for a particular topic area were represented in the development of the recommendations.

A national interprofessional consensus panel was convened to provide further input into the recommendations and a final review was conducted by an external group of stroke and methods experts before release.

Identification of Key Topic Areas and Core Reference Guidelines

The process used to identify key topic areas and core reference guidelines is outlined below.

  1. An ongoing structured literature review is conducted every two to three months to monitor emerging evidence and new or updated stroke-related guidelines.
  2. Scans of the primary research literature focused on meta-analyses, systematic reviews, randomized trials, quasi-experimental studies, other related guidelines and reports, and Canadian consensus statements by healthcare professional groups.
  3. The strength of the research evidence was graded using a standardized grading system (see the "Rating Scheme for the Strength of the Evidence" field). In some areas, the levels of evidence for a given topic varied among selected guidelines or research papers depending on the nature of the research. The totality of the information for each topic provided a comprehensive understanding of the strength of the evidence, the state of the research, and gaps for future inquiry.
  4. A detailed literature search for international stroke-related guidelines was also undertaken. The Appraisal of Guidelines Research and Evaluation (AGREE) tool was applied to determine the quality of the guidelines. This tool can be used to assess the process of guideline development based on six domains: identification of a clinical area to promote best practice, stakeholder involvement, rigour of development, clarity and presentation, applicability, and editorial independence. Based on the results of the appraisals, several guidelines met the Working Group criteria to be considered as 'reference guidelines' for the development process.
  5. Once the high-quality guidelines were identified, a content review was conducted to identify a list of stroke topic areas that were supported by the highest levels of evidence. A secondary list of topic areas with lower levels of supporting evidence but considered being key system drivers (such as acute diagnostic imaging with computed tomography scans) was also compiled.
  6. Potential topics that emerged from the research and guideline review were compiled into a "Topic Matrix" to allow easy comparison by topic and strength of evidence.
  7. The topic areas and levels of supporting evidence were reviewed and debated by the Working Group. Using a consensus model, a final list of stroke topic areas that were considered most relevant to optimal stroke care in Canada was developed.
  8. Topic areas were assigned to one of eight task groups to develop detailed recommendation statements.

See Appendix 7 in the original guideline document for a list of guidelines and significant research trials that were considered during the 2010 update process.

Synthesis of Best Practice Recommendations

Expert task groups (see Appendix 2 in the original guideline document for a list of task group members) were convened for each segment of the continuum of stroke care, to select relevant recommendations arising from the evidence review and if necessary draft new recommendations based on emerging evidence. Task groups were instructed that recommendations could address structure and/or processes of care at either the system level or the patient level, and that they could be taken directly from other existing guidelines, adapted from one or more guidelines, or written by the task group. Appropriate references were to accompany all recommendation statements derived from evidence or existing guidelines.

For the 2010 update, each task group participated in a series of teleconferences between May 2009 and February 2010 to complete their research reviews and develop the recommendations. The Director of Performance and Standards at the CSN participated in all teleconferences to ensure consistency, standardization, and rigour of development across task groups.

See the original guideline document for more information on the recommendation development process.

Rating Scheme for the Strength of the Recommendations

Not applicable

Cost Analysis
  • Despite the absence of randomized trials, there is uniform agreement that non-contrast computed tomography (CT) should be the initial imaging study of patients who present with acute ischemic stroke. The primary purpose of the head CT is to exclude intracranial hemorrhage although other important information may be obtained. A head CT should be obtained emergently in those patients potentially eligible for thrombolytic therapy. In a decision-analysis model, a policy of "scan all immediately" was more cost-effective than "scan all within 48 hours" or "scan patients on anticoagulants or in a life-threatening condition immediately and the rest within 14 days".
  • One study conducted a cost-effectiveness analysis of the use of CT and tested 13 strategies. The study indicates that of 13 possible imaging strategies, a policy of "CT scan all patients immediately" is dominant. Although the costs of CT scanning are highest for this strategy because of more scanning occurring after hours, these higher costs are offset by savings in the length of inpatient stay because many management decisions and better outcomes depend on accurate early diagnosis of stroke.
Method of Guideline Validation
External Peer Review
Internal Peer Review
Description of Method of Guideline Validation

National Expert Consensus Process

Following completion of the task group work, the draft recommendations and supporting information were presented for discussion and decision-making to a broad group of stakeholders at a national expert consensus meeting held in Toronto, Ontario in April, 2010 (see Appendix 3 of the original guideline document for a list of consensus participants). Consensus participants included the Best Practices Working Group, the chairs of each task group, and invited opinion leaders, stroke survivors, and healthcare professionals external to the development process. The selection of consensus participants was based on ensuring representation from stroke-related health professional disciplines, all sectors of the healthcare continuum, all provinces in Canada, and rural and urban work environments.

Consensus participants received the draft recommendations, including proposed changes to existing recommendations as well as new recommendations, in advance of the consensus meeting. They were asked to review the information, provide feedback to the Working Group prior to the meeting, and indicate their degree of support for each recommendation. Votes were taken after each topic area discussion.

Recommendations

Major Recommendations

Definitions of the levels of evidence (A-C) are provided at the end of the "Major Recommendations" field.

Note from the Canadian Stroke Network/Heart & Stroke Foundation of Canada (CSN/HSFC) and the National Guideline Clearinghouse (NGC): The Canadian Best Practice Recommendations for Stroke Care, 2010 update, has been divided into individual summaries. In addition to the current summary, the following are available:

What's New for 2010?

The 2010 content update focuses on:

  • Access: Providing good stroke care, quickly
  • Continuity: Helping people move smoothly through the stroke continuum, from symptom onset to diagnosis, treatment, management, and recovery

For 2010 the SCORE (Stroke Canada Optimization of Rehabilitation through Evidence) recommendations for upper and lower limb have been integrated within the Canadian Best Practice Recommendations for Stroke Care. Also new for 2010 is a section on transitions of care to help patients, families, and caregivers access the right type of care in the right settings at the right time. To facilitate uptake of the best practice recommendations by front-line clinicians, the best practice recommendations also include a new section on information about implementation resources.

Other significant changes for 2010:

  • Atrial fibrillation and carotid endarterectomy recommendations were revised to address the findings of two recently published clinical trials (RE-LY and CREST), which have important implications for stroke prevention.
  • Intracranial hemorrhage and subarachnoid hemorrhage recommendations were revised and expanded to address immediate assessment and management of these patients.
  • New recommendations on fall prevention to address an important patient safety issue

Hyperacute Stroke Management

Best Practice Recommendation: Outpatient Management of Transient Ischemic Attack and Non-disabling Ischemic Stroke

  1. Timing of Initial Assessment
    1. Patients presenting to a family physician's office or other community primary care setting within one week of a suspected transient ischemic attack or non-disabling ischemic stroke should have an immediate clinical evaluation and investigations to establish the diagnosis, rule out stroke mimics, and develop a management plan [Evidence Level B].
    2. Patients who cannot be evaluated as an outpatient within 24 hours from clinical presentation should be transported to an emergency department that has access to neurovascular imaging facilities and stroke expertise [Evidence Level B].
    3. Patients presenting to a family physician's office or other community primary care setting more than one week following a suspected transient ischemic attack or non-disabling ischemic stroke should be seen by a stroke specialist on a less urgent basis, generally within one month of presentation [Evidence Level B].
  1. Evaluation
    1. Patients presenting to a family physician's office or walk-in clinic with a suspected transient ischemic attack or non-disabling ischemic stroke should be immediately referred to a designated stroke prevention clinic with an interprofessional stroke team, or to a stroke specialist [Evidence Level B].
    2. All patients with suspected transient ischemic attack or non-disabling ischemic stroke should undergo an assessment that includes an electrocardiogram, brain imaging, and non-invasive vascular imaging (for carotid territory transient ischemic attacks or non-disabling strokes) within seven days of symptom onset, and have a consultation with a stroke specialist [Evidence Level B].
    3. Patients presenting with transient ischemic attack or non-disabling ischemic stroke and motor or speech symptoms should optimally have the assessment on the day of symptom onset [Evidence Level B].
    4. The following laboratory investigations should be undertaken routinely for patients with suspected transient ischemic attack or non-disabling ischemic stroke: haematology, electrolytes, coagulation, renal function, creatine kinase (CK), fasting lipid profile, fasting glucose level and A1c, and thyroid-stimulating hormone (TSH) [Evidence Level C]. Additional blood work may be required if a hypercoagulable or vasculitic cause is suspected.
    5. Patients with non-disabling ischemic stroke who are not admitted to hospital should be considered or referred for a comprehensive outpatient assessment of functional impairment, which should include a cognitive evaluation, screening for depression, screening of fitness to drive, and functional assessments for potential rehabilitation treatment [Evidence Level B].
  1. Management (see also the NGC summary of the CSN/HSFC guideline Prevention of Stroke)
    1. All patients with transient ischemic attack or non-disabling ischemic stroke who are not on an antiplatelet agent at time of presentation should be started on antiplatelet therapy immediately after brain imaging has excluded intracranial hemorrhage [Evidence Level A] (Chinese Acute Stroke Trial [CAST] Collaborative Group, 1997). A loading dose of acetylsalicylic acid (ASA) should be at least 160 mg. If clopidogrel is used, a loading dose of 300 mg should be given, then maintenance therapy should be started according to parameters set out for long-term antiplatelet therapy. [Evidence Level A].
    2. Patients with transient ischemic attack or non-disabling ischemic stroke with a 50 to 99 percent carotid stenosis on the side implicated by their neurologic symptoms, who are otherwise candidates for carotid revascularization, should have carotid endarterectomy performed as soon as possible, ideally, within two to fourteen days [Evidence Level A].
    3. Patients with transient ischemic attack or non-disabling ischemic stroke and atrial fibrillation should begin anticoagulation immediately after brain imaging has excluded intracranial hemorrhage or large infarct. For patients on warfarin, the target therapeutic international normalized ratio (INR) is 2.5 with a range of two to three [Evidence Level A].
    4. All risk factors for cerebrovascular disease must be aggressively managed, through pharmacological and non-pharmacological means, to achieve optimal control [Evidence Level A]. While evidence for the benefit of modifying individual risk factors in the acute phase is lacking, there is evidence of benefit when adopting a comprehensive approach, including antihypertensives and statin medication [Evidence Level C] (Rothwell et al., 2007).
    5. Patients with transient ischemic attack or non-disabling ischemic stroke who smoke should be strongly advised to quit immediately, and be provided with the pharmacological and non-pharmacological means to do so [Evidence Level B].

Rationale

The goal of outpatient management of transient ischemic attack and non-disabling ischemic stroke is rapid assessment and management to reduce the risk of a recurrent, possibly more serious, event.

There is clear evidence that transient ischemic attacks or minor strokes are unstable conditions that warn of high future risk of stroke, other vascular events, or death. The risk of recurrent stroke after a transient ischemic attack is 10 to 20 percent within 90 days, and the risk is "front-loaded," with half of strokes occurring in the first 2 days following initial symptom onset. The 7-day risk of stroke following a transient ischemic attack can be as high as 36 percent in patients with additional risk factors. Timely initiation of secondary prevention medical therapy and carotid endarterectomy has been shown to significantly reduce the risk of major stroke after an initial transient ischemic attack or non-disabling stroke.

Best Practice Recommendation: Emergency Medical Services Management of Acute Stroke Patients

NOTES on This Recommendation*

  • This recommendation covers management of potential stroke patients between the time of first contact with the local emergency medical services to transfer of care to the hospital, as well as care of suspected or confirmed stroke patients who are being transferred between healthcare facilities by emergency medical services.
  • This recommendation is directed to paramedics and those individuals who support emergency medical services, including communications officers and dispatchers. It also applies to other first responders such as emergency medical responders and primary care paramedics who have been trained to screen for stroke and manage potential stroke patients during transfer.

* Local variations need to be taken into consideration for pre-hospital time.

Patients who show signs and symptoms of hyperacute stroke must be treated as a time-sensitive emergency and should be transported without delay to the closest institution that provides emergency stroke care [Evidence Level C].

  1. Immediate contact with emergency medical services (e.g., 911) by patients or other members of the public is strongly recommended because it reduces time to treatment for acute stroke [Evidence Level B].
  2. The emergency medical services system must be set up to categorize patients exhibiting signs and symptoms of a hyperacute stroke as a high priority [Evidence Level C] (National Association of EMS Physicians, 2007).
  3. Paramedics should use a standardized acute stroke out-of-hospital diagnostic screening tool [Evidence Level B].
  4. Out-of-hospital patient management should be optimized to meet the needs of suspected acute stroke patients [Evidence Level A].
  5. Direct Transport Protocols must be in place to facilitate the transfer of eligible patients to the closest and most appropriate facility providing acute stroke care [Evidence Level C].
  6. Direct Transport Protocol criteria must be based on (1) the local emergency department performance which is recommended as being 60 minutes or less; (2) the pre-hospital phase, including symptom duration and anticipated transport time, being 3.5 hours or less; and (3) other acute care needs of the patient [Evidence Level B].
  7. Paramedics should obtain a history of the stroke event, including time of onset, signs and symptoms, and previous medical and drug history from the patient if able or informant when available [Evidence Level C].
  8. Paramedics must notify the receiving facility of a suspected acute stroke patient so the facility may prepare for patient arrival [Evidence Level C].
  9. Transfer of care from paramedics to receiving facility personnel must occur without delay [Evidence Level C].
  10. Patients who are considered ineligible for time-sensitive thrombolytic therapy should be transported to the closest emergency department which provides access to neuroimaging and stroke expertise for assessment and initiation of secondary prevention management [Evidence Level C].

Rationale

Acute stroke is a medical emergency and optimizing out-of-hospital care improves patient outcomes. Emergency medical services play a critical role in out-of-hospital (pre-hospital) assessment and management of suspected stroke patients. Acute interventions such as thrombolytic therapy are time-sensitive and therefore strategies such as re-directing ambulances to stroke centres facilitates earlier assessment, diagnosis, and treatment, and may result in better outcomes.

Best Practice Recommendation: Emergency Department Evaluation and Management of Patients with Transient Ischemic Attack and Ischemic Stroke

NOTE on This Recommendation

  • Time is Brain! The goal of emergency department (ED) management is rapid assessment of all patients with a suspected acute stroke. For patients who may be eligible for intravenous tissue plasminogen activator, the target is to complete rapid assessment and initiate treatment within 90 minutes of stroke symptom onset.

All patients presenting to an emergency department with suspected stroke or transient ischemic attack must have an immediate clinical evaluation and investigations to establish the diagnosis, rule out stroke mimics, determine eligibility for thrombolytic therapy, and develop a plan for further management.

Patients presenting with stroke or transient ischemic attack should not be discharged from the ED without diagnostic evaluations, consideration of functional impairments, initiation or modification of secondary prevention therapy, and a plan for ongoing management.

  1. Initial Evaluation
    1. Patients with suspected acute stroke should have a rapid initial evaluation for airway, breathing and circulation [Evidence Level B].
    2. A neurological examination should be conducted to determine focal neurological deficits and assess stroke severity [Evidence Level B]. A standardized stroke scale should be used.
    3. Monitoring in the acute phase should include heart rate and rhythm, blood pressure, temperature, oxygen saturation, hydration, swallowing ability, and presence of seizure activity [Evidence Level B]. Acute blood work, including routine chemistry, electrolytes, hematology and coagulation should be conducted as part of the initial evaluation [Evidence Level B]. Refer to recommendations above for additional information.
    4. Electrocardiogram and chest X-ray should be completed, especially where the patient has a clinical history or evidence of heart disease or pulmonary disease [Evidence Level B].
  1. Neurovascular Imaging

    All patients with suspected acute stroke or transient ischemic attack should undergo brain imaging (magnetic resonance imaging [MRI] or computed tomography [CT]) immediately [Evidence Level A], and vascular imaging of the brain and neck arteries as soon as possible [Evidence Level B].

    1. If MRI is performed, it should include diffusion-weighted sequences to detect recent ischemia and gradient echo and fluid-attenuated inversion recovery (FLAIR) sequences to determine extent of infarct or presence of hemorrhage [Evidence Level B].
    2. If MRI is not possible as the initial imaging, a non-contrast CT scan of the brain should be performed [Evidence Level B].
    3. Vascular imaging of the carotid and vertebral arteries by duplex ultrasonography, CT angiography (CTA), magnetic resonance angiography (MRA) or catheter angiography should be performed within 24 hours of a transient ischemic attack or ischemic stroke unless the patient is clearly not a candidate for revascularization [Evidence Level B]. Ideally CTA or MRA is performed at the time of the initial CT or MRI.
    4. If not done as part of the original assessment in the emergency department, extracranial vascular imaging should be done as soon as possible to better understand the cause of the stroke event and guide management decisions. Imaging of the intracranial vessels might be warranted in some cases. Duplex ultrasonography, CTA, or MRA of the extracranial and intracranial vessels may be considered. In some circumstances catheter angiography of the extracranial and intracranial vessels should be considered [Evidence Level B].
  1. Cardiovascular Investigations
    1. Following an initial electrocardiogram, serial electrocardiograms (i.e., daily) should be done over the first 72 hours post-stroke to detect atrial fibrillation and other acute arrhythmias [Evidence Level B].
    2. Serial electrocardiograms in the first 72 hours combined with a Holter monitor during hospitalization may be considered in order to increase detection of atrial fibrillation [Evidence Level C] (Douen, Pageau, & Medic, 2008).
    3. Echocardiography, either 2-dimensional (2-D) or transesophageal, should be considered for patients with suspected embolic stroke and normal neurovascular imaging in whom there are no contraindications to anticoagulation [Evidence Level B].
  1. Acute Blood Pressure Management

    There is a lack of clear evidence from randomized controlled trials to guide the emergent and urgent treatment of elevated blood pressure in the setting of acute ischemic or hemorrhagic stroke. Pharmacological agents and routes of administration should be chosen to avoid precipitous falls in blood pressure [Evidence Level C]. The following recommendations reflect the paucity of evidence in this area and indicate the need for further research.

    1. Ischemic stroke eligible for thrombolytic therapy: Very high blood pressure (BP) (>185/110 mm Hg) should be treated concurrently in patients receiving thrombolytic therapy for acute ischemic stroke in order to reduce the risk of secondary intracranial hemorrhage [Evidence Level B].
    2. Ischemic stroke patients not eligible for thrombolytic therapy: Treatment of hypertension in the setting of acute ischemic stroke should not be routinely undertaken [Evidence Level C]. Extreme blood pressure elevation (e.g., systolic >220 or diastolic >120 mm Hg) may be treated to reduce the blood pressure by approximately 15 percent, and not more than 25%, over the first 24h with gradual reduction thereafter [Evidence Level C]. Avoid excessive lowering of blood pressure as this may exacerbate existing ischemia or may induce ischemia, particularly in the setting of intracranial arterial occlusion or extracranial carotid or vertebral artery occlusion [Evidence Level C].
  1. Blood Glucose Abnormalities
    1. All patients with suspected acute stroke should have their blood glucose concentration checked immediately [Evidence Level B].
    2. Blood glucose measurement should be repeated if the first random glucose value is elevated greater than 10 mmol/L. The repeat measures should include a fasting glucose and an A1c [Evidence Level B].
    3. Hypoglycemia should be corrected immediately [Evidence Level B].
    4. If the repeat glucose levels and the A1c are elevated (fasting glucose greater than 7 mmol/L; A1c greater than 7 percent), the use of anti-hyperglycemic agents should be considered [Evidence level C], and in the longer term, education on lifestyle changes and diabetes [Evidence level A] ("Canadian Diabetes Association," 2008). Refer to recommendations above for additional information.
  1. Other Investigations That May Be Required in the Emergency Department
    1. Blood cultures if endocarditis is suspected [Evidence level B]
    2. Fasting lipid profile [Evidence level A]
    3. Investigations for hypercoagulability and vasculitis [Evidence Level C]

    Initial Bloodwork for Assessment of Acute Stroke Patients

    All suspected stroke patients: complete blood count (CBC), electrolytes, creatinine, urea, glucose, INR, partial thromboplastin time (PTT), thyroid-stimulating hormone (TSH), fasting lipid profile, creatine kinase (CK), troponin test

    Arterial coagulopathy screen: anticardiolipin (antiphospholipid) antibody, lupus anticoagulant

    Venous coagulopathy: protein S, protein C, antithrombin III, prothrombin gene mutation, factor V Leiden mutation

    Vasculitis: erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), antinuclear antibody (ANA), syphilis screen

Rationale

Patients who present to hospital with suspected stroke often also have significant physiological abnormalities and comorbidities. These can complicate management of stroke. Signs and symptoms that may explain etiology or predict later complications such as space-occupying infarction, bleeding, or recurrent stroke, and medical conditions such as hypertension and the presence of a coagulopathy will have an impact on treatment decisions. An efficient and focused assessment is required to understand the complex needs of each patient.

It is impossible to differentiate infarct from hemorrhage by clinical examination alone. Brain imaging is required to guide management, including the selection of time-sensitive interventions. A CT scan or MRI is important since clinicians may disagree on the clinical diagnosis of stroke (versus not stroke) in about 20 percent of patients.

Initial management of elevated blood pressure in acute stroke patients remains controversial due to the lack of evidence to clearly guide practice. At the same time, this is an area where clinicians often seek guidance from stroke specialists. The recommendations for this area emphasize caution and diligence in monitoring and treating extremely high blood pressure in the first hours after stroke onset.

Diabetes is a major modifiable risk factor for vascular disease that may be first diagnosed at the time of a stroke. Severe hyperglycemia (blood glucose greater than 22 mmol/L) is a relative contraindication to the administration of intravenous alteplase. Hyperglycemia at the time of acute stroke increases size of the damaged area in experimental animals and is associated with poor clinical outcomes in epidemiological studies.

Best Practice Recommendation: Acute Thrombolytic Therapy

All patients with disabling acute ischemic stroke who can be treated within 4.5 hours of symptom onset should be evaluated without delay to determine their eligibility for treatment with intravenous tissue plasminogen activator (alteplase).

  1. Eligible patients are those who can receive intravenous alteplase within 4.5 hours of the onset of stroke symptoms in accordance with criteria adapted from National Institute of Neurological Disorders and Stroke (NINDS) tPA Stroke Study and the European Cooperative Acute Stroke Study (ECASS III) (Bluhmki et al., 2009) [Evidence Level A]. See below for inclusion and exclusion criteria.
  2. All eligible patients should receive intravenous alteplase as soon as possible after hospital arrival, with a target door-to-needle time of less than 60 minutes [Evidence Level C].
  3. Administration of alteplase should follow the American Stroke Association guidelines: total dose 0.9 mg/kg with 10 percent (0.09 mg/kg) given as intravenous bolus over one minute and the remaining 90 percent (0.81 mg/kg) given as an intravenous infusion over 60 minutes [Evidence Level A].
  4. Features on the initial CT brain scan of an otherwise alteplase-eligible ischemic stroke patient that modify the response to treatment remain poorly defined. Some of the trials of alteplase excluded patients with severe hemispheric stroke if the initial CT scan showed early signs of infarction involving more than one-third of the territory of the middle cerebral artery (i.e., a score of less than five on the Alberta Stroke Program Early CT Score [ASPECTS]) (Pexman et al., 2001). In clinical practice, the decision to treat such a patient with alteplase should be based on the clinical judgment of the treating physician, and the wishes of the patient and family, until such time as additional data from randomized controlled trials are made available [Evidence Level B].
  5. There remain situations where there are sparse or no clinical trial data to support the use of thrombolytic therapy: paediatric stroke, stroke in patients over the age of 80 years with diabetes, adults who present within the first few hours of onset of an acute ischemic stroke but do not meet current criteria for treatment with intravenous alteplase, and intra-arterial thrombolysis. In clinical practice, the decision to use alteplase in these situations should be based on the clinical judgment of the treating physician, and the wishes of the patient and family, until such time as additional data from randomized controlled trials are available [Evidence Level A].

Note on This Recommendation

In Canada, alteplase is currently approved by Health Canada for use in adults with acute ischemic stroke within three hours after the onset of stroke symptoms. Exemptions may apply, e.g., a "Letter of No Objection" from Health Canada is required for clinical trials examining the use of intravenous alteplase for other treatment protocols.

Criteria for Acute Thrombolytic Therapy

Criteria adapted in accordance with the criteria identified in National Institute of Neurological Disorders and Stroke (NINDS) (Marler et al., 2000) tPA Stroke Study and the European Cooperative Acute Stroke Study (ECASS III) (Bluhmki et al., 2009).

Treatment Criteria

  • Diagnosis of ischemic stroke causing measurable neurologic deficit in a patient who is 18 years of age or older
  • Onset of symptoms more than one hour and less than 4.5 hours before alteplase administration

Exclusion Criteria

Historical

  • History of intracranial hemorrhage
  • Stroke or serious head or spinal trauma in the preceding three months
  • Recent major surgery
  • Arterial puncture at a non-compressible site in the previous seven days
  • Any other condition that could increase the risk of hemorrhage after alteplase administration 

Clinical

  • Symptoms suggestive of subarachnoid hemorrhage
  • Stroke symptoms due to another non-ischemic acute neurological condition such as seizure with post-ictal Todd's paralysis or focal neurological signs due to severe hypo- or hyperglycemia
  • Hypertension refractory to antihypertensives such that target blood pressure <185/110 cannot be achieved 

Laboratory

  • Blood glucose concentration below 2.7 mmol/L or above 22.2 mmol/L
  • Elevated activated partial-thromboplastin time
  • INR greater than 1.7
  • Platelet count below 100,000 per cubic millimetre

CT or MRI Findings

  • Any hemorrhage on brain CT or MRI
  • CT or MRI signs of acute hemispheric infarction involving more than one-third of the middle cerebral artery territory (Alberta Stroke Program Early CT Score [ASPECTS] <5)

Rationale

Meta-analyses of the randomized controlled trials of intravenous alteplase for acute ischemic stroke have shown that thrombolytic treatment can reduce the risk of disability and death, despite the risk of serious bleeding. The latest time for alteplase administration after stroke onset remains imprecisely defined, but currently available data show clear evidence of benefit when given up to 4.5 hours after the onset of symptoms. The available evidence demonstrates a strong inverse relationship between treatment delay and clinical outcome; eligible patients should be treated without delay, regardless of when they present within the treatment window.

Best Practice Recommendation: Acute Aspirin Therapy

All acute stroke patients not already on an antiplatelet agent should be given at least 160 mg of acetylsalicylic acid (ASA) immediately as a one time loading dose after brain imaging has excluded intracranial hemorrhage [Evidence Level A].

  1. In patients treated with recombinant tissue plasminogen activator (r-tPA), ASA should be delayed until after the 24-hour post-thrombolysis scan has excluded intracranial hemorrhage [Evidence Level B].
  2. Acetylsalicylic acid (80 to 325 mg daily) should then be continued indefinitely or until an alternative antithrombotic regime is started [Evidence Level A]. See the NGC summary of the CSN/HSFC guideline Prevention of Stroke for additional information.
  3. In dysphagic patients, acetylsalicylic acid may be given by enteral tube or by rectal suppository [Evidence Level A].
  4. In paediatric patients, initial treatment with low molecular weight heparin should be considered and continued indefinitely or until an alternative antithrombotic regime is started [Evidence Level A]. Refer to until cervical artery dissection and intracardiac thrombus is excluded. If neither is present, switch to acute aspirin therapy at dose of 1 to 5 mg/kg [Evidence Level B].
  5. In patients already on acetylsalicylic acid prior to ischemic stroke or transient ischemic attack, clopidogrel may be considered as an alternative [Evidence Level B]. If rapid action is required then a loading dose of 300 mg of clopidogrel could be considered, followed by a maintenance dose of 75 mg once a day.

Rationale

Acute-phase aspirin therapy reduces the risk of early recurrent ischemic stroke. Long-term aspirin therapy reduces the risk of ischemic stroke, myocardial infarction, and vascular death. There are no data from randomized controlled trials to support the use of other antiplatelet regimes in acute stroke patients. In the National Institute of Neurological Disorders and Stroke r-tPA Stroke Study, antithrombotic drugs (including aspirin) were avoided until after the 24-hour post-thrombolysis scan had excluded intracranial hemorrhage. Aspirin therapy also reduces the risk of venous thromboembolism.

Best Practice Recommendation: Early Management of Acute Subarachnoid Hemorrhage

NOTES on This Recommendation

  • This recommendation is for patients with subarachnoid hemorrhage (SAH). It applies to the initial assessment in the emergency department within the first few hours of patient arrival.
  • Treatment and management of hemorrhagic stroke patients is outside the scope of these recommendations.
  • Symptoms include sudden onset of severe headache (sometimes described as "thunderclap headache") that patients will often characterize as the worst of their life. The headache of SAH is usually associated with nausea, vomiting, meningismus and photophobia and can also be associated with altered level of consciousness. Signs on physical examination vary depending on the location of the aneurysm and the extent of the hemorrhage as well as whether there is intraventricular of intracerebral extension of the subarachnoid hemorrhage. Physical signs can include diminished level of consciousness, cranial nerve palsy, hemiparesis and subhyaloid hemorrhage on funduscopic exam, but it is important to note that patients with acute SAH often have a NORMAL neurological examination, so the absence of physical findings should not alter the index of suspicion raised by the clinical presentation.

Patients with aneurysmal subarachnoid hemorrhage should be treated as a medical emergency and evaluated immediately by physicians with expertise in stroke management [Evidence Level B].

  1. Patients with suspected subarachnoid hemorrhage should have a non-contrast CT scan as soon as possible after hospital arrival to confirm the diagnosis [Evidence Level B].
  2. Patients with a strongly suggestive clinical history of subarachnoid hemorrhage, but negative non-contrast CT scan as reported by a radiologist, should undergo lumbar puncture for cerebrospinal fluid analysis. Xanthochromia evaluation may be more sensitive after a delay of 12 hours from symptom onset, but such a delay may not be practical or clinically appropriate [Evidence Level B].
  3. Cerebrospinal fluid analysis for xanthochromia by spectrophotometry is preferable to visual inspection, but is not routinely available in Canada [Evidence Level B].
  4. Patients with subarachnoid hemorrhage should undergo vascular imaging of the brain. High-quality noninvasive CT angiography may be preferable to catheter angiography as an initial investigation [Evidence Level B].
  5. Patients with subarachnoid hemorrhage should have an urgent consultation with a neurosurgeon [Evidence Level B].
  6. Patients with subarachnoid hemorrhage and negative non-invasive vascular imaging should be considered for further imaging with catheter angiography [Evidence Level C].
  7. Patients with aneurysmal subarachnoid hemorrhage and CT evidence of hydrocephalus that is clinically symptomatic should undergo urgent placement of an external ventricular drain or other cerebrospinal fluid diversion technique [Evidence Level B].
  8. Patients who present within 96 hours of a subarachnoid hemorrhage and have an adequate blood pressure should immediately be started on nimodipine 60 mg every four hours by mouth for 14 to 21 days [Evidence Level A].
  9. Patients with subarachnoid hemorrhage should have their blood pressure closely monitored and maintained as normotensive [Evidence Level B]. Treatment for high blood pressure should be initiated while the aneurysm is unsecured to reduce the risk of hypertension-induced rebleeding [Evidence Level B].
  10. Patients with an aneurysmal subarachnoid hemorrhage should have the aneurysm secured urgently by endovascular coiling or microsurgical clipping within 24 to 48 hours [Evidence Level B]. For patients with poor prognosis for neurological recovery, an initial course of supportive non-surgical management may be appropriate [Evidence Level B].
  11. For subarachnoid hemorrhage patients with intraparenchymal extension at the time the aneurysm is secured, urgent evacuation of the hematoma should be considered [Evidence Level C].
  12. Decisions regarding modality of treatment should be based on patient-specific characteristics, which include consideration of patient age, clinical grade, morphology of the aneurysm, medical co-morbidity and institutional experience and resources [Evidence Level B]. However, the International Subarachnoid Aneurysm Trial (ISAT), which studied subarachnoid hemorrhage patients who were technically eligible for either treatment, demonstrated that outcomes were better among those treated by endovascular methods than by microsurgery [Evidence Level A].
  13. Patients with aneurysmal subarachnoid hemorrhage should receive venous thromboembolism prophylaxis. [Evidence Level A]. Refer to the NGC summary of the CSN/HSFC guideline Acute Stroke Management for additional information.

Rationale

Subarachnoid hemorrhage is a common and often catastrophic neurosurgical emergency that is prevalent in approximately seven percent of adults with stroke, and also in children. Recent mortality rates in Canada for patients with subarachnoid hemorrhage are just over 40 percent within 30 days of the event, and account for prolonged hospital lengths of stay. Over the past decade, several advances have been made in early treatment of subarachnoid hemorrhage, including endovascular techniques. Prompt recognition and access to expert medical professionals may reduce mortality and morbidity and improve long-term outcomes.

Best Practice Recommendation: Early Management of Intracerebral Hemorrhage

NOTES on This Recommendation

  • This recommendation is for patients with intracerebral hemorrhage (ICH). It applies to the initial assessment in the emergency department within the first few hours of patient arrival.
  • Treatment and management of hemorrhagic stroke patients is outside the scope of these recommendations.

Patients with intracerebral hemorrhage must be treated as a medical emergency. Intracerebral hemorrhage should be promptly recognized and patients evaluated immediately by physicians with expertise in stroke management [Evidence Level A].

  1. Evaluation of patients with acute intracerebral hemorrhage should include questions about anticoagulant therapy, measurement of platelet count, PTT, and INR [Evidence Level A].
  2. Patients with suspected intracerebral hemorrhage should undergo a CT or MRI immediately to confirm diagnosis, location and extent of hemorrhage [Evidence Level A].
  3. Patients with acute intracerebral hemorrhage and an established coagulopathy or a history of anti-coagulant use should be treated appropriately to reverse the coagulopathy (prothrombin complex concentrate, vitamin K, or fresh-frozen plasma [Evidence Level B].
    1. If there is a persisting strong indication for anticoagulation (e.g., mechanical heart valve), the decision about when to restart anticoagulant therapy should be made on a case-by-case basis [Evidence Level C].
  1. Administration of recombinant Factor VIIa (NiaStase®) prevents hematoma growth, but increases the risk of arterial thromboembolic phenomena and does not provide a clinical benefit for survival or outcome. It is not recommended for routine use (FAST trial) (Diringer et al., 2010) [Evidence Level A].
  2. Patients with cerebellar hemorrhage should be referred for urgent neurosurgical consultation and consideration of evacuation of intracerebral hemorrhage particularly in the setting of altered level of consciousness or new cranial neuropathy [Evidence Level B].
  3. Patients with acute intracerebral hemorrhage should be considered for CT angiography or other imaging modality to exclude an underlying lesion such as an aneurysm, arteriovenous malformation, or tumour [Evidence Level B].
  4. Medically stable patients with an acute intracerebral hemorrhage should be admitted to a Stroke Unit or neuro-intensive care unit [Evidence Level B], and undergo interprofessional stroke team assessment to determine their rehabilitation and other care needs (refer to the NGC summary of the CSN/HSFC guideline Stroke Rehabilitation).
  5. No randomized trials provide specific targets for systolic or diastolic blood pressure in patients with intracerebral hemorrhage at the time of publication of these recommendations [Evidence Level C]. Randomized trials are ongoing.
  6. A majority of patients with acute supratentorial ICH will not require neurosurgical evacuation of the hemorrhage. However, selected patients with acute supratentorial ICH may be considered for surgical intervention including placement of extraventricular drain (EVD) for treatment of hydrocephalus, or craniotomy for evacuation of superficial lobar intracerebral hemorrhage [Evidence Level B] (Mendelow et al., 2005).
  7. Beyond the acutely symptomatic period, patients with intracerebral hemorrhage should be managed similarly to those with ischemic stroke, except for avoidance of antithrombotics [Evidence Level B].
  8. Intracerebral hemorrhage should not be considered an indication for statin therapy [Evidence Level A] (Amarenco et al., 2006). Continued use in patients previously on a statin for another appropriate indication should be reviewed following ICH because of a potential increased risk of recurrent hemorrhage. Currently, there is insufficient evidence to determine whether the potential increased risk of hemorrhage outweighs the potential benefits for prevention of ischemic cardiovascular disease in ICH survivors with other appropriate indications for statins (Huisa, Stemer, & Zivin, 2010).

Refer to the original guideline document for information on symptoms of intracerebral hemorrhage.

Rationale

Intracerebral hemorrhage is a life-threatening emergency and requires prompt recognition and action. Intracerebral hemorrhage commonly occurs in about 12 to 15 percent of all stroke patients admitted to Canadian hospitals, and is associated with high rates of early mortality – 25 to 50 percent in the first 30 days. Patients who survive an intracerebral hemorrhage are often left with moderate to severe persistent functional deficits which place a significant burden on families and the healthcare system.

Definitions:

Summary of Definitions for Levels of Evidence*

Grade Criteria
A Strong recommendation. Evidence from randomized controlled trials or meta-analyses of randomized controlled trials. Desirable effects clearly outweigh undesirable effects, or vice versa.
B Single randomized controlled trial or well-designed observational study with strong evidence; or well-designed cohort or case–control analytic study; or multiple time series or dramatic results of uncontrolled experiment. Desirable effects closely balanced with undesirable effects.
C At least one well-designed, nonexperimental descriptive study (e.g., comparative studies, correlation studies, case studies) or expert committee reports, opinions and/or experience of respected authorities, including consensus from development and/or reviewer groups.

*Based on Guyatt GH, Cook DJ, Jaeschke R, et al. Grades of recommendation for antithrombotic agents: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th edition). [published erratum in Chest 2008;34:47]. Chest 2008;133(6 Suppl):123S-131S.

Clinical Algorithm(s)

None provided

Evidence Supporting the Recommendations

References Supporting the Recommendations
Type of Evidence Supporting the Recommendations

The type of evidence is specifically stated for each recommendation (see the "Major Recommendations" field).

This document is the result of an extensive review of national and international stroke research and published evidence-based best practice recommendations or guidelines related to stroke.

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits
  • Timely initiation of secondary prevention medical therapy and carotid endarterectomy has been shown to significantly reduce the risk of major stroke after an initial transient ischemic attack or non-disabling stroke.
  • Optimizing out-of-hospital care improves patient outcomes.
  • Thrombolytic treatment can reduce the risk of disability and death, despite the risk of serious bleeding.
  • Acute-phase aspirin therapy reduces the risk of early recurrent ischemic stroke. Long-term aspirin therapy reduces the risk of ischemic stroke, myocardial infarction, and vascular death. Aspirin therapy also reduces the risk of venous thromboembolism.
  • Prompt recognition of subarachnoid hemorrhage and access to expert medical professionals may reduce mortality and morbidity and improve long-term outcomes.
Potential Harms
  • Excessive blood pressure lowering in stroke patients may be harmful, as demonstrated by several trials.
  • Antithrombotic drugs given soon after thrombolysis may increase the risk of death. Thrombolytic treatment carries the risk of serious bleeding.
  • Alteplase may cause intracranial hemorrhage.

Contraindications

Contraindications

Exclusion Criteria for Acute Thrombolytic Therapy

Historical

  • History of intracranial hemorrhage
  • Stroke or serious head or spinal trauma in the preceding three months
  • Recent major surgery
  • Arterial puncture at a non-compressible site in the previous seven days
  • Any other condition that could increase the risk of hemorrhage after alteplase administration

Clinical

  • Symptoms suggestive of subarachnoid hemorrhage
  • Stroke symptoms due to another non-ischemic acute neurological condition such as seizure with post-ictal Todd's paralysis or focal neurological signs due to severe hypo- or hyperglycemia
  • Hypertension refractory to antihypertensives such that target blood pressure <185/110 cannot be achieved 

Laboratory

  • Blood glucose concentration below 2.7 mmol/L or above 22.2 mmol/L
  • Elevated activated partial-thromboplastin time
  • International normalized ratio (INR) greater than 1.7
  • Platelet count below 100,000 per cubic millimetre

Computed Tomography (CT) or Magnetic Resonance Imaging (MRI) Findings

  • Any hemorrhage on brain CT or MRI
  • CT or MRI signs of acute hemispheric infarction involving more than one-third of the middle cerebral artery territory (Alberta Stroke Program Early CT Score [ASPECTS] <5)

Qualifying Statements

Qualifying Statements
  • The Canadian Stroke Strategy (CSS) recognizes that human, financial, and system resource limitations may make it difficult to implement all recommendations in this document. However, the recommendations and performance measures are presented as "gold standard" benchmarks toward which all organizations and systems should strive. Additionally, these recommendations can be valuable tools and information sources for anyone advocating for improved stroke care services.
  • The recommendations in this document are better seen as guidelines rather than rigid rules. They are not meant to supplant clinical judgment and consideration of unique patient circumstances.
  • Every attempt has been made to keep these recommendations up to date; however, given the rapid evolution of stroke research, late-breaking evidence may not be reflected. For this update, the literature review completion date was September 30, 2010.
  • It was not feasible to present the expert panel with all available evidence, and therefore the primary evidence was initially screened and evaluated by the task groups. Wherever possible, late-breaking evidence was reviewed by the task group leaders to identify areas where the current recommendations might be significantly altered.

Implementation of the Guideline

Description of Implementation Strategy

Networking and Distribution

The Canadian Stroke Strategy (CSS) makes the Canadian Best Practice Recommendations for Stroke Care available openly and at no cost, in English and French. Publication and dissemination strategies have changed in response to user needs and feedback. In 2006, printed documents and CDs were provided to all contacts in the CSS database, to others on request, and to interested groups throughout Canada and internationally. The 2008 Update was published through the Canadian Medical Association Journal (CMAJ) as a supplement to subscribers and posted on the CMAJ website with links to the document on the CSS website; the CSS provided a limited number of printed copies upon request. The 2010 Update is available on the Canadian Stroke Network (CSN) Best Practices web site, at www.strokebestpractices.ca External Web Site Policy.

Also on the website, patients and the general public can find A Patient's Guide to the Canadian Best Practice Recommendations for Stroke Care. The CSS created the patient's guide in recognition of the fact that the best practice recommendations are lengthy and written primarily for a healthcare audience.

The CSS encourages provincial or territorial and regional stroke strategies to adopt the Canadian Best Practice Recommendations for Stroke Care in their entirety. While the process and speed of implementation will vary depending on circumstances, the vision of offering integrated, high quality, and efficient stroke services to all Canadians should be shared and supported across the country.

The CSS disseminates the Canadian Best Practice Recommendations for Stroke Care by:

  • Posting the recommendations on the Canadian Stroke Network Best Practices website and other central guideline repository websites such as the World Stroke Organization website, the National Guideline Clearinghouse, the Internet Stroke Centre, and the Canadian Medical Association website
  • Writing feature articles for publications such as the Canadian Medical Association Journal and the Canadian Stroke Network Brainwaves newsletter
  • Alerting all contacts in the CSS database of Updates and how to access them
  • Encouraging others to set up electronic links to the recommendations (e.g., Canadian Stroke Network, Heart and Stroke Foundation of Canada, provincial stroke strategies)
  • Sharing details with all the CSS working groups to ensure alignment and collaboration in dissemination
  • Engaging provincial stroke champions through presentations and discussion
  • Consulting other national guideline groups in related fields (e.g., hypertension, dyslipidemia, diabetes)
  • Presenting at national, provincial, and regional meetings of healthcare professionals across healthcare disciplines and across the continuum of stroke care
  • Making presentations to front-line healthcare professionals at the local level and using local consensus processes to review and provide structured assessment of the enablers and barriers to guideline implementation, as well as innovative implementation strategies
  • E-mailing key stakeholders and front-line healthcare professionals working with persons with stroke and their families throughout the continuum of stroke care
  • Highlighting specific recommendations in stroke-related newsletters such as the National Stroke Nursing Council's newsletter
  • Disseminating the recommendations at international stroke meetings through the World Stroke Organization, the Guidelines International Network, and international partners and collaborators

The CSS encourages provincial or territorial and regional stroke strategy leaders to use these or other applicable approaches to further disseminate the recommendations and supporting tools to healthcare professionals, health system planners, decision-makers, and funders.

Tools to Support Implementation of the Best Practice Recommendations

The national professional development and training platform of the CSS focuses on developing and implementing an integrated professional development and training plan for stroke professionals who care for patients, families, and caregivers. Professional development and training activities are carried out by a sub-group of the Best Practices and Standards Working Group, using a three-pronged approach that encompasses pre-professional education, professional development, and systems change.

Several point-of-care tools have been developed and are available through the websites of the CSN at www.strokebestpractices.ca External Web Site Policy and the Heart and Stroke Foundation of Canada at www.heartandstroke.com External Web Site Policy. These tools address pre-hospital care, acute stroke care, stroke unit care, prevention, and long-term care (refer to Appendix 8 of the original guideline document for a list of professional development resources). The target audiences for each tool vary, but generally these tools are relevant to all interprofessional team members in a given setting.

See the original guideline document for System Implication Categories and Performance Measures Development.

Implementation Tools
Audit Criteria/Indicators
Foreign Language Translations
Patient Resources
Resources
Staff Training/Competency Material
Tool Kits
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
Living with Illness
Staying Healthy
IOM Domain
Effectiveness
Patient-centeredness
Timeliness

Identifying Information and Availability

Bibliographic Source(s)
Hyperacute stroke management. In: Lindsay MP, Gubitz G, Bayley M, Hill MD, Davies-Schinkel C, Singh S, Phillips S, Canadian Stroke Strategy Best Practices and Standards Writing Group. Canadian best practice recommendations for stroke care. Ottawa (ON): Canadian Stroke Network; 2010 Dec 8. p. 55-84.
Adaptation

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

Date Released
2008 (revised 2010 Dec 8)
Guideline Developer(s)
Canadian Stroke Network - Disease Specific Society
Heart and Stroke Foundation of Canada - Disease Specific Society
Source(s) of Funding

The development of these Canadian stroke care guidelines is funded in its entirety by the Canadian Stroke Strategy, a joint initiative of the Canadian Stroke Network and the Heart and Stroke Foundation of Canada. The Canadian Stroke Strategy is funded primarily by the Canadian Stroke Network, which is in turn funded by the Networks of Centres of Excellence program.

No funds for the development of these guidelines come from commercial interests, including pharmaceutical companies.

Guideline Committee

Canadian Stroke Strategy Best Practices and Standards Working Group

Composition of Group That Authored the Guideline

Working Group Members: Stephen Phillips (Co-Chair), Director, Acute Stroke Program, Queen Elizabeth II Health Sciences Centre, Nova Scotia; Mark Bayley (Co-Chair), Physiatrist and Medical Director, Neuro Rehabilitation Program, Toronto Rehabilitation Institute, Ontario; Gord Gubitz, Lead, 2010 Best Practices Update; Neurologist, Acute Stroke Unit and Outpatient Neurovascular Clinic, Queen Elizabeth II Health Sciences Centre, Nova Scotia; Laurie Cameron, Program Coordinator & Executive Assistant, Canadian Stroke Strategy; Corrine Davies-Schinkel, Project Coordinator, Canadian Stroke Network; Michelle Edwards, Occupational Therapist, Foothills Medical Centre, Alberta; Ian Graham, Vice-President, Knowledge Translation, Canadian Institutes of Health Research; Mary Elizabeth Harriman, Associate Executive Director, Heart and Stroke Foundation of Canada; Anthony Herd, CAEP Representative, Emergency Physician, Winnipeg Regional Health Authority, Manitoba; Linda Kelloway, Best Practices Lead, Ontario Stroke Network, Ontario; Katie Lafferty, Executive Director, Canadian Stroke Network; Louise-Hélène LeBrun, Directeur du Centre des maladies vasculairescérébrales du CHUM, Centre Hospitalier de l'Université de Montréal (CHUM), Quebec; Patrice Lindsay, Staff Lead, Director of Performance and Standards, Canadian Stroke Network; Samantha Singh, Project Coordinator, Canadian Stroke Network; Elizabeth Woodbury, Executive Director, Canadian Stroke Strategy

Financial Disclosures/Conflicts of Interest

Participants in the development and review process are required to sign confidentiality agreements and to declare all potential conflicts of interest in writing. Only seven out of 143 participants declared a minor conflict such as receipt of honoraria to speak about stroke in other venues. None of these conflicts were deemed to prevent unbiased participation in the process. The recommendations were approved following a rigorous development process and through a consensus of independent experts and stakeholders, thereby minimizing the potential influence of any one participant. See Appendices 1, 2, 3, and 4 in the original guideline document for complete statements of competing interests.

Guideline Status

This is the current release of the guideline.

This guideline updates a previous version: Lindsay P, Bayley M, Hellings C, Hill M, Woodbury E, Phillips S. Canadian best practice recommendations for stroke care. CMAJ 2008 Dec 2;179(12 Suppl).

The Canadian Best Practice Recommendations for Stroke Care include an ongoing plan to formally update the recommendations every 2 years to ensure that the best practice recommendations remain current and are coordinated with other similar initiatives nationally and internationally.

Guideline Availability

Electronic copies: Available in Portable Document Format (PDF) in English External Web Site Policy and French External Web Site Policy from the Canadian Stroke Network Web site.

Availability of Companion Documents

The following are available:

  • Canadian Best Practice Recommendations for Stroke Care: 2008 toolkit. Available in English and French from the Heart & Stroke Foundation of Ontario Web site External Web Site Policy.
  • Secondary prevention best practice workshop tool kit: preventing strokes one at a time. Available from the Heart & Stroke Foundation of Ontario Web site External Web Site Policy.
  • Acute stroke management workshop. Available in English and French from the Heart & Stroke Foundation of Ontario Web site External Web Site Policy.
  • Canadian Best Practice Recommendations for Stroke Care: educational workshop for emergency medical care of suspected acute care patients. Available in Portable Document Format (PDF) in English External Web Site Policy and French External Web Site Policy from the Canadian Stroke Network Web site.
  • Canadian Stroke Strategy performance measurement manual: a supplement to the Canadian best practice recommendations for stroke care. 2008 May. 48 p. Electronic copies: Available in PDF in English External Web Site Policy and French External Web Site Policy from the Canadian Stroke Network Web site.
  • Canadian Stroke Strategy core performance indicator update 2010. 2010 Jun. 8 p. Electronic copies: Available in PDF in English External Web Site Policy and French External Web Site Policy from the Canadian Stroke Network Web site.
  • A guide to the implementation of stroke unit care. A resource for implementation of Canadian Best Practice Recommendations for Stroke Care. 2009 Dec. 24 p. Available in PDF in English External Web Site Policy and French External Web Site Policy from the Canadian Stroke Network Web site.

Additional resources are available in English External Web Site Policy and French External Web Site Policy from the Canadian Stroke Network Best Practices Web site.

Patient Resources

The following are available:

  • A patient's guide to Canadian best practice recommendations for stroke care. 2011. 8 p. Electronic copies: Available in Portable Document Format (PDF) in English External Web Site Policy and French External Web Site Policy from the Canadian Stroke Network Best Practices Web site.
  • Getting on with the rest of your life after stroke: a guide for patients and their families. 68 p. Electronic copies: Available in PDF in English External Web Site Policy and French External Web Site Policy from the Canadian Stroke Network Web site.
  • A family guide to pediatric stroke. 2011. 34 p. Electronic copies: Available in Portable Document Format (PDF) in English External Web Site Policy and French External Web Site Policy from the Canadian Stroke Network Best Practices Web site.

Additionally, a variety of patient information resources, including a list of stroke warning signs, is available from the Heart & Stroke Foundation of Canada Web site External Web Site Policy.

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 December 11, 2009. This summary was updated by ECRI Institute on May 17, 2010 following the U.S. Food and Drug Administration advisory on Plavix (clopidogrel). This NGC summary was updated by ECRI Institute on December 1, 2011. The updated information was verified by the guideline developer on January 9, 2012. This summary was updated by ECRI Institute on April 13, 2012 following the U.S. Food and Drug Administration advisories on Statin Drugs and Statins and HIV or Hepatitis C drugs. This summary was updated by ECRI Institute on March 10, 2014 following the U.S. Food and Drug Administration advisory on Low Molecular Weight Heparins.

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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