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Hyperacute

5th Edition
2015 UPDATE June 2015
 

Working Together with Stroke Survivors and their Caregivers to Achieve Optimal Outcomes is imperative across the system of care, with the participation of individuals with stroke, their families and caregivers, healthcare providers, and the broader community. The primary underpinnings of ‘hyperacute stroke care’ are to RECOGNIZE and MOBILIZE. This starts with recognition of stroke symptoms by patients, families and bystanders. The Heart and Stroke Foundation has launched a new signs of stroke campaign in 2014 that uses the FAST mnemonic (FACE, ARM, SPEECH, TIME) aiming to increase recognition of the signs of stroke and take appropriate action immediately. Mobilization has to occur without delay, from emergency medical services response to a potential new stroke patient, transport to hospitals with specialized stroke services, rapid access to neuroimaging, stroke specialists and time-sensitive treatments, such as acute thrombolysis and endovascular therapy. A coordinated and seamless system taking all these components into account will minimize the time from stroke symptom onset (time last known well) to arrival at a hospital providing specialized stroke diagnostic and intervention services and lead to better outcomes.

Working Together for hyperacute care requires all healthcare professionals involved in this phase to have specialized stroke training, develop knowledge and skills for competent and efficient care delivery, and function as an integrated and seamless team. The hyperacute stroke team involves a range of providers from both the community and several hospital departments. Key team members during the hyperacute phase include primary care when patients with symptoms initially present to a community physician or nurse practitioner, emergency medical service professionals including paramedics and dispatch staff, emergency department physicians and nurses, stroke neurologists, diagnostic imaging, laboratory services, pharmacists, intensive care specialists, neuroradiologists, neurosurgeons and social workers. Several other specialists may be required in the hyperacute phase to meet the needs of individual patients and their unique clinical presentations. Communication among these professionals and departments are paramount to coordinated hyperacute care, and protocols and agreements should be in place for high priority rapid access to all specialists, departments and services required for each stroke patient to \achieve response time targets, optimize outcomes and meet patient and family needs in the immediate post stroke time frame.

Recent reports on the quality of stroke services across Canada have shown that half of stroke patients take almost six hours after symptom onset to arrive at hospital, and more than one third of patients are not getting access to a CT scan within the first hours of arriving at hospital, both of which place them well outside the 4 ½-hour window to benefit from intravenous tPA. Less than one third of hospitals that have CT scanners also provide specialized stroke services including acute thrombolysis. New evidence for endovascular therapy has emerged and has significant impact on patient outcomes including mortality and disability. For these new therapies to be effective, seamless systems of care need to be in place that includes coordinated teams with seamless work flows, innovative imaging and novel technology. These therapies benefit people up to six hours from stroke onset, and in selected cases can be administered up to twelve hours. Telemedicine technology which can be used to link healthcare sites is being underutilized for stroke. Working Together in hyperacute stroke care going forward aims to improve performance in these areas and thereby improve outcomes and reduces morbidity and long-term disability for all stroke patients.

Notable Changes in the Hyperacute Stroke Care 2015 Update

The 2015 update of the Canadian Stroke Best Practice Recommendations Hyperacute Stroke Care module reinforces the growing and changing body of research evidence available to guide assessment, diagnosis and management in the first hours following a stroke. A coordinated and integrated approach to hyperacute stroke care is emphasized throughout this module.

Highlights of the moderate and significant updates as well as new additions to the Hyperacute Stroke Care module recommendations for 2015 include:

  • new recommendations on endovascular thrombectomy based on the findings of five major clinical trials released in early 2015
  • enhanced recommendations on neurovascular imaging and consideration of completing imaging of intra and extracranial vessels using CT angiography at the time of the initial neuroimaging;
  • strong emphasis on educating the public to call 911 or local emergency number to access paramedic services for on-site assessment, management and transport to appropriate facilities providing advanced stroke services;
  • further enhancements on the critical role paramedics and emergency medical services dispatch personnel play in all aspects of pre-hospital stroke care and communication with receiving hospital during transport;
  • call for regional stroke systems to be updated to ensure seamless access to neurointerventional specialists for appropriate patients in specialized stroke centres;
  • need for essential coordination among all hospital departments and services involved in hyperacute care to reduce process delays to acute stroke treatments, and ensure appropriate specialized post-hyperacute care in stroke units;
  • extending the time windows for acute stroke interventions up to 6 hours endovascular therapies for patients with large vessel occlusions;
  • inclusion of recommendations and evidence on tPA administration to women with stroke during pregnancy;
  • new recommendations on the management of seizures in the hyperacute phase of care;
  • update on the management of blood pressure in the hyperacute phase of care for ischemic stroke, subarachnoid hemorrhage and Intracerebral hemorrhage.

Guideline Development Methodology

The detailed methodology and explanations for each of these steps in the development and dissemination of the Canadian Stroke Best Practice Recommendations is available in the Canadian Stroke Best Practice Recommendations Overview and Methodology manual available on the Canadian stroke best practices website at http://www.strokebestpractices.ca/wp-content/uploads/2014/08/CSBPR2014_Overview_Methodology_ENG.pdf

A unique situation presented itself as we worked through the final stages of review for these hyperacute stroke recommendations. The results of four randomized clinical trials investigating the use of endovascular therapy for large ischemic stroke were released simultaneously in February 2015, and a fifth trial in April 2015. These clinical trials all had similar positive findings, resulting in strong evidence to support the use of endovascular thrombectomy for people experiencing large vessel ischemic stroke. An additional multi-step guideline development cycle was undertaken to be able to confidently include recommendations related to endovascular treatment in this edition of the Canadian hyperacute stroke guidelines. A subgroup of the hyperacute writing group was convened along with the ESCAPE trial investigators and several physician members of the Canadian Stroke Best Practices advisory committee. This group thoroughly reviewed and discussed the recent endovascular trials, and compared and contrasted differences in methodology, clinical process steps and patient outcomes. A draft set of recommendations were developed that impacted sections 2 (emergency medical system management of stroke), section 3 (emergency department initial assessment and treatment), and section 4 (acute ischemic stroke therapies). The group went through eight rounds of review to achieve a final first draft. This draft was then sent to the whole original hyperacute stroke writing group for review and input. It was also sent to the investigators of all four trials to ensure the recommendations reflect accurate interpretation of their individual trial findings, and to seek their input on the wording of the recommendations. All feedback was reviewed and a final draft resulted. The final draft was then sent to the external international reviewers for this module. All feedback was considered and final edits were made based on consensus between the writing group and the advisory committee, as is our normal process.

Citing the Hyperacute Stroke Care 2014 Module

Casaubon LK, Boulanger JM, on behalf of the Hyperacute and Acute Stroke Writing Group. Hyperacute Stroke Care Module 2015. In Lindsay MP, Gubitz G, Bayley M, and Smith EE (Editors) on behalf of the Canadian Stroke Best Practices and Advisory Committee. Canadian Stroke Best Practice Recommendations, 2015; Ottawa, Ontario Canada: Heart and Stroke Foundation.

Comments

We invite comments, suggestions, and inquiries on the development and application of the Canadian Stroke Best Practice Recommendations.

Please forward comments to the Heart and Stroke Foundation’s Stroke Team at strokebestpractices@hsf.ca.

Hyperacute Stroke Care Module Contents: