The European Stroke Organisation (ESO) Guidelines

Abstract

In 2008, the European Stroke Organisation (ESO) updated the European Stroke Initiative (EUSI) recommendations for the management of ischemic stroke and transient ischemic attack, initially published in 2000 and updated in 2003 (1-3). Since then, the ESO has begun the process of implementing a new standardized system for the production and presentation of evidencebased clinical guidelines. The ESO guidelines committee agreed on two major developments: use of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system (4-7); and the transition to a model in which several guideline documents deal with specific topics of interest called modules rather than a single document on a large topic.The GRADE system has a series of advantages over other systems that include clear separation between quality of evidence and strength of recommendation, explicit comprehensive criteria for downgrading and upgrading quality of evidence ratings, transparent process of moving from evidence to recommendations, explicit evaluation of the importance of outcomes of alternative management strategies, explicit acknowledgment of values and preferences, and clear pragmatic interpretation of strong versus weak recommendations for clinicians, patients, and policy makers (4-7). In summary, the GRADE approach starts with the formulation of the PICO (population, intervention, comparator, and outcome) questions. The selected outcomes are rated using a 9-degree scale (7-9: critical; 4-6: important; 1-3: of limited importance) and a search strategy is formulated. After a thorough literature search leading to the identification of all available evidence, eligible studies are then selected and their data are extracted and analyzed. The results can be imported into the GRADEPro software (8), allowing for efficient quality grading of the available evidence for each outcome and each clinical question. Then we determine the direction (either 'against' or 'for') and strength of the recommendation (either 'strong' or 'weak'), and finally the recommendation is formulated using a standardized language (4-7).The second major development in the ESO guidelines policy was to move from the classical model of a single guideline document on a major topic -e.g. management of ischemic stroke, transient ischemic attack, and hemorrhagic stroke -to subdivision of the major topic into focused modules. This enables the ESO Guidelines Committee to react quickly when new developments in a specific area of stroke medicine occur, and update recommendations on the related module with speed. With the

Peak perihemorrhagic edema correlates with functional outcome in intracerebral hemorrhage

“…38 Thus, European Stroke Organisation guidelines do not recommend the use of corticosteroids at this time. 39 Other anti-inflammatory substances, e. g., fingolimod, are under clinical investigation. 31 However, it remains to be elucidated whether the inflammatory response related to PHE evolution represents rather a reaction to the occurrence of blood within brain parenchyma, a reaction to additional infectious diseases in severely ill patients, or both, and whether an immunosuppressive strategy, an antiinfectious strategy, or both will resolve the inflammatory dilemma in ICH patients.…”

Direct Mechanical Intervention Versus Combined Intravenous and Mechanical Intervention in Large Artery Anterior Circulation Stroke

“…[10][11][12] Intravenous thrombolysis in our institution was performed according to international and institutional guidelines. 13,14 Our bridging group received either full dose (0.9 mL/kg body weight) or two-thirds dose (0.6 mL/kg body weight) intravenous tPA within 4.5 hours after symptom onset. Intravenous tPA was usually started in the scanner immediately after exclusion of ICH.…”

Reversal strategies for vitamin K antagonists in acute intracerebral hemorrhage

“…This group was relatively small (131 patients vs >350 patients in each of the other 3 groups), and it is of note that the combination group had slightly higher rates of surgery (15% vs 10–13%). Surgery was not adjusted for in our prespecified Cox regression model, given the existing uncertainty around the impact of surgery on outcome 10, 12, 30. However, adding surgery into the model post hoc did not markedly change our findings.…”

“…This has led to PCC being recommended as a reasonable alternative to FFP in the USA10 and the first‐line treatment in the United Kingdom 11. The 2014 European consensus‐based ICH guidelines do not provide a recommendation, citing lack of evidence 12. Furthermore, different preparations of PCC have different concentrations of the vitamin K–dependent clotting factors, classified as 3‐factor or 4‐factor depending on the concentration of factor VII (FVII).…”