New release for Canadian Stroke Best Practice Recommendations

 

An important update and a new consensus statement have been released for the Heart & Stroke Canadian Stroke Best Practice Recommendations (CSBPR). Acute Stroke Management: Prehospital, Emergency Department, and Acute Inpatient Stroke Care as well as a new consensus statement on Acute Stroke Management during Pregnancy are now available.

The CSBPR for Acute Stroke Management address the first hours and days after stroke occurs, starting with the onset of stroke signs and symptoms through to discharge from the emergency department or acute inpatient care. This module combines what was formerly two separate modules on hyperacute stroke care and acute inpatient stroke care, and contains several significant changes based on recent emerging research evidence. The acute stroke management writing group chairs are Jean-Martin Boulanger (First author) and Kenneth Butcher (Senior Author).

The acute stroke management recommendations set the bar for early recognition and intervention of acute stroke which can lead to decreased mortality and increased quality of life for people experiencing stroke. People who experience a stroke in Canada still take too long to recognize the signs and get to a hospital where they can be treated. In fact 40% of people in Canada still do not know any of the FAST signs of stroke, and a significant number of healthcare providers also lack awareness.

Based on recently published clinical trials, the window for a highly selected group of patients with large ischemic strokes to receive endovascular thrombectomy has been increased to up to 24 hours after last known to be well. Increasing timely access to endovascular thrombectomy will require an expanded role for paramedics, to ensure that patients with large vessel occlusion are recognized early and triaged to thrombectomy-capable hospitals. There will also be an expanded role for advanced imaging for patient selection for later arriving patients. This will require stroke systems to adapt to meet these targets and the increased demand for acute stroke services.

New clinical considerations have been added for acute intravenous thrombolysis treatments for a highly selected group of people with stroke of unknown time of onset with lapse time (the time between when someone was last seen normal to the when they were seen experiencing symptoms or they woke up) beyond the 4.5 hour time window. 

Prevention of recurring stroke is an important priority following an acute ischemic stroke or transient ischemic attack. New recommendations have been developed for use of dual antiplatelet therapy during the initial post-stroke period, based on recently released clinical trial results.

Sections addressing hemorrhagic stroke after the point of diagnosis have been removed and will be included in a dedicated hemorrhagic stroke module, to be released in the fall of 2018.

A new consensus statement on acute stroke management during pregnancy is the second of a two-part series on stroke in pregnancy (part one focused on prevention of recurrent stroke in pregnancy) and the first of its kind. It addresses stroke during pregnancy or in the postpartum period (generally including the first 12 weeks post-delivery), which is a devastating event for new parents and their families. Noor Ladhani and Richard Swartz chair the stroke in pregnancy writing group.

When a stroke occurs in pregnancy, a standardized approach to coordinated care is essential for investigation, diagnosis, and intervention planning. The goal is to maximize maternal and fetal wellbeing, while considering multiple competing etiologies and ensuring interdisciplinary perspectives, while time is of the essence. Factors to consider include the timing of stroke within the pregnancy, stroke severity, expected maternal outcomes, and the known or theoretical impact of decisions and interventions on the fetus.

Whenever possible, the same decisions for acute treatment and management should be considered for a woman who is pregnant. Maternal health should be the priority and delays or deferral of critical steps in diagnosis and life-saving care due to pregnancy should be minimized.

Revised CSBPR for Acute Stroke Management and the consensus statement on Acute Stroke Management during Pregnancy have been published in the International Journal of Stroke and are part of the sixth edition of the Heart & Stroke Canadian Stroke Best Practice Recommendations.

Click here to access the methodology on the CSPBR website.

As part of this update to Acute Stroke Management, a new training video has been produced using the Canadian Neurological Scale. The link has been added to our webinar series pages in the Resources section of the SBP website. All supporting materials for both the acute stroke module and the acute stroke in pregnancy consensus statement including implementation resources and performance measures are available at www.strokebestpractices.ca.

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