Canadian Stroke Best Practice Recommendations for Acute Stroke Management: Prehospital, Emergency Department, and Acute Inpatient Stroke Care, 6th Edition, Update 2018

Abstract

The 2018 update of the Canadian Stroke Best Practice Recommendations for Acute Stroke Management, 6th edition, is a comprehensive summary of current evidence-based recommendations, appropriate for use by healthcare providers and system planners caring for persons with very recent symptoms of acute stroke or transient ischemic attack. The recommendations are intended for use by a interdisciplinary team of clinicians across a wide range of settings and highlight key elements involved in prehospital and Emergency Department care, acute treatments for ischemic stroke, and acute inpatient care. The most notable changes included in this 6th edition are the renaming of the module and its integration of the formerly separate modules on prehospital and emergency care and acute inpatient stroke care. The new module, Acute Stroke Management: Prehospital, Emergency Department, and Acute Inpatient Stroke Care is now a single, comprehensive module addressing the most important aspects of acute stroke care delivery. Other notable changes include the removal of two sections related to the emergency management of intracerebral hemorrhage and subarachnoid hemorrhage. These topics are covered in a new, dedicated module, to be released later this year. The most significant recommendation updates are for neuroimaging; the extension of the time window for endovascular thrombectomy treatment out to 24 h; considerations for treating a highly selected group of people with stroke of unknown time of onset; and recommendations for dual antiplatelet therapy for a limited duration after acute minor ischemic stroke and transient ischemic attack. This module also emphasizes the need for increased public and healthcare provider's recognition of the signs of stroke and immediate actions to take; the important expanding role of paramedics and all emergency medical services personnel; arriving at a stroke-enabled Emergency Department without delay; and launching local healthcare institution code stroke protocols. Revisions have also been made to the recommendations for the triage and assessment of risk of recurrent stroke after transient ischemic attack/minor stroke and suggested urgency levels for investigations and initiation of management strategies. The goal of this updated guideline is to optimize stroke care across Canada, by reducing practice variations and reducing the gap between current knowledge and clinical practice.

Statement by a Working Group conceived by the Polish National Consultants in Cardiology and Neurology addressing the use of implantable cardiac monitors in patients after ischaemic embolic stroke of undetermined source

“…Therefore, cardiological diagnostic workup, especially screening for cardiac arrhythmias, is one of the key elements of a hospital stay in the stroke unit [12]. A positive history of atrial fibrillation or its identification after ischaemic stroke is a clear indication for implementation of oral anticoagulation, preferably with the use of a NOAC [13].…”

“…In Poland, the hospital stay of an acute stroke patient lasts in most cases eight days or longer. This time is fully sufficient to conduct the standard diagnostic process recommended by guidelines, including the guidelines from the Section of Vascular Diseases at the Polish Neurological Society [12,24,25]: -Brain imaging: CT (usually), CT and MRI (sometimes), or only MRI (rarely); performed at least once on admission to hospital; allows a determination to be made as to whether the stroke is ischaemic or haemorrhagic; it can reveal an acute lesion, silent brain infarcts, and signs of small vessel disease -Vascular imaging: carotid ultrasound (always), transcranial Doppler (usually), CT angiography or MRI angiography (sometimes additionally); performed to assess atherosclerosis and confirm or exclude other less common vascular pathologies -Screening for cardiac arrhythmias: resting ECG (at least once), monitoring of heart rate with a cardiomonitor for at least 24 hours (almost always), 24-hour Holter monitoring (usually); may detect previously undiagnosed atrial fibrillation -Echocardiography: transthoracic echocardiography (usually), transoesophageal echocardiography (as a supplementary examination is some cases); may detect source of cardiac embolism Reperfusion therapy is the gold standard of treatment in all eligible cases. Intravenous thrombolysis is available at all Polish stroke units and is fully reimbursed.…”

“…All acute patients who are not eligible for reperfusion therapy should receive anti-platelet therapy (usually 150-300 mg of aspirin, or sometimes a combination of aspirin and clopidogrel). Aspirin is also initiated 24 hours after reperfusion therapy [12,24,25].…”

A new era in stroke care

“…Included in this edition of the CJEM is a synopsis of the updated and comprehensive Canadian Stroke Best Practice Recommendations, 6th Edition (2018), directed to emergency physicians and nurses, emergency medical services (EMS) personnel, diagnostic imaging teams, and acute stroke teams. 2 These guidelines reflect a new era in stroke care.…”

Computed tomography angiography to identify the cause of a transient ischemic attack versus irradiating patients without cause (or even a TIA)

“…The 2018 Heart and Stroke Foundation of Canada guidelines categorize as "very high risk," patients presenting within 48 hours of a suspected TIA with one of the following clinical pictures: 1) transient, fluctuating, or persistent unilateral weakness; 2) transient, fluctuating, or persistent language/speech disturbance; or 3) fluctuating or persistent symptoms without weakness or language/speech disturbance (e.g., hemibody sensory symptoms, monocular vision loss, hemifield vision loss, binocular diplopia, dysarthria, dysphagia, or ataxia). 4 For these patients, it is suggested that they be seen immediately in an ED with the capability of brain imaging. They recommend brain imaging (computed tomography or magnetic resonance imaging [MRI]) and vascular imaging (CTA or magnetic resonance angiography from aortic arch to vertex) within 24 hours.…”