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These National Clinical Guidelines for stroke cover the management of patients with acute stroke and the secondary prevention of stroke. Primary prevention of stroke, rehabilitation and subarachnoid hemorrhage are excluded from the scope of these guidelines. These guidelines cover the management of stroke in adults (over 18 years) from onset to chronic care and focus on patients with a new clinical event (first stroke or recurrent stroke).
The primary goal of the guidelines is to continuously improve the quality of care in patients with stroke nationally. Our intention is closing the gap between best practice and actual practice.
The objective of the guidelines is to provide clinicians and administrators with explicit statements, where evidence is available, on the best way to manage specific problems. Local health service facilities (e.g. hospitals, nursing homes, etc.) will need to add detail.
The guidelines are directed primarily at practising clinicians involved in management of patients with stroke. Their aim is to help clinicians, at any level – primary, secondary or tertiary - to make the best decisions for each patient, using the evidence currently available. The focus is on the more common clinical questions faced in day-to-day practice. The guidelines may be used by all health professionals or health care planners involved in the management of the patients with stroke.
The secondary objectives of the guidelines are to identify areas where gaps in knowledge or lack of evidence exist and to stimulate research in each area.
The guidelines are concerned with the management of patients who present with a new clinical event that might be stroke. Stroke in this context is defined as ‘a clinical syndrome characterized by rapidly developing signs and symptoms of focal or at times global loss (as in subarachnoid hemorrhage or brain stem involvement) of cerebral brain functions, lasting more than 24 hours or leading to death, with no apparent cause other than of vascular origin.’
While appraisal of evidence forms the basis of the development of these guidelines, we wish to clarify some points:
The working group is aware of recent developments in evaluating levels of evidence and strength of recommendations, and also that the GRADE methodology has been adopted by more than 25 organizations around the world including the WHO. The group endorses the use of GRADE methodology (Guyatt and Oxman) for this purpose and will incorporate this in the next version of the guidelines.
These guidelines should be taken as statements to inform the clinician, not as rigid rules. Practitioners may need to deviate from the guidelines in individual cases but such deviations should be justifiable and justified.
The guidelines may be used to inform decisions on standards of good practice and are likely to be used for audit of stroke services. Before the guidelines are used as ‘standards’, it is important to ensure that the relevance and appropriateness of the guidelines are discussed in the context proposed.
These guidelines do not cover specific management of associated illnesses like diabetes mellitus, cardiac problems and others as these may addressed by guidelines from related organizations or are generally expected from a physician.
Stroke care may be organized at three levels - a basic stroke care facility, a primary stroke care facility and a comprehensive stroke care facility. The basic stroke care facility should be the minimum setup at district hospitals; primary stroke care facility should be mandatory for all medical colleges and multispeciality hospitals; and well-equipped hospitals including some medical colleges should develop comprehensive stroke care facilities. The basic stroke facility may not have artificial ventilators, echocardiography and carotid Doppler facility, primary stroke care facilities may have these facilities but not neurosurgery, MRI or angiography. Comprehensive stroke care facilities should have all these facilities.
Emergency medical services (EMS) should be developed and upgraded for stroke care at the hospital or district level to include transport and triage of patients from peripheral medical centers.
Evidence: Albers, Alberts, Audebert, Calvet, Evans, Intercollegiate Stroke Working Party, Katzan, Koton, LaMonte, Prabhakaran, Purroy, Ronning, Silva, Stavem, Stroke Unit Trialists’ Collaboration.
Most patients with stroke should be admitted to a hospital because their neurological condition may worsen over the first few days, they may develop non-neurological complications (e.g., aspiration pneumonia), and urgent investigations (like CT scan) may be required.
Patients with acute stroke (onset within last 72 hours or altered consciousness due to stroke) should be admitted to hospital for initial care and assessment. Circumstances where a physician might reasonably choose not to admit selected patients with stroke include the following:
The aims of emergent evaluation are to:
Brain imaging should be performed immediately for patients with persistent neurological symptoms if any of the following apply:
Patients with acute stroke without the above indications for immediate brain imaging, scanning should be performed within 24 hours after onset of symptoms.
All patients with disabling acute ischemic stroke who can be treated within 3 hours (4.5 hours as soon as approved by the Drug Controlling authority) after symptom onset should be evaluated without delay to determine their eligibility for treatment with intravenous tissue plasminogen activator (alteplase).
Surgery for ischaemic stroke
Patients with middle cerebral artery (MCA) infarction who meet all of the criteria below should be considered for decompressive hemicraniectomy and operated within a maximum of 48 hours:
Patients with large cerebellar infarct causing compression of brainstem and altered consciousness should be surgically managed with suboccipital craniectomy.
Symptomatic hydrocephalus should be treated surgically with ventriculostomy.
Until more data are available
This includes measures to reduce the risk of recurrence of stroke in patients who have had TIA or stroke. These guidelines apply to vast majority of patients with TIA or stroke, although some of the recommendations may not be appropriate for those with unusual causes of stroke, like trauma, infections, etc.
Every patient should be evaluated for modifiable risk factors within one week of onset. This includes:
In any patient where no risk factor is found, consideration for investigating for rare causes may be given. The investigations may include anti-phospholipid antibodies, protein C,S and anti-thrombin III.
Source of Support: Nil
Conflict of Interest: None declared.