Stroke management: updated recommendations for treatment along the care continuum

Authors


  • Funding: The Clinical Guidelines for Stroke Management 2010 were funded by the Department of Health and Ageing, Australian Government, Canberra.

  • Conflict of interest: None.

Leah Wright, Guidelines Program, National Stroke Foundation, Level 7, 461 Bourke Street, Melbourne, Vic. 3000, Australia. Email: lwright@strokefoundation.com.au

Abstract

The Australian Clinical Guidelines for Stroke Management 2010 represents an update of the Clinical Guidelines for Stroke Rehabilitation and Recovery (2005) and the Clinical Guidelines for Acute Stroke Management (2007). For the first time, they cover the whole spectrum of stroke, from public awareness and prehospital response to stroke unit and stroke management strategies, acute treatment, secondary prevention, rehabilitation and community care. The guidelines also include recommendations on transient ischaemic attack. The most significant changes to previous guideline recommendations include the extension of the stroke thrombolysis window from 3 to 4.5 h and the change from positive to negative recommendations for the use of thigh-length antithrombotic stockings for deep venous thrombosis prevention and the routine use of prolonged positioning for contracture management.

There are approximately 60 000 first ever or recurrent strokes in Australia every year. Nine in 10 people who have a stroke are admitted to hospital.1 There is now good evidence that coordinated, multidisciplinary care for stroke reduces death and disability.2 To promote consistent, evidence-based care, the Clinical Guidelines for Stroke Rehabilitation and Recovery (2005) and the Clinical Guidelines for Acute Stroke Management (2007) were developed. Recognising the need for acute and rehabilitative care for stroke to be synchronous and the rapid accumulation of new evidence, the National Stroke Foundation (NSF) has overseen the review and consolidation of the two guidelines. This position statement provides a summary of the updated national clinical guidelines for adults with stroke or transient ischaemic attack (TIA).

Development of the Clinical Guidelines for Stroke Management

The Clinical Guidelines for Stroke Management 20103 were developed by the NSF according to processes prescribed by the National Health and Medical Research Council (NHMRC)4 under the direction of an interdisciplinary Expert Working Group (EWG). Grading of each recommendation is included using the NHMRC grading system (Table 1). The full guidelines and related resources can be downloaded from the NSF website (http://www.strokefoundation.com.au/clinical-guidelines).

Table 1.  Grading of recommendations
Grade of recommendationDescription
ABody of evidence can be trusted to guide practice
BBody of evidence can be trusted to guide practice in most situations
CBody of evidence provides some support for recommendation(s), but care should be taken in its application
DBody of evidence is weak, and recommendation must be applied with caution
Good practice point (GPP)Recommended best practice based on clinical experience and expert opinion

Organisation of stroke services

Improving care in the first 24 h after stroke is critical in reducing the damage to the brain and to minimise the effects of stroke.3 Eighty per cent of Australian patients arrive in the emergency department (ED) by ambulance3 so it is of concern that only one in five hospitals reported arrangements with local ambulance services to preferentially transport suspected stroke patients to dedicated centres or to notify the hospital of a stroke admission in advance.5

Stroke unit care for all people with stroke remains the most important recommendation of these guidelines.2 There is overwhelming evidence that hospital-based stroke unit care (organised, active, evidence-based care provided by dedicated staff within a defined geographical area) significantly reduces death and disability by approximately 20% compared with conventional care in general wards. There are now 74 stroke units in Australia, but despite an increase in the number of stroke units in Australian hospitals since 2007, only 39% of patients with acute stroke receive stroke unit care.5

Organised stroke unit care is most effective when the focus of care includes active rehabilitation,2 and there is growing evidence that rehabilitation should commence in the acute setting as early as possible.6,7

Early supported discharge (ESD), including appropriate community rehabilitation services, has been found to reduce inpatient length of stay and adverse events (e.g. readmission rates) while increasing the likelihood of stroke survivors living independently at home.8,9 Despite this evidence, the availability of stroke-specific ESD services in Australia is limited.5

Key recommendations for organisation of stroke services are listed in Table 2.

Table 2.  Organisation of services recommendations
RecommendationGrade
  1. ED, emergency department; GPP, good practice point.

2.1 Hyperacute care 
 Local protocols developed jointly by staff from prehospital emergency service; the hospital ED and the acute stroke team should be used for all people with suspected stroke. Such protocols should include systems to receive early notification by paramedic staff, high-priority transportation and triage, rapid referrals from ED staff to stroke specialists and rapid access to imaging.Grade C
2.2 Hospital care 
 2.2.1 Stroke unit care 
 a) All people with stroke should be admitted to hospital and be treated in a stroke unit with a multidisciplinary team.Grade A
 b) All people with stroke should be admitted directly to a stroke unit (preferably within 3 h of stroke onset).Grade C
 c) Smaller hospitals should consider stroke services that adhere as closely as possible to the criteria for stroke unit care. Where possible, patients should receive care on geographically discrete units.Grade B
 d) If people with suspected stroke present to non-stroke unit hospitals, transfer protocols should be developed and used to guide urgent transfers to the nearest stroke unit hospital.Grade C
2.4 Care after hospital discharge 
 2.4.1 Community rehabilitation and follow-up services 
 a) Health services with a stroke unit should provide comprehensive, experienced multidisciplinary community rehabilitation and adequately resourced support services for stroke survivors and their families/carers. If services such as the multidisciplinary community rehabilitation services and carer support services are available, then early supported discharge should be offered for all stroke patients with mild-to-moderate disability.Grade A
 b) Rehabilitation delivered in the home setting should be offered to all stroke survivors, as needed. Where home rehabilitation is unavailable, patients requiring rehabilitation should receive centre-based care.Grade B
 c) Stroke survivors should have regular and ongoing review by a member of a stroke team, including at least one specialist medical review. The first review should occur within 3 months, then again at 6 and 12 months postdischarge.GPP

Early assessment and diagnosis

As with stroke, the diagnosis of TIA is based on careful clinical history and examination. Rapid expert assessment and management have been shown to reduce rates of subsequent stroke.10 Several studies11–13 have questioned the utility of risk stratification tools, such as the ABCD2 score, in predicting stroke risk following a TIA. One systematic review that included 20 validation studies, 9808 subjects and 456 strokes at 7 days, found the predictive value of the ABCD2 tool to be modest but clinically useful.14 However, the ABCD2 score is not intended to be a substitute for clinical judgment and identification of other important indications of risk, particularly the presence of atrial fibrillation (AF) or carotid territory symptoms (e.g. isolated aphasia, motor weakness with hemianopia, isolated distal arm weakness). If carotid disease is suspected, urgent carotid duplex scanning or other methods (e.g. contrast-enhanced magnetic resonance angiography or computerised tomography (CT) angiography) should be performed. The risk of subsequent stroke after TIA or minor stroke is lower for patients treated in services that provide emergency intervention (blood pressure-lowering therapy, lipid-lowering therapy and antithrombotic therapy) preferably in specialised stroke centres.15 To improve the timely assessment and early management for both TIA and stroke, strong working relationships between ED staff and the stroke team are required and have proven benefits. Resources to promote improved care of TIA and stroke in ED have been developed by the NHMRC/ National Institute of Clinical Studies and are available at http://www.nhmrc.gov.au/nics/programs/emergency/stroke_tia.htm

Recommendations for early assessment and diagnosis are listed in Table 3.

Table 3.  Early assessment and diagnosis
RecommendationGrade
  1. AF, atrial fibrillation; CT, computerised tomography; DWI, diffusion-weighted imaging; ECG, electrocardiogram; GPP, good practice point; MRI, magnetic resonance imaging.

3.1 Assessment of TIA 
 a) All patients with suspected TIA should have a full assessment that includes a detailed history and clinical, prognostic (e.g. ABCD2 score) and investigative tests (e.g. blood tests, brain and carotid imaging, and ECG) at the initial point of healthcare contact whether first seen in primary or secondary care.Grade B
 b) Patients identified as high risk (e.g. ABCD2 score >3 and/or any one of the following: AF, carotid territory symptoms or crescendo TIA) should undergo: 
  • Urgent brain imaging (preferably MRI with DWI), ‘urgent’ being immediately where available but within 24 h);Grade B
  • Carotid imaging should also be undertaken urgently in patients with anterior circulation symptoms who are candidates for carotid revascularisation. In settings with limited access to these investigations, referral within 24 h should be made to the nearest centre where such tests can be quickly conducted.Grade B
  • Patients classified as low risk (e.g. ABCD2 score <4 without AF or carotid territory symptoms or who present more than 1 week after last symptoms) should have brain and carotid imaging (where indicated) as soon as possible (i.e. within 48 h).Grade B
  • The following investigations should be undertaken routinely for all patients with suspected TIA: full blood count, electrolytes, erythrocyte sedimentation rate (ESR), renal function, lipid profile, glucose level and ECG.GPP
3.2 Rapid assessment in ED 
 a) Initial diagnosis should be reviewed by a clinician experienced in the evaluation of stroke.Grade C
 b) Emergency department staff should use a validated stroke screening tool to assist in rapid accurate assessment for all people with stroke.Grade C
3.3 Imaging 
 a) All patients with suspected stroke should have an urgent brain CT or MRI (‘urgent’ being immediately where facilities are available but within 24 h). Patients who are candidates for thrombolysis should undergo brain imaging immediately.Grade A
 b) All patients with carotid territory symptoms who would potentially be candidates for carotid revascularisation should have urgent carotid imaging.Grade B

Acute medical and surgical management

As in many countries, stroke thrombolysis rates are low in Australia (overall, only 7% of all ischaemic stroke patients).5 However, some Australian centres have achieved thrombolysis rates of 20%.16 Only 41% of all acute stroke patients arrive in hospital within 4.5 h and prehospital delays (particularly time to seek medical help) is one of the main challenges to using thrombolysis.5 Based on recent evidence, the recommended treatment window (and Australian licence criterion) for thrombolysis (i.e. intravenous recombinant tissue plasminogen activator) has been increased from 3 h to within 4.5 h after stroke. However, time is brain, and it is imperative that eligible stroke patients receive thrombolytic therapy as early as possible. Collaboration between clinicians in prehospital emergency services, emergency medicine, stroke services and neuroradiology is recommended to enable prompt identification of potentially eligible patients, timely treatment, and audit- and quality-improvement initiatives.3 Advanced brain imaging may provide improved selection for thrombolytic therapy; however, plain brain CT remains the standard imaging strategy.

Recommendations for specific acute therapies are listed in Table 4.

Table 4.  Acute medical and surgical management
RecommendationGrade
  1. GPP, good practice point; rt-PA, recombinant tissue plasminogen activator.

4.1 Thrombolysis 
 a) Intravenous rt-PA in acute ischaemic stroke should only be undertaken in patients satisfying specific inclusion and exclusion criteria.Grade A
 b) Intravenous rt-PA should be given as early as possible in carefully selected patients with acute ischaemic stroke, as the effect size of thrombolysis is time-dependent. Where possible, therapy should commence in the first few hours but may be used up to 4.5 h after stroke onset.Grade A
 c) Intravenous rt-PA should only be given under the authority of a physician trained and experienced in acute stroke management.Grade B
 d) Thrombolysis should only be undertaken in a hospital setting with appropriate infrastructure, facilities and network support including: 
  • access to an multidisciplinary acute care team with expert knowledge of stroke management who are trained in delivery and monitoring of patients receiving thrombolytic therapy;GPP
  • pathways and protocols available to guide medical, nursing and allied health acute phase management, in particular acute blood pressure management;Grade C
  • immediate access to imaging facilities and staff trained to interpret images.GPP
 e) A minimum set of de-identified data from all patients treated with thrombolysis should be recorded in a central register to allow monitoring, review, comparison and benchmarking of key outcomes measures over time.Grade C
 f) The commencement of aspirin for patients who have received thrombolysis should be delayed for 24 h (usually after a follow-up scan has excluded significant bleeding).GPP

Secondary prevention interventions

A person with stroke has an accumulated risk of subsequent stroke of 43% over 10 years with an annual rate of approximately 4%.3 The rate of strokes after TIA may be even higher (up to 10% after 3 months) suggesting greater opportunities to prevent stroke after TIA.14 Long-term management of lifestyle risk factors and adherence to medication recommendations, particularly in relation to the management of hypertension and cholesterol, and antithrombotic therapies, are essential for effective secondary-stroke prevention.3 Routine pharmacotherapy following stroke or TIA should include blood pressure-lowering (irrespective of blood pressure level), cholesterol lowering and antiplatelet therapy (for the secondary prevention of ischaemic stroke unless in AF or other clear indication for anticoagulation). There is good evidence to support aspirin alone, clopidogrel alone, or the combination of aspirin and dipyridamole. One large, randomised trial published in 200717 found no difference in the net risk of recurrent stroke or major haemorrhagic events between the use of clopidogrel and the combination regimen of extended release dipyridamole plus low-dose aspirin (11.7% vs 11.4%) thus slightly modifying relevant recommendations in these updated guidelines. Patient and clinician preferences, and consideration of the different side-effect profiles will determine which regimen is used for the individual patient. Recent trials support carotid endarterectomy rather than carotid stenting for patients with recent stroke (in those with good recovery) or TIA, and a significant stenosis of the relevant carotid artery.18,19

Regarding other therapies, hormone replacement therapy (HRT) increases the risk of stroke in primary prevention studies by 29–44%. HRT also significantly increases the risk of venous thromboembolism. The decision on whether to use HRT should be based on an overall assessment of individual risk and benefit, and patient preferences. Recommendations for early secondary prevention are listed in Table 5.

Table 5.  Secondary prevention
RecommendationGrade
  1. CT, computerised tomography; GPP, good practice point; MRI, magnetic resonance imaging; TIA, transient ischaemic attack.

5.37 Blood pressure-lowering 
 a) All stroke and TIA patients, whether normotensive or hypertensive, should receive blood pressure-lowering therapy, unless contraindicated by symptomatic hypotension.Grade A
 b) New blood pressure-lowering therapy should commence before discharge for those with stroke or TIA, or soon after TIA if the patient is not admitted.Grade B
5.4 Antiplatelet therapy 
 a) Long-term antiplatelet therapy should be prescribed to all people with ischaemic stroke or TIA who are not prescribed anticoagulation therapy.Grade A
 b) Low-dose aspirin and modified release dipyridamole or clopidogrel alone should be prescribed to all people with ischaemic stroke or TIA, taking into consideration patient comorbidities.Grade A
 c) Aspirin alone can be used, particularly in people who do not tolerate aspirin plus dipyridamole or clopidogrel.Grade A
 d) The combination of aspirin plus clopidogrel is NOT recommended for the secondary prevention of cerebrovascular disease in people who do not have acute coronary disease or recent coronary stent.Grade A
5.5 Anticoagulation therapy 
 a) Anticoagulation therapy for secondary prevention for people with ischaemic stroke or TIA from presumed arterial origin should NOT be routinely used.Grade A
 b) Anticoagulation therapy for long-term secondary prevention should be used in people with ischaemic stroke or TIA who have atrial fibrillation or cardioembolic stroke.Grade A
 c) In stroke patients, the decision to begin anticoagulation therapy can be delayed for up to 2 weeks but should be made prior to discharge.Grade C
 d) In patients with TIA, anticoagulation therapy should begin once CT or MRI has excluded intracranial haemorrhage as the cause of the current event.GPP
5.6 Cholesterol lowering 
 a) Therapy with a statin should be used for all patients with ischaemic stroke or TIA.Grade A
 b) Statins should NOT be used routinely for haemorrhagic stroke.Grade B
5.10 Hormone replacement therapy (HRT) 
 Following a stroke event, HRT should be stopped. The decision whether to start or continue HRT in patients with a history of previous stroke or TIA should be discussed with the individual patient and based on an overall assessment of risk and benefit.Grade B
5.11 Oral contraception 
 The decision whether to start or continue oral contraception in women of child-bearing age with a history of stroke should be discussed with the individual patient and based on an overall assessment of risk and benefit. Non-hormonal methods of contraception should be considered.Grade C

Rehabilitation

Rehabilitation is a holistic process that should begin the first day after stroke, where possible, ultimately to maximise the stroke survivor's participation in the community. As increased rehabilitation input has been linked with improved recovery and most people are able to tolerate an increase in rehabilitation time, these are the first Australian guidelines to provide recommendations for the ‘dose’ of rehabilitation. Patients that are undergoing active rehabilitation are recommended to have as much physical therapy (physiotherapy and occupational therapy) as possible with a minimum of 1 h of active practice per day at least 5 days per week.

Annual assessment by a general practitioner (GP) or specialist to consider whether access to further interventions is needed is recommended for stroke survivors at the end of the formal rehabilitation phase of care. This assessment should identify any ongoing rehabilitation needs. However, stroke rehabilitation services are rarely available after the first 6 months despite evidence demonstrating that further improvements can be made after this time.20,21 Recommendations for rehabilitation are listed in Table 6.

Table 6.  Rehabilitation
RecommendationGrade
  1. GPP, good practice point.

6.1 Amount, intensity and timing of rehabilitation 
 6.1.1 Amount and intensity of rehabilitation 
 a) Rehabilitation should be structured to provide as much practice as possible within the first 6 months after stroke.Grade A
 b) For patients undergoing active rehabilitation, as much physical therapy (physiotherapy and occupational therapy) should be provided as possible with a minimum of 1-h active practice per day at least 5 days a week.GPP
 c) For patients undergoing active rehabilitation, as much therapy for dysphagia or communication difficulties should be provided as they can tolerate.Grade C
 6.1.2 Timing of rehabilitation 
 a) Patients should be mobilised as early and as frequently as possible.Grade B
 b) Treatment for aphasia should be offered as early as tolerated.Grade B

Managing complications

Many strategies to prevent and manage complications should commence immediately in the acute phase (e.g. nutrition and hydration, incontinence management) and continue as needed during post-acute and long-term care. For the first time, recommendations for managing poor oral hygiene and fatigue have been included. Several trials have now demonstrated a lack of benefit for the routine use of prolonged positioning for muscle stretch to prevent or treat contracture when applied on top of early comprehensive rehabilitation.3 Similarly, new evidence has shown that thigh-length compression stockings did not prevent deep venous thrombosis and pulmonary embolism, and actually increased adverse effects in immobile stroke patients.22

Depression is the most common mood disturbance post-stroke affecting approximately one third of patients.23 Assessment of clinical depression can be difficult because of the complex interaction of stroke-specific deficits, such as aphasia, or cognitive impairment with symptoms of depression and the sometimes overlapping nature of symptom presentation. Furthermore, depressed mood can be indicative of the normal adjustment to a potentially devastating situation. Management with pharmacotherapy does not appear to be useful in prevention but may be useful in those with depression or emotional lability.24 Evidence-based psychological interventions, such as cognitive-behavioural therapy, should be used to both prevent and treat depression.25

Recommendations for managing complications are listed in Table 7.

Table 7.  Managing complications
RecommendationGrade
  1. DVT, deep venous thrombosis; GPP, good practice point; PE, pulmonary embolism.

7.4 Contracture 
 a) Conventional therapy (i.e. early-tailored interventions) should be provided for stroke survivors at risk of or who have developed contracture.GPP
 b) For stroke survivors at risk of or who have developed contractures and are undergoing comprehensive rehabilitation, the routine use of splints or prolonged positioning of muscles in a lengthened position is NOT recommended.Grade B
7.9 Fatigue 
 a) Therapy for stroke survivors with fatigue should be organised for periods of the day when they are most alert.GPP
 b) Stroke survivors and their families/carers should be provided with information and education about fatigue; including potential management strategies, such as exercise, establishing good sleep patterns, avoid sedating drugs and too much alcohol.GPP
7.11 Mood disturbance 
 Identification 
 a) All patients should be screened for depression using a validated tool.GPP
 b) Patients with suspected altered mood (e.g. depression, anxiety, emotional lability) should be assessed by trained personnel using a standardised and validated scale.Grade B
 c) If required, diagnosis should only be made following clinical interview.GPP
 Prevention 
 a) Psychological strategies (e.g. problem solving, motivational interviewing) can be used to prevent depression after stroke.Grade B
 b) Routine use of antidepressants to prevent post-stroke depression is NOT recommended.Grade B
 Intervention 
 a) Antidepressants can be used for stroke patients who are depressed (following due consideration of the benefit and risk profile for the individual) and for those with emotional lability.Grade B
 b) Psychological (cognitive behavioural) intervention can be used for stroke patients who are depressed.Grade B
7.13 DVT/PE 
 a) Early mobilisation and adequate hydration should be encouraged in all acute stroke patients to help prevent DVT and PE.GPP
 b) Antiplatelet therapy should be used for people with ischaemic stroke to help prevent DVT/PE.Grade A
 c) Low molecular weight heparin or heparin in prophylactic doses can be used with caution for selected patients with acute ischaemic stroke at high risk of DVT/PE. If low molecular weight heparin is contraindicated or not available, unfractionated heparin should be used.Grade B
 d) Antithrombotic therapy is NOT recommended for the prevention of DVT/PE in haemorrhagic stroke patients.GPP
 e) Thigh-length antithrombotic stockings are NOT recommended for the prevention of DVT/PE post-stroke.Grade B

Community participation and long-term recovery

While there remains little robust evidence for interventions to promote community participation and long-term recovery, aspects of daily living, such as driving, leisure, return to work, sexuality and socialisation, and aspects of support for both stroke survivors and carers are very important to many people with stroke. In regard to driving, the recommendations have been changed in light of the update of the Australian standards for Assessing Fitness to Drive for commercial and private drivers 2012.26 Stroke survivors should not return to driving for at least 1 month post-event. A follow-up assessment (normally undertaken by a GP or specialist) should be conducted prior to driving to assess suitability. Patients with TIA should be instructed not to drive for 2 weeks. Recommendations for community participation and long-term recovery are listed in Table 8.

Table 8.  Community participation and long-term recovery
RecommendationGrade
  1. GP, general practitioner; GPP, good practice point; TIA, transient ischaemic attack.

8.2 Driving 
 a) All patients admitted to hospital should be asked if they intend to drive again.GPP
 b) Any patient who does wish to drive should be given information about driving after stroke and be assessed for fitness to return to driving using the national guidelines (Assessing Fitness to Drive) and relevant state guidelines. Patients should be informed that they are required to report their condition to the relevant driver licence authority and notify their car insurance company before returning to driving.GPP
 c) Stroke survivors should not return to driving for at least 1 month post-event. A follow-up assessment (normally undertaken by a GP or specialist) should be conducted prior to driving to assess suitability. Patients with TIA should be instructed not to drive for 2 few weeks.GPP
 d) If a person is deemed medically fit but is required to undertake further testing, they should be referred for an occupational therapy driving assessment. Relevant health professionals should discuss the results of the test and provide a written record of the decision to the patient as well as informing the GP.GPP

Conclusion

Evidence for the management of acute stroke, post-acute care and long-term care is steadily evolving, and it is important that clinicians are actively informed regarding the latest guidelines (available at http://www.strokefoundation.com.au/health-professionals) in order to help reduce the evidence practice gaps. Early recognition of stroke symptoms, the subsequent response of individuals following a TIA or stroke, and the appropriate response of ambulance, ED and stroke services is paramount to the management of a person with a stroke. Following stroke, timely and comprehensive care ideally in a stroke unit is critical. Early initiation of secondary prevention and rehabilitation is also essential. However, changing clinician practice remains a challenge. The existence of up-to-date clinical guidelines without targeted implementation strategies do not always ensure evidence uptake. The NSF strongly recommends a systematic approach to guideline implementation involving strategies such as audit and feedback, local gap and barrier analysis, reminders, and education. Institutional support for guideline implementation is also crucial.

Acknowledgements

The Clinical Guidelines for Stroke Management 2010 was developed by a multidisciplinary Expert Working Group, and the National Stroke Foundation wants to acknowledge the significant contribution of these people. For details, go to http://www.strokefoundation.com.au/clinical-guidelines.

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