Canadian Stroke Best Practice Recommendations: Acute Stroke Management, 7^th Edition Practice Guidelines Update, 2022

Abstract

The 2022 update of the Canadian Stroke Best Practice Recommendations (CSBPR) for Acute Stroke Management, 7 th Edition, is a comprehensive summary of current evidence-based recommendations, appropriate for use by an interdisciplinary team of healthcare providers and system planners caring for persons with an acute stroke or transient ischemic attack. These recommendations are a timely opportunity to reassess current processes to ensure efficient access to acute stroke diagnostics, treatments and management strategies, proven to reduce mortality and morbidity. The topics covered include prehospital care, emergency department care, intravenous thrombolysis and endovascular thrombectomy, prevention and management of inhospital complications, vascular risk factor reduction, early rehabilitation and end of life care. These recommendations pertain primarily to an acute ischemic vascular event. Notable changes in the 7 th edition include recommendations pertaining the use of tenecteplase, thrombolysis as a bridging therapy prior to mechanical thrombectomy, dual antiplatelet therapy for stroke prevention, 1 the management of symptomatic intracerebral hemorrhage following thrombolysis, acute stroke imaging, care of patients undergoing endovascular thrombectomy, medical assistance in dying (MAiD) and virtual stroke care. An explicit effort was made to address sex and gender differences wherever possible. The theme of the 7 th Edition of the CSBPR is building connections to optimize individual outcomes, recognizing that many people who present with acute stroke often also have multiple comorbid conditions, are medically more complex, and require a coordinated interdisciplinary approach for optimal recovery. Additional materials to support timely implementation and quality monitoring of these recommendations are available at www.strokebestpractices.ca.

Effect of Time to Thrombolysis on Clinical Outcomes in Patients With Acute Ischemic Stroke Treated With Tenecteplase Compared to Alteplase: Analysis From the AcT Randomized Controlled Trial

“…[20][21][22] The AcT trial was the first phase 3 RCT to compare intravenous tenecteplase with alteplase in all patients presenting with acute ischemic stroke within 4.5 hours from symptom onset and eligible for thrombolysis with alteplase. 23 The trial showed that tenecteplase (0.25 mg/kg) was noninferior to alteplase (0.9 mg/kg) in treatment of acute ischemic stroke (unadjusted risk difference, 2.1% [95% CI, −2.6 to 6.9]) and comparable for all other secondary and safety outcomes. 7 These results have changed Canadian, European, and Australian guidelines, all of which now recommend the use of tenecteplase for acute ischemic stroke within 4.5 hours of symptoms onset.…”

“…7 These results have changed Canadian, European, and Australian guidelines, all of which now recommend the use of tenecteplase for acute ischemic stroke within 4.5 hours of symptoms onset. [23][24][25] Unlike the clinical practice guidelines, regulatory approval for intravenous alteplase use in patients with acute ischemic stroke is restricted to patients presenting within 3 hours of stroke symptom onset. 10,11 This key secondary analyses from the AcT trial aims to therefore present in detail the effect of tenecteplase versus alteplase in the early versus late (3-4.5 hours) presenters while also assessing if the well-known relationship of time to thrombolysis on outcomes with alteplase is also seen with tenecteplase.…”

Assessment of remote ischemic conditioning delivery with optical sensor in acute ischemic stroke: Randomised clinical trial protocol

“…All patients in the sham and intervention arm will receive standard of care management for ischemic stroke as per the Canadian Stroke Best Practices Guidelines [ 16 ].…”

Clinical Uncertainty In Large Vessel Occlusion Ischemic Stroke (CULVO): An Intrarater And Interrater Agreement Study

“…For the late window (6-24 hours) however, both the American Heart Association and Canadian Stroke Best Practices recommend that perfusion CT neuroimaging (NCCT, CTA and perfusion imaging) be utilized to allow for more nuanced patient selection. 6,7 These recommendations are driven by use of perfusion imaging in late-window EVT trials. Both DAWN and DEFUSE 3, used perfusion imaging to derive quantitative values for core infarct and excluded those that were considered to have a large core.…”