The Acute Stroke Management module provides guidance to healthcare providers caring for people who present to the healthcare system with current or very recent symptoms of acute stroke or transient ischemic attack (TIA). This module also addresses the issue of public and healthcare provider’s recognition of the signs of stroke and immediate actions to take, including contacting emergency medical services, arriving at a stroke – enabled emergency department, and launching local healthcare institution code stroke protocols. It represents care at the outset and in the middle of the stroke continuum (Figure 1). Stroke patients may move back and forth between different stages of care as their healthcare needs and situation changes.
With each update edition of the Canadian Stroke Best Practice modules, the most current evidence on the included topics are reviewed by the writing group members and internal and external reviewers. Recommendations from the previous edition may be continued unchanged, modified to reflect updated evidence (either wording or evidence levels), or removed. New recommendations may be added to address emerging evidence and practice changes.
- For the Sixth Edition, the module on Prehospital and Emergency Department Stroke Care, and the module on Acute Inpatient Stroke Care have been combined into one comprehensive Acute Stroke Management: Prehospital, Emergency Department and Inpatient Stroke Care Module.
- Sections addressing hemorrhagic stroke in previous editions of the Prehospital and Emergency Stroke Care module have been removed and will be included in a dedicated hemorrhagic stroke module, to be released in the fall of 2018.
- Note, a stroke cannot be classified as ischemic or hemorrhagic until initial braining imaging has been completed, therefore Sections 1 – 4 in the Prehospital and Emergency Department Stroke Care module apply to all patients with stroke signs and symptoms.
The following list highlights more notable changes for this 6th edition of the Prehospital and Emergency Stroke Care module:
- The sections on emergency management of intracerebral hemorrhage and subarachnoid hemorrhage have been removed from this module. A new module will be released in late 2018 that focus on assessment, diagnosis and management of hemorrhagic stroke across the continuum of care.
- Revisions to the recommendations for the triage and assessment of risk of recurrent stroke after TIA/minor stroke and suggested urgency levels for investigations and initiation of management strategies (Section 2);
- For Emergency Medical Services, a two-step screening has been recommended for paramedics: first to determine presence of stroke signs and symptoms, then a second screen for severity of presenting symptoms using validated scales (Section 3);
- The management of blood pressure in the first hours following stroke has been updated to address recent evidence (Section 4);
- Updates and clarity for recommendations have been made with respect to initial imaging in the emergency department – all imaging recommendations have now been consolidated into Section 4;
- New clinical considerations for treating a highly selected group of people with stroke of unknown time of onset with presentation beyond the 4.5 hour time window which incorporates findings from WAKE-UP (Thomalla et al, 2018) (Section 5.1);
- Updates to endovascular thrombectomy treatment recommendations and time windows based on emerging evidence have been completed (Section 5.5);
- Revised section on acute antiplatelet therapy with new and updated recommendations for dual antiplatelet therapy for a limited duration after acute minor ischemic stroke and TIA incorporating the findings from POINT (Johnston et al, 2018) (Section 6).
The following list highlights more notable changes for this 6th edition of the Acute Inpatient Stroke Care module:
- All recommendations related to intracerebral hemorrhage and subarachnoid hemorrhage have been removed, and will be included in a new module dedicated to hemorrhagic stroke (for release Fall 2018);
- Revisions to recommendations for care of patients experiencing stroke while already in hospital for other causes (Section 8);
- Updates to early mobilization recommendations based on newer evidence from the AVERT trials sub-analyses and cohort studies (Section 9);
- Moderate revisions to advanced care planning and palliative and end-of-life care recommendations (Sections 10 and 11 respectively).
- Writing Group Members and External Reviewers, Declaration of Conflicts of Interest
- Definitions for Acute Stroke Management
- Figure 1: Stroke Continuum of Care, 2018
Prehospital and Emergency Department Stroke Care Recommendations
- Section 1 – Stroke Awareness, Recognition and Response
- Section 2 – Outpatient Management of Transient Ischemic Attack and Non-Disabling Stroke
- Section 3 – Emergency Medical Services (EMS) Management of Acute Stroke Patients
- Section 4 – Emergency Department Evaluation and Management of Patients with TIA and Acute Stroke
- Box 4a: Alteplase Selection Imaging Exclusion Criteria: CT Findings
- Box 4B: Endovascular Selection Imaging Criteria for Patients Arriving within 6 Hours of Stroke Onset
- Box 4C: Advanced CT Imaging Criteria for Endovascular Thrombectomy Selection
- Box 4D: Endovascular Selection Imaging Criteria for Patients Arriving Later than 6 Hours of Stroke Onset
- Evidence Table and Reference List
- Section 5 – Acute Ischemic Stroke Treatment
- Refer to Box 5A for Criteria for Stroke Centres Providing Acute Ischemic Stroke Treatment
- Refer to Box 5B for inclusion and exclusion criteria for intravenous alteplase eligibility.
- Refer to Box 5C for Inclusion Criteria for endovascular therapy.
- Evidence Table A and Reference List
- Evidence Table B and Reference List
- Section 6 – Acute Antiplatelet Therapy
- Section 7 – Early Management of Patients Considered for Hemicraniectomy
- Section 8 – Acute Stroke Unit Care
- Section 9 – Inpatient Prevention and Management of Complications following Stroke
- Section 10 – Advanced Care Planning
- Section 11 – Palliative and End of Life Care
- Appendix Two
- Appendix Three – Screening and Assessment Tools for Acute Stroke Severity
- Appendix Four – Selection of Validated Swallow Screening and Assessment Tools
Boulanger JM (First Author), Lindsay MP (Corresponding Author), Stotts G, Gubitz, G, Smith EE, Foley N, Bhogal S, Boyle K, Braun L, Goddard T, Heran MKS, Kanya-Forster N, Lang E, Lavoie P, McClelland M, O’Kelly C, Pageau P, Pettersen J, Purvis H, Shamy M, Tampieri D, vanAdel B, Verbeek R, Blacquiere D, Casaubon L, Ferguson D, Hegedus J, Jacquin GJ, Kelly M, Linkewich B, Mann B, Milot G, Newcommon N, Poirier P, Simpkin W, Snieder E, Trivedi A, Whelan R, Smitko, E, Butcher K (Senior Author). On behalf of the on Behalf of the Acute Stroke Management Best Practice Writing Group, and the Canadian Stroke Best Practices and Quality Advisory Committees; in collaboration with the Canadian Stroke Consortium and the Canadian Association of Emergency Physicians. In Lindsay MP, Gubitz G, Dowlatshahi D, Harrison E, and Smith EE (Editors) on behalf of the Canadian Stroke Best Practices Advisory and Quality Committees. Canadian Stroke Best Practice Recommendations, 2018; Ottawa, Ontario Canada: Heart and Stroke FoundationComments
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 firstname.lastname@example.org.