Comparative Guidelines

Introduction

I have tried to compare like with like between the UK Royal College of Physician and the American Heart Association Stroke Guidelines. Both have differing approaches and so the order and structure of the content is different so comparisons can be difficult and I have more work to do. It is interesting as the guidelines are 2 years apart with the RCP being 2016 and the AHA from early 2018. I hope it is useful for those trying to develop their own unit guidance. Here are links to both if you want to download them UK RCP 2016 and American Heart Association February Guidance 2018 on Acute Ischaemic Stroke. I have also listed other online guidance but I have not as yet done any comparisons and many of them are out of date.

International Stroke Guidelines

Comparing UK vs USA Stroke Guidance

IssueUK RCP 2016 AHA feb 2018
  • Do not give heparin (in any dose) for the prevention of DVT and PE in patients who are immobile after acute stroke, and do not attempt to select those patients in whom the risk of VTE is sufficiently high to warrant the use of heparin. Do use intermittent pneumatic compression instead (Section 3.13).
  • Do not treat recurrent TIA in patients in sinus rhythm with anticoagulants. Do use antiplatelet treatment and investigate for carotid stenosis and paroxysmal atrial fibrillation before considering unusual causes of TIA or an alternative diagnosis (Section 3.3).
  • Do not routinely perform echocardiography in people with stroke or TIA. Do select those patients in whom an echocardiogram may be appropriate according to a history of structural cardiac disease or abnormal physical or ECG findings (Section 5.2).
  • Do not routinely use a urinary catheter or continence pads as first line management for people with continence problems after a stroke. Do use behavioural interventions such as timed toileting and prompted voiding first (Section 4.5).
  • Do not routinely offer oral nutritional supplements to patients with acute stroke who are adequately nourished on admission. Do assess hydration and risk of malnutrition in patients admitted to hospital with acute stroke (Section 4.7.1).
  • Do not use overhead arm slings and pulleys in people with stroke who have functional loss in the arm. Do ensure careful positioning of the affected arm and that carers and family handle the arm correctly (Section 4.12.3).
  • Do not assess driving eligibility with cognitive tests if the person's language impairment would invalidate the results. Do refer for an on-road assessment if there is uncertainty about eligibility for driving (Section 4.1.3).
  • Do not routinely provide specialist occupational therapy for people who have reached the end of their stroke rehabilitation and are now living in a care home. Do offer assessment and activities that might improve quality of life (Sections 2.17 and 5.9).
  • Do not routinely close a patent foramen ovale in a patient with stroke. Do offer antiplatelet treatment for the prevention of recurrent stroke (Section 5.7). xviii
  • Do not use fibrates, ezetimibe, bile acid sequestrants, nicotinic acid or omega-3 fatty acids for cholesterol-lowering after stroke if the patient is unable to tolerate a statin. Do try alternative methods to improve the tolerability of a statin such as a reduced dose, alternateday dosing or a lower-intensity statin (Section 5.5).
IssueUK RCP 2016 AHA feb 2018
Immediate Management Suspected TIA
  • Give 300mg of aspirin immediately
  • Assessed urgently < 24 hours by a specialist physician in a neurovascular clinic or an acute stroke unit.
  • Suspected TIA > 1 week ago should be seen by specialist physician < 7 days
  • Inform family/carers about the recognition of stroke symptoms and the action to be taken if they occur.
  • Should be seen by a specialist physician before a decision on brain imaging is made
  • If haemorrhage suspected then Non contrast CT urgently in those on anticoagulant or with a bleeding disorder
  • If Imaging > 7 days after symptoms then T2* MRI preferred means of excluding haemorrhage.
  • Confirmed diagnosis of TIA Give Clopidogrel 300 mg loading dose and 75 mg daily thereafter
  • Confirmed diagnosis of TIA Give high intensity statin therapy (e.g. atorvastatin 20-80 mg daily) started immediately.
N/A
Immediate Management TIA/Non disabling stroke
  • Discussion of individual lifestyle factors (smoking, alcohol excess, diet, exercise);
  • Clopidogrel 300 mg loading dose followed by 75 mg daily;
  • High intensity statin therapy with atorvastatin 20-80 mg daily;
  • BP-lowering therapy with a thiazide diuretic, long-acting CCB or ACE inhibitor.
  • AF should be anticoagulated as soon as intracranial bleeding excluded. Use an anticoagulant that has rapid onset, provided no other contraindications.
N/A
Management of Carotid disease for TIA/Non Disabling stroke
  • If after specialist assessment are considered candidates for carotid intervention should have carotid imaging performed urgently within 24 hours. Use NASCET method to and those with stable neurological symptoms who have symptomatic severe carotid stenosis of 50-99% should be assessed and referred for carotid endarterectomy within 7 days of the onset of symptoms in a vascular surgical centre routinely participating in national audit;
  • Receive optimal medical treatment: control of BP, anti-platelet treatment, AND have cholesterol reduction through diet and drugs, and lifestyle advice including smoking cessation.
  • Those with stenosis < 50% (NASCET method) should not undergo carotid intervention but receive optimal medical treatment: control of blood pressure, antiplatelet treatment, cholesterol reduction through diet and drugs, and lifestyle advice including smoking cessation.
  • Patients with recurrent attacks of transient neurological symptoms despite optimal medical treatment, in whom an embolic source has been excluded, should be reassessed for an alternative neurological diagnosis.
  • Patients who meet the criteria for carotid intervention but who are unsuitable for open surgery (e.g. inaccessible carotid bifurcation, re-stenosis following endarterectomy, radiotherapy-associated carotid stenosis) should be considered for carotid angioplasty and stenting.
  • People who have undergone carotid revascularisation should be reviewed post-operatively by a stroke physician to optimise medical aspects of vascular secondary prevention.
  • For patients with nondisabling (mRS score 0-2) AIS in the carotid territory who are candidates for CEA or stenting, noninvasive imaging of the cervical vessels should be performed routinely within 24 hours of admission.
  • When revascularization is indicated for secondary prevention in patients with minor, nondisabling stroke (mRS score 0-2), it is reasonable to perform the procedure between 48 hours and 7 days of the index event rather than delay treatment if there are no contraindications to early revascularization.
Immediate Management Suspected Acute Stroke
  • Admit directly to a HASU and be assessed for emergency stroke treatments by a specialist physician without delay.
  • Suspected acute stroke should receive brain imaging urgently and at most within 1 hour of arrival at hospital.
  • Interpretation of acute stroke imaging for thrombolysis decisions should only be made by healthcare professionals who have received appropriate training.
  • Patients with Ischaemic stroke who are eligible for endovascular therapy should have a CTA from aortic arch to skull vertex immediately. This should not delay the administration of IV thrombolysis.
  • MRI with stroke-specific sequences (DWI imaging, T2*) should be performed in patients with suspected acute stroke when there is diagnostic uncertainty.
  • All patients admitted to hospital with suspected acute stroke should receive brain imaging evaluation on arrival to hospital. In most cases, noncontrast CT (NCCT) will provide the necessary information to make decisions about acute management.
  • Systems should be established so that brain imaging studies can be performed within 20 minutes of arrival in the ED in at least 50% of patients who may be candidates for IV alteplase and/or mechanical thrombectomy.
Airways Breathing Circulation
  • Acute hospitals receiving medical admissions that include people with suspected stroke should have arrangements to admit them directly to a hyperacute stroke unit on site or at a neighbouring hospital, to monitor and regulate basic physiological functions such as neurological status, blood glucose, oxygenation, and blood pressure.
  • Patients with acute stroke should only receive supplemental oxygen if their oxygen saturation is below 95% and there is no contraindication.
  • Airway support and ventilatory assistance are recommended for the treatment of patients with acute stroke who have decreased consciousness or who have bulbar dysfunction that causes compromise of the airway.
  • Supplemental oxygen should be provided to maintain oxygen saturation >94%.
  • Supplemental oxygen is not recommended in nonhypoxic patients with AIS.
  • Hyperbaric oxygen (HBO) is not recommended for patients with AIS except when caused by air embolization.
Diagnostic tests in suspected Acute Stroke
  • Suspected acute stroke should receive brain imaging urgently and at most within 1 hour of arrival at hospital.
  • Interpretation of acute stroke imaging for thrombolysis decisions should only be made by healthcare professionals who have received appropriate training.
  • Patients with Ischaemic stroke who are eligible for endovascular therapy should have a CTA from aortic arch to skull vertex immediately. This should not delay the administration of IV thrombolysis.
  • MRI with stroke-specific sequences (DWI imaging, T2*) should be performed in patients with suspected acute stroke when there is diagnostic uncertainty.
  • All patients admitted to hospital with suspected acute stroke should receive brain imaging evaluation on arrival to hospital. In most cases, noncontrast CT (NCCT) will provide the necessary information to make decisions about acute management.
  • Systems should be established so that brain imaging studies can be performed within 20 minutes of arrival in the ED in at least 50% of patients who may be candidates for IV alteplase and/or mechanical thrombectomy.
  • There remains insufficient evidence to identify a threshold of acute CT hypoattenuation severity or extent that affects treatment response to IV alteplase. The extent and severity of acute hypoattenuation or early ischemic changes should not be used as a criterion to withhold therapy for such patients who otherwise qualify.
  • The CT hyperdense MCA sign should not be used as a criterion to withhold IV alteplase from patients who otherwise qualify.
  • Routine use of magnetic resonance imaging (MRI) to exclude cerebral microbleeds (CMBs) before administration of IV alteplase is not recommended.
  • Use of imaging criteria to select ischemic stroke patients who awoke with stroke or have unclear time of symptom onset for treatment with IV alteplase is not recommended outside a clinical trial.
  • Multimodal CT and MRI, including perfusion imaging, should not delay administration of IV alteplase.
  • For patients who otherwise meet criteria for EVT, a noninvasive intracranial vascular study is recommended during the initial imaging evaluation of the acute stroke patient, but should not delay IV alteplase if indicated. For patients who qualify for IV alteplase according to guidelines from professional medical societies, initiating IV alteplase before noninvasive vascular imaging is recommended for patients who have not had noninvasive vascular imaging as part of their initial imaging assessment for stroke. Noninvasive intracranial vascular imaging should then be obtained as quickly as possible.
  • For patients who otherwise meet criteria for EVT, it is reasonable to proceed with CTA if indicated in patients with suspected intracranial LVO before obtaining a serum creatinine concentration in patients without a history of renal impairment.
  • In patients who are potential candidates for mechanical thrombectomy, imaging of the extracranial carotid and vertebral arteries, in addition to the intracranial circulation, is reasonable to provide useful information on patient eligibility and endovascular procedural planning.
  • Additional imaging beyond CT and CTA or MRI and magnetic resonance angiography (MRA) such as perfusion studies for selecting patients for mechanical thrombectomy in <6 hours is not recommended.
  • In selected patients with AIS within 6 to 24 hours of last known normal who have LVO in the anterior circulation, obtaining CTP, DW-MRI, or MRI perfusion is recommended to aid in patient selection for mechanical thrombectomy, but only when imaging and other eligibility criteria from RCTs showing benefit are being strictly applied in selecting patients for mechanical thrombectomy.
  • It may be reasonable to incorporate collateral flow status into clinical decision making in some candidates to determine eligibility for mechanical thrombectomy.
  • Only the assessment of blood glucose must precede the initiation of IV alteplase in all patients.
  • Baseline ECG assessment is recommended in patients presenting with AIS, but should not delay initiation of IV alteplase.
  • Baseline troponin assessment is recommended in patients presenting with AIS, but should not delay initiation of IV alteplase.
  • Usefulness of CXR in the hyperacute stroke setting in the absence of evidence of acute pulmonary, cardiac, or pulmonary vascular disease is unclear. If obtained, they should not unnecessarily delay administration of IV alteplase.
Dysphagia
  • People with acute stroke should have their swallowing screened, using a validated screening tool, by a trained healthcare professional within four hours of arrival at hospital and before being given any oral food, fluid or medication.
  • Until a safe swallowing method is established, people with swallowing difficulty after acute stroke should: be immediately considered for alternative fluids; have a comprehensive specialist assessment of their swallowing; be considered for nasogastric tube feeding within 24 hours; be referred to a dietitian for specialist nutritional assessment, advice and monitoring; receive adequate hydration, nutrition and medication by alternative means.
  • Patients with swallowing difficulty after acute stroke should only be given food, fluids and medications in a form that can be swallowed without aspiration.
  • People with stroke with suspected aspiration or who require tube feeding or dietary modification should be considered for instrumental assessment (videofluoroscopy or fibreoptic endoscopic evaluation of swallowing).
  • People with stroke who require instrumental assessment of swallowing (videofluoroscopy or fibre-optic endoscopic evaluation of swallowing) should only receive this: in conjunction with a specialist in dysphagia management; to investigate the nature and causes of aspiration; to direct an active treatment/rehabilitation programme for swallowing difficulties.
  • People with swallowing difficulty after stroke should be considered for swallowing rehabilitation by a specialist in dysphagia management. This should include one or more of: compensatory strategies such as postural changes (e.g. chin tuck) or swallowing manoeuvres (e.g. supraglottic swallow); restorative strategies to improve oropharyngeal motor function (e.g. Shaker headlifting exercises); sensory modification, such as altering the taste and temperature of foods or carbonation of fluids; texture modification of food and/or fluids.
  • People with stroke who require modified food or fluid consistency should have these provided in line with nationally agreed descriptors.
  • People with difficulties self-feeding after stroke should be assessed and provided with the appropriate equipment and assistance (including physical help and verbal encouragement) to promote independent and safe feeding.
  • People with swallowing difficulty after stroke should be provided with written guidance for all staff/carers to use when feeding or providing fluids.
  • People with stroke should be considered for gastrostomy feeding if they: need but are unable to tolerate nasogastric tube feeding; are unable to swallow adequate food and fluids orally by four weeks from the onset of stroke; are at high long-term risk of malnutrition.
  • People with stroke who are discharged from specialist treatment with continuing problems with swallowing food or fluids safely should be trained, or have family/carers trained, in the management of their swallowing difficulty and be regularly reassessed.
  • People with stroke receiving end-of-life (palliative) care should not have burdensome restrictions imposed on oral food and/or fluid intake if those restrictions would exacerbate suffering.
  • Dysphagia screening before the patient begins eating, drinking, or receiving oral medications is reasonable to identify patients at increased risk for aspiration.
  • It is reasonable for dysphagia screening to be performed by a speech-language pathologist or other trained healthcare provider.
  • An instrumental evaluation is reasonable for those patients suspected of aspiration to verify the presence/absence of aspiration and to determine the physiological reasons for the dysphagia to guide the treatment plan.
  • It is not well established which instrument to choose for evaluation of swallowing with sensory testing, but the choice may be based on instrument availability or other considerations (ie, fiberoptic endoscopic evaluation of swallowing, videofluoroscopy, fiberoptic endoscopic evaluation).
Nutrition
  • Patients with acute stroke should be screened for the risk of malnutrition on admission and at least weekly thereafter. Screening should be conducted by trained staff using a structured tool.
  • Patients with acute stroke who are adequately nourished on admission and are able to meet their nutritional needs orally should not routinely receive oral nutritional supplements. Patients with acute stroke who are at risk of malnutrition or who require tube feeding or dietary modification should be referred to a dietitian for specialist nutritional assessment, advice and monitoring.
  • Patients with stroke who are at risk of malnutrition should be offered nutritional support. This may include oral nutritional supplements, specialist dietary advice and/or tube feeding in accordance with their expressed wishes or, if the patient lacks mental capacity, in their best interests.
  • Patients with stroke who are unable to maintain adequate nutrition and fluids orally should be: referred to a dietitian for specialist nutritional assessment, advice and monitoring; be considered for nasogastric tube feeding within 24 hours of admission; assessed for a nasal bridle if the nasogastric tube needs frequent replacement, using locally agreed protocols; assessed for gastrostomy if they are unable to tolerate a nasogastric tube with nasal bridle.
  • People with stroke who require food or fluid of a modified consistency should: be referred to a dietitian for specialist nutritional assessment, advice and monitoring; have the texture of modified food or fluids prescribed using nationally agreed descriptors.
  • People with stroke should be considered for gastrostomy feeding if they: need but are unable to tolerate nasogastric tube feeding; are unable to swallow adequate food and fluids orally by four weeks from the onset of stroke; are at high long-term risk of malnutrition.
  • People with difficulties self-feeding after stroke should be assessed and provided with the appropriate equipment and assistance (including physical help and verbal encouragement) to promote independent and safe feeding.
  • People with stroke discharged from specialist care services with continuing problems meeting their nutritional needs should have their dietary intake and nutritional status monitored regularly.
  • People with stroke receiving end-of-life (palliative) care should not have burdensome restrictions imposed on oral food and/or fluid intake if those restrictions would exacerbate suffering.
  • Enteral diet should be started within 7 days of admission after an acute stroke.
  • For patients with dysphagia, it is reasonable to initially use nasogastric tubes for feeding in the early phase of stroke (starting within the first 7 days) and to place percutaneous gastrostomy tubes in patients with longer anticipated persistent inability to swallow safely (>2-3 weeks).
  • Nutritional supplements are reasonable to consider for patients who are malnourished or at risk of malnourishment.
  • Implementing oral hygiene protocols to reduce the risk of pneumonia after stroke may be reasonable
DVT Prophylaxis
  • Patients with immobility after acute stroke should be offered IPC within 3 days of admission to hospital for the prevention of DVT thrombosis. Treatment should be continuous for 30 days or until the patient is mobile or discharged, whichever is sooner.
  • Patients with immobility after acute stroke should not be routinely given LMWH or graduated compression stockings (either full-length or below-knee) for the prevention of deep vein thrombosis.
  • Patients with ischaemic stroke and symptomatic DVT or PE should receive anticoagulant treatment provided there are no contraindications.
  • Patients with ICH and symptomatic DVT or pulmonary embolism should receive treatment with a vena caval filter.
  • In immobile stroke patients without contraindications, intermittent pneumatic compression (IPC) in addition to routine care (aspirin and hydration) is recommended over routine care to reduce the risk of DVT.
  • The benefit of prophylactic-dose subcutaneous heparin (unfractionated heparin [UFH] or LMWH) in immobile patients with AIS is not well established.
  • When prophylactic anticoagulation is used, the benefit of prophylactic-dose LMWH over prophylactic-dose UFH is uncertain.
  • In ischaemic stroke, elastic compression stockings should not be used.
Depression
  • People with stroke with one mood disorder (e.g. depression) should be assessed for others (e.g. anxiety).
  • People with or at risk of depression or anxiety after stroke should be offered brief psychological interventions such as motivational interviewing or problem-solving therapy (adapted if necessary for use with people with aphasia or cognitive problems) before considering antidepressant medication.
  • People with mild or moderate symptoms of psychological distress, depression or anxiety after stroke should be given information, support and advice and considered for one or more of the following interventions: increased social interaction; increased exercise; other psychosocial interventions such as psychosocial education groups.
  • People with aphasia and low mood after stroke should be considered for individual behavioural therapy e.g. from an assistant psychologist.
  • People with depression or anxiety after stroke who are treated with antidepressant medication should be monitored for adverse effects and treated for at least four months beyond initial recovery. If the person's mood has not improved after 2-4 weeks, medication adherence should be checked before considering a dose increase or a change to another antidepressant.
  • People with severe or persistent symptoms of emotional disturbance after stroke should receive specialist assessment and treatment from a clinical neuropsychologist/clinical psychologist.
  • People with persistent moderate to severe emotional disturbance after stroke who have not responded to high intensity psychological intervention or pharmacological treatment should be considered for collaborative care. Their care should involve collaboration between the GP, primary and secondary physical health services and case management, with supervision from a senior mental health professional and should include long term follow-up.
  • Administration of a structured depression inventory is recommended to routinely screen for poststroke depression, but the optimal timing of screening is uncertain. used.
  • Patients diagnosed with post-stroke depression should be treated with antidepressants in the absence of contraindications and closely monitored to verify effectiveness.
Blood pressure
  • Patients with AIS should only receive blood pressure-lowering treatment if there is an indication for emergency treatment, such as: SBP > 185 mmHg or DBP > 110 mmHg when the patient is otherwise eligible for treatment with alteplase; hypertensive encephalopathy; hypertensive nephropathy; hypertensive cardiac failure or myocardial infarction; aortic dissection; pre-eclampsia or eclampsia.
  • People with stroke or TIA should have their blood pressure checked, and treatment should be initiated and/or increased as tolerated to consistently achieve a clinic SBP below 130 mmHg, except for people with severe bilateral carotid artery stenosis, for whom a SBP of 140-150 mmHg is appropriate.
  • For people with stroke or TIA aged 55 or over, or of African or Caribbean origin at any age, antihypertensive treatment should be initiated with a long-acting dihydropyridine CCB or a thiazide-like diuretic. If target BP is not achieved, an ACE inhibitor or AT2 blocker should be added.
  • For people with stroke or TIA not of African or Caribbean origin and younger than 55 years, antihypertensive treatment should be initiated with an ACEI or an AT2 blocker.
  • BP-lowering treatment for people with stroke or TIA should be initiated prior to the transfer of care out of hospital or at 2 weeks, whichever is the soonest, or at the first clinic visit for people not admitted.
  • BP-lowering treatment for people with stroke or TIA should be monitored frequently and increased to achieve target blood pressure as quickly as tolerated and safe in primary care. People whose blood pressure remains above target despite treatment should be checked for medication adherence before being referred for a specialist opinion.
  • Hypotension and hypovolemia should be corrected to maintain systemic perfusion levels necessary to support organ function.
  • Patients who have elevated BP and are otherwise eligible for treatment with IV alteplase should have their BP carefully lowered so that their systolic BP is <185 mm Hg and their diastolic BP is <110 mm Hg before IV fibrinolytic therapy is initiated.
  • Until additional data become available, in patients for whom intra-arterial therapy is planned and who have not received IV thrombolytic therapy, it is reasonable to maintain BP ≤185/110 mm Hg before the procedure
  • The usefulness of drug-induced hypertension in patients with AIS is not well established.
Temperature
  • Sources of hyperthermia (temperature >38°C) should be identified and treated, and antipyretic medications should be administered to lower temperature in hyperthermic patients with stroke.
  • The benefit of induced hypothermia for treating patients with ischemic stroke is not well established. Hypothermia should be offered only in the context of ongoing clinical trials.
PFO
  • People with ischaemic stroke or TIA and a patent foramen ovale should receive optimal secondary prevention, including antiplatelet therapy, blood pressure treatment, lipidlowering therapy and lifestyle modification. Anticoagulation is not recommended unless there is another recognised indication.
  • People with stroke or TIA and patent foramen ovale should not be routinely offered device closure except in the context of a clinical trial or prospective register.
Blood Glucose
  • People seen by community-based clinicians (e.g. ambulance paramedics) with the sudden onset of focal neurological symptoms should be screened for hypoglycaemia with a capillary blood glucose, and for stroke or TIA using a validated tool.
  • Patients with acute stroke should be treated to maintain a blood glucose concentration between 5 and 15 mmol/L with close monitoring to avoid hypoglycaemia.
  • Evidence indicates that persistent in-hospital hyperglycemia during the first 24 hours after AIS is associated with worse outcomes than normoglycemia and thus, it is reasonable to treat hyperglycemia to achieve blood glucose levels in a range of 140 to 180 mg/dL and to closely monitor to prevent hypoglycemia in patients with AIS.
  • Hypoglycemia (blood glucose <60 mg/dL) should be treated in patients with AIS.
Management of Acute Ischaemic Stroke (AIS) with Alteplase
  • Patients with AIS, regardless of age or stroke severity, in whom treatment can be started within 3 hours of known onset should be considered for treatment with alteplase.
  • Patients with AIS under the age of 80 years in whom treatment can be started between 3 and 4.5 hours of known onset should be considered for treatment with alteplase.
  • Patients with AIS over 80 years in whom treatment can be started between 3 and 4.5 hours of known onset should be considered for treatment with alteplase on an individual basis. In doing so, treating clinicians should recognise that the benefits of treatment are smaller than if treated earlier, but that the risks of a worse outcome, including death, will on average not be increased.
  • Patients with AIS otherwise eligible for treatment with alteplase should have their blood pressure reduced to below 185/110 mmHg before treatment.
  • Alteplase should only be administered within a well-organised stroke service with:
  • Emergency medical staff, if appropriately trained and supported, should only administer alteplase for the treatment of AIS provided that patients can be subsequently managed on a HASU with appropriate neuroradiological and stroke physician support.
  • IV alteplase (0.9 mg/kg, maximum dose 90 mg over 60 minutes with initial 10% of dose given as bolus over 1 minute) is recommended for selected patients who may be treated within 3 hours of ischemic stroke symptom onset or patient last known well or at baseline state. Physicians should review the criteria outlined in Table 6 to determine patient eligibility.
  • IV alteplase (0.9 mg/kg, maximum dose 90 mg over 60 minutes with initial 10% of dose given as bolus over 1 minute) is also recommended for selected patients who can be treated within 3 and 4.5 hours of ischemic stroke symptom onset or patient last known well. Physicians should review the criteria outlined in Table 6 determine patient eligibility.
  • For otherwise eligible patients with mild stroke presenting in the 3 to 4.5-hour window, treatment with IV alteplase may be reasonable. Treatment risks should be weighed against possible benefits.
  • In otherwise eligible patients who have had a previously demonstrated small number (1-10) of CMBs on MRI, administration of IV alteplase is reasonable.
  • In otherwise eligible patients who have had a previously demonstrated high burden of CMBs (>10) on MRI, treatment with IV alteplase may be associated with an increased risk of sICH, and the benefits of treatment are uncertain. Treatment may be reasonable if there is the potential for substantial benefit.
  • IV alteplase for adults presenting with an AIS with known sickle cell disease can be beneficial.
  • Abciximab should not be administered concurrently with IV alteplase.
  • IV alteplase should not be administered to patients who have received a treatment dose of low-molecular-weight heparin (LMWH) within the previous 24 hours.
  • The potential risks should be discussed during thrombolysis eligibility deliberation and weighed against the anticipated benefits during decision making.
  • Given the extremely low risk of unsuspected abnormal platelet counts or coagulation studies in a population, it is reasonable that urgent IV alteplase treatment not be delayed while waiting for hematologic or coagulation testing if there is no reason to suspect an abnormal test.
  • Treating clinicians should be aware that hypoglycemia and hyperglycemia may mimic acute stroke presentations and determine blood glucose levels before IV alteplase initiation. IV alteplase is not indicated for nonvascular conditions.
  • Because time from onset of symptoms to treatment has such a powerful impact on outcomes, treatment with IV alteplase should not be delayed to monitor for further improvement.
  • In patients undergoing fibrinolytic therapy, physicians should be prepared to treat potential emergent adverse effects, including bleeding complications and angioedema that may cause partial airway obstruction.
  • BP should be maintained <180/105 mm Hg for at least the first 24 hours after IV alteplase treatment
  • The risk of antithrombotic therapy within the first 24 hours after treatment with IV alteplase (with or without EVT) is uncertain. Use might be considered in the presence of concomitant conditions for which such treatment given in the absence of IV alteplase is known to provide substantial benefit or withholding such treatment is known to cause substantial risk.
  • In patients eligible for IV alteplase, benefit of therapy is time dependent, and treatment should be initiated as quickly as possible.
Management of Acute Ischaemic Stroke (AIS)with Alteplase and Thrombectomy
  • Patients with AIS should be considered for combination IV thrombolysis and intra-arterial clot extraction (using stent retriever and/or aspiration techniques) if they have a proximal intracranial large vessel occlusion causing a disabling neurological deficit (NIHSS &ge 6) and the procedure can begin (arterial puncture) within 5 hours of known onset.
  • Patients with AIS and a contraindication to IV thrombolysis but not to thrombectomy should be considered for intra-arterial clot extraction (using stent retriever and/or aspiration techniques) if they have a proximal intracranial large vessel occlusion causing a disabling neurological deficit(NIHSS &ge 6) and the procedure can begin (arterial puncture) within 5 hours of known onset.
  • Patients with AIS causing a disabling neurological deficit (NIHSS ≥6 ) may be considered for intraarterial clot extraction (using stent retriever and/or aspiration techniques, with prior IV thrombolysis unless contraindicated) beyond an onset-to-arterial puncture time of 5 hours if:
    • the large artery occlusion is in the posterior circulation, in which case treatment up to 24 hours after onset may be appropriate;
    • a favourable profile on salvageable brain tissue imaging has been proven, in which case treatment up to 12 hours after onset may be appropriate.
  • Patients with AIS treated with thrombolysis should be started on an antiplatelet agent after 24 hours unless contraindicated, once significant haemorrhage has been excluded.
  • Patients with AIS should be given aspirin 300mg as soon as possible within 24 hours (unless contraindicated):
    • orally if they are not dysphagic;
    • rectally or by enteral tube if they are dysphagic.
  • Thereafter aspirin 300 mg daily should be continued until 2 weeks after the onset of stroke at which time long-term antithrombotic treatment should be initiated. Patients being transferred to care at home before 2 weeks should be started on long-term treatment earlier.
  • Patients with AIS reporting previous dyspepsia with an antiplatelet agent should be given a proton pump inhibitor in addition to aspirin.
  • Patients with AIS who are allergic to or intolerant of aspirin should be given an alternative antiplatelet agent (e.g. clopidogrel).
  • Patients eligible for IV alteplase should receive IV alteplase even if EVTs are being considered.
  • In patients under consideration for mechanical thrombectomy, observation after IV alteplase to assess for clinical response should not be performed.
  • Patients should receive mechanical thrombectomy with a stent retriever if they meet all the following criteria: (1) prestroke mRS score of 0 to 1; (2) causative occlusion of the internal carotid artery or MCA segment 1 (M1); (3) age ≥18 years; (4) NIHSS score of ≥6; (5) ASPECTS of ≥6; and (6) treatment can be initiated (groin puncture) within 6 hours of symptom onset.
  • Although the benefits are uncertain, the use of mechanical thrombectomy with stent retrievers may be reasonable for carefully selected patients with AIS in whom treatment can be initiated (groin puncture) within 6 hours of symptom onset and who have causative occlusion of the MCA segment 2 (M2) or MCA segment 3 (M3) portion of the MCAs.
  • Although the benefits are uncertain, the use of mechanical thrombectomy with stent retrievers may be reasonable for carefully selected patients with AIS in whom treatment can be initiated (groin puncture) within 6 hours of symptom onset and who have causative occlusion of the anterior cerebral arteries, vertebral arteries, basilar artery, or posterior cerebral arteries.
  • Although its benefits are uncertain, the use of mechanical thrombectomy with stent retrievers may be reasonable for patients with AIS in whom treatment can be initiated (groin puncture) within 6 hours of symptom onset and who have prestroke mRS score >1, ASPECTS <6, or NIHSS score <6, and causative occlusion of the internal carotid artery (ICA) or proximal MCA (M1). Additional randomized trial data are needed.
  • In selected patients with AIS within 6 to 16 hours of last known normal who have LVO in the anterior circulation and meet other DAWN or DEFUSE 3 eligibility criteria, mechanical thrombectomy is recommended.
  • In selected patients with AIS within 6 to 24 hours of last known normal who have LVO in the anterior circulation and meet other DAWN eligibility criteria, mechanical thrombectomy is reasonable
  • The technical goal of the thrombectomy procedure should be reperfusion to a modified Thrombolysis in Cerebral Infarction (mTICI) 2b/3 angiographic result to maximize the probability of a good functional clinical outcome.
  • As with IV alteplase, reduced time from symptom onset to reperfusion with endovascular therapies is highly associated with better clinical outcomes. To ensure benefit, reperfusion to TICI grade 2b/3 should be achieved as early as possible within the therapeutic window.
  • Use of stent retrievers is indicated in preference to the Mechanical Embolus Removal in Cerebral Ischemia (MERCI) device.
  • The use of mechanical thrombectomy devices other than stent retrievers as first-line devices for mechanical thrombectomy may be reasonable in some circumstances, but stent retrievers remain the first choice
  • The use of a proximal balloon guide catheter or a large-bore distal-access catheter, rather than a cervical guide catheter alone, in conjunction with stent retrievers may be beneficial. Future studies should examine which systems provide the highest recanalization rates with the lowest risk for nontarget embolization.
  • Use of salvage technical adjuncts including intra-arterial thrombolysis may be reasonable to achieve mTICI 2b/3 angiographic results
  • EVT of tandem occlusions (both extracranial and intracranial occlusions) at the time of thrombectomy may be reasonable
  • It is reasonable to select an anesthetic technique during endovascular therapy for AIS on the basis of individualized assessment of patient risk factors, technical performance of the procedure, and other clinical characteristics. Further randomized trial data are needed.
  • In patients who undergo mechanical thrombectomy, it is reasonable to maintain the BP ≤180/105 mm Hg during and for 24 hours after the procedure.
  • In patients who undergo mechanical thrombectomy with successful reperfusion, it might be reasonable to maintain BP at a level <180/105 mm Hg.
Antiplatelets post AIS
  • Administration of aspirin is recommended in patients with AIS within 24 to 48 hours after onset. For those treated with IV alteplase, aspirin administration is generally delayed until 24 hours later but might be considered in the presence of concomitant conditions for which such treatment given in the absence of IV alteplase is known to provide substantial benefit or withholding such treatment is known to cause substantial risk.
  • Aspirin is not recommended as a substitute for acute stroke treatment in patients who are otherwise eligible for IV alteplase or mechanical thrombectomy.
  • In patients presenting with minor stroke, treatment for 21 days with dual antiplatelet therapy (aspirin and clopidogrel) begun within 24 hours can be beneficial for early secondary stroke prevention for a period of up to 90 days from symptom onset.
  • For patients with non-cardioembolic AIS, the use of antiplatelet agents rather than oral anticoagulation is recommended to reduce the risk of recurrent stroke and other cardiovascular events.
  • For patients who have a noncardioembolic AIS while taking aspirin, increasing the dose of aspirin or switching to an alternative antiplatelet agent for additional benefit in secondary stroke prevention is not well established.
  • For patients who have a noncardioembolic AIS while taking antiplatelet therapy, switching to warfarin is not beneficial for secondary stroke prevention.
  • For early secondary prevention in patients with noncardioembolic AIS, the selection of an antiplatelet agent should be individualized on the basis of patient risk factor profiles, cost, tolerance, relative known efficacy of the agents, and other clinical characteristics.
  • For patients with a history of ischemic stroke, atrial fibrillation, and coronary artery disease, the usefulness of adding antiplatelet therapy to oral anticoagulants is uncertain for purposes of reducing the risk of ischemic cardiovascular and cerebrovascular events. Unstable angina and coronary artery stenting represent special circumstances in which management may warrant dual antiplatelet/oral anticoagulation.
  • For patients with AIS and hemorrhagic transformation, initiation or continuation of antiplatelet or anticoagulation therapy may be considered, depending on the specific clinical scenario and underlying indication.
  • For patients with AIS and extracranial carotid or vertebral arterial dissection, treatment with either antiplatelet or anticoagulant therapy for 3 to 6 months may be reasonable.
  • For patients with AIS and extracranial carotid or vertebral arterial dissection who have definite recurrent cerebral ischemic events despite medical therapy, the value of EVT (stenting) is not well established.
Anticoagulants
  • For people with ischaemic stroke or TIA and paroxysmal, persistent or permanent AF (AF: valvular or non-valvular) or atrial flutter, anticoagulation should be the standard treatment. Anticoagulation: should not be given until brain imaging has excluded haemorrhage; should not be commenced in people with uncontrolled hypertension;
  • for people with disabling ischaemic stroke should be deferred until at least 14 days from onset - aspirin 300 mg daily should be used in the meantime;
  • for people with non-disabling ischaemic stroke should be deferred for an interval at the discretion of the prescriber, but no later than 14 days from the onset;
  • should be commenced immediately after a TIA once brain imaging has excluded haemorrhage, using an agent with a rapid onset (e.g. low molecular weight heparin or a direct thrombin or factor Xa inhibitor - the latter confined to people with non-valvular AF).
  • People with stroke or TIA in sinus rhythm should not receive anticoagulation unless there is an indication such as a cardiac source of embolism, cerebral venous thrombosis or arterial dissection.
  • Anticoagulation for people with TIA or stroke should be with:adjusted-dose warfarin (target INR 2.5, range 2.0 to 3.0) with a target time in the therapeutic range of greater than 72%; or a direct thrombin or factor Xa inhibitor (for people with non-valvular AF).
  • For people with cardioembolic stroke for whom treatment with anticoagulation is considered inappropriate: antiplatelet treatment should not be used as an alternative for people with absolute contraindications to anticoagulation (e.g. undiagnosed bleeding);measures should be taken to reduce bleeding risk, using a tool such as HAS-BLED to identify modifiable risk factors. If after intervention for relevant risk factors the bleeding risk is considered too high for anticoagulation, antiplatelet treatment should not be used as an alternative; consider a left atrial appendage occlusion device as an alternative.
  • People with recurrent TIA or stroke should receive the same antithrombotic treatment as those who have had a single event. More intensive antiplatelet therapy or anticoagulation treatment should only be given as part of a clinical trial or in exceptional clinical circumstances.
  • For most patients with an AIS in the setting of atrial fibrillation, it is reasonable to initiate oral anticoagulation within 4 to 14 days after the onset of neurological symptoms.
  • Urgent anticoagulation, with the goal of preventing early recurrent stroke, halting neurological worsening, or improving outcomes after AIS, is not recommended for treatment of patients with AIS.
  • The usefulness of urgent anticoagulation in patients with severe stenosis of an internal carotid artery ipsilateral to an ischemic stroke is not well established.
  • The safety and usefulness of short-term anticoagulation for nonocclusive, extracranial intraluminal thrombus in the setting of AIS are not well established.
Volume Expansion/Hemodilution, Vasodilators, and Hemodynamic Augmentation
  • Patients with acute stroke should have their hydration assessed using multiple methods within four hours of arrival at hospital, and should be reviewed regularly and managed so that normal hydration is maintained.
  • Hemodilution by volume expansion is not recommended for treatment of patients with AIS.
Cholesterol
  • Do not use fibrates, ezetimibe, bile acid sequestrants, nicotinic acid or omega-3 fatty acids for cholesterol-lowering after stroke if the patient is unable to tolerate a statin. Do try alternative methods to improve the tolerability of a statin such as a reduced dose, alternateday dosing or a lower-intensity statin
  • People with ischaemic stroke or TIA should be offered advice on lifestyle factors that may modify lipid levels, including diet, physical activity, weight, alcohol and smoking.
  • People with ischaemic stroke or TIA should be offered treatment with a statin drug unless contraindicated. Treatment should: begin with a high intensity statin such as atorvastatin 20-80mg daily; Be with an alternative statin at the maximum tolerated dose if a high intensity statin is unsuitable or not tolerated; aim for a greater than 40% reduction in non-HDL cholesterol. If this is not achieved within 3 months, the prescriber should discuss adherence and timing of dose and optimise dietary and lifestyle measures; consider increasing to a higher dose if this was not prescribed from the outset.
  • People with ischaemic stroke or TIA should not be prescribed fibrates, bile acid sequestrants, nicotinic acid or omega-3 fatty acid compounds for secondary vascular prevention. Ezetimibe should be used only in people who also have familial hypercholesterolaemia.
  • People with primary intracerebral haemorrhage should avoid statin treatment unless it is required for other indications.
  • Routine measurement of blood cholesterol levels in all patients with ischemic stroke presumed to be of atherosclerotic origin who are not already taking a high-intensity statin is not recommended
  • Measurement of blood cholesterol levels in patients with ischemic stroke presumed to be of atherosclerotic origin who are already taking an optimized regimen of statin therapy may be useful for identifying patients who would be candidates for outpatient proprotein convertase subtilisin/kexin type 9 inhibitor treatment to reduce the risk of subsequent cardiovascular death, MI, or stroke.
  • Among patients already taking statins at the time of onset of ischemic stroke, continuation of statin therapy during the acute period is reasonable.
  • High-intensity statin therapy should be initiated or continued as first-line therapy in women and men ≤75 years of age who have clinical ASCVD*, unless contraindicated.
  • In individuals with clinical ASCVD* in whom high-intensity statin therapy would otherwise be used, when high-intensity statin therapy is contraindicated or when characteristics predisposing to statin-associated adverse effects are present, moderate-intensity statin should be used as the second option if tolerated.
  • In individuals with clinical ASCVD* >75 years of age, it is reasonable to evaluate the potential for ASCVD risk-reduction benefits and for adverse effects and drug-drug interactions and to consider patient preferences when initiating a moderate- or high-intensity statin. It is reasonable to continue statin therapy in those who are tolerating it.
  • Patients with ischemic stroke and other comorbid ASCVD should be otherwise managed according to the 2013 ACC/AHA cholesterol guidelines, which include lifestyle modification, dietary recommendations, and medication recommendations.
  • For patients with an AIS who qualify for statin treatment, in-hospital initiation of statin therapy is reasonable.
Vertebral Artery and Intracranial Disease
  • People with ischaemic stroke or TIA and symptomatic vertebral artery stenosis should receive optimal secondary prevention including antiplatelet therapy, blood pressure treatment, lipidlowering therapy and lifestyle modification. Angioplasty and stenting of the vertebral artery should only be offered in the context of a clinical trial.
  • People with ischaemic stroke or TIA due to severe symptomatic intracranial stenosis should be offered dual antiplatelet therapy with aspirin and clopidogrel for the first three months in addition to optimal secondary prevention including blood pressure treatment, lipid-lowering therapy and lifestyle modification. Endovascular or surgical intervention should only be offered in the context of a clinical trial.
Cervical Dissection
  • Any patient suspected of cervical artery dissection should be investigated with CT or MR including angiography.
  • Patients with acute ischaemic stroke suspected to be due to cervical arterial dissection should receive alteplase if they are otherwise eligible.
  • Patients with acute ischaemic stroke suspected to be due to cervical arterial dissection should be treated with either an anticoagulant or an antiplatelet agent for at least 3 months.
  • IV alteplase in AIS known or suspected to be associated with extracranial cervical arterial dissection is reasonably safe within 4.5 h and probably recommended.
  • IV alteplase usefulness and hemorrhagic risk in AIS known or suspected to be associated with intracranial arterial dissection remain unknown, uncertain, and not well established.†
  • For patients with AIS and extracranial carotid or vertebral arterial dissection, treatment with either antiplatelet or anticoagulant therapy for 3 to 6 months may be reasonable.
  • For patients with AIS and extracranial carotid or vertebral arterial dissection who have definite recurrent cerebral ischemic events despite medical therapy, the value of EVT (stenting) is not well established.
  • People with stroke or TIA in sinus rhythm should not receive anticoagulation unless there is an indication such as a cardiac source of embolism, cerebral venous thrombosis or arterial dissection
Secondary Prevention tests
  • People with ischaemic stroke or TIA in whom other conditions such as AF and large or small vessel atherosclerotic disease have been excluded should be investigated for antiphospholipid syndrome (APS) (with IgG and IgM anticardiolipin ELISA and lupus anticoagulant), particularly if the person: is under 50 years of age; has any autoimmune rheumatic disease, particularly SLE; has a history of one or more venous thromboses; has a history of recurrent first trimester pregnancy loss or at least one late pregnancy loss (second or third trimester).
  • People with APS who have an ischaemic stroke or TIA: should be managed acutely in the same way as people without APS; should have decisions on long-term secondary prevention made on an individual basis in conjunction with appropriate specialists including haematology and/or rheumatology.
  • Baseline troponin assessment is recommended in patients presenting with AIS but should not delay initiation of IV alteplase or mechanical thrombectomy.
  • Routine screening for hyperhomocysteinemia among patients with a recent ischemic stroke is not indicated.
  • The usefulness of screening for thrombophilic states in patients with ischemic stroke is unknown.
  • Anticoagulation might be considered in patients who are found to have abnormal findings on coagulation testing after an initial ischemic stroke, depending on the abnormality and the clinical circumstances.
  • Routine testing for antiphospholipid antibodies is not recommended for patients with ischemic stroke who have no other manifestations of the antiphospholipid syndrome and who have an alternative explanation for their ischemic event, such as atherosclerosis, carotid stenosis, or AF.
Decompressive Hemicraniectomy (AIS)
Patients with middle cerebral artery (MCA) infarction who meet the criteria below should be considered for decompressive hemicraniectomy. Patients should be referred to neurosurgery within 24 hours of stroke onset and treated within 48 hours of stroke onset.
  • pre-stroke modified Rankin Scale score of less than 2;
  • clinical deficits indicating infarction in the territory of the MCA;
  • NIHSS > 15;
  • A decrease in the level of consciousness to a score of 1 or more on item 1a of the NIHSS;
  • Signs on CT of an infarct of at least 50% of the MCA territory with or without additional infarction in the territory of the ACA or PCA on the same side, or infarct volume greater than 145 cubic centimetres on diffusion-weighted MRI.
  • Although the optimal trigger for decompressive craniectomy is unknown, it is reasonable to use a decrease in level of consciousness attributed to brain swelling as selection criteria.
  • In patients ≤60 years of age with unilateral MCA infarctions who deteriorate neurologically within 48 hours despite medical therapy, decompressive craniectomy with dural expansion is reasonable because it reduces mortality by close to 50%, with 55% of the surgical survivors achieving moderate disability (able to walk) or better (mRS score 2 or 3) and 18% achieving independence (mRS score 2) at 12 months.
  • In patients >60 years of age with unilateral MCA infarctions who deteriorate neurologically within 48 hours despite medical therapy, decompressive craniectomy with dural expansion may be considered because it reduces mortality by close to 50%, with 11% of the surgical survivors achieving moderate disability (able to walk [mRS score 3]) and none achieving independence (mRS score ≤2) at 12 months.
  • Use of osmotic therapy for patients with clinical deterioration from cerebral swelling associated with cerebral infarction is reasonable.
  • Use of brief moderate hyperventilation (Pco2 target 30-34 mm Hg) is a reasonable treatment for patients with acute severe neurological decline from brain swelling as a bridge to more definitive therapy.
  • Because of a lack of evidence of efficacy and the potential to increase the risk of infectious complications, corticosteroids (in conventional or large doses) should not be administered for the treatment of cerebral edema and increased intracranial pressure complicating ischemic stroke.
Training
  • Ensure processes throughout the emergency pathway to minimise delays to treatment, to ensure that thrombolysis is administered as soon as possible after stroke onset;
  • staff trained in the delivery of thrombolysis and monitoring for post-thrombolysis complications;
  • nurse staffing levels equivalent to those required in level 1 or level 2 nursing care with training in acute stroke and thrombolysis;
  • immediate access to imaging and re-imaging, and staff appropriately trained to interpret the images;
  • protocols in place for the management of post-thrombolysis complications.
  • Hyperacute stroke services providing endovascular therapy should participate in national stroke audit to enable comparison of the clinical and organisational quality of their services with national data, and use the findings to plan and deliver service improvements.
Fabry Disease
  • Young people with stroke or TIA should be investigated for Fabry disease if they have suggestive clinical features such as acroparesthesias, angiokeratomas, sweating abnormalities, corneal opacities, unexplained renal insufficiency or a family history suggesting the condition.
  • People with stroke or TIA and a diagnosis of Fabry disease should receive optimal secondary prevention and be referred to specialist genetic and metabolic services for advice on other aspects of care including the provision of enzyme replacement therapy.
  • No comments
Seizures
  • Recurrent seizures after stroke should be treated in a manner similar to when they occur with other acute neurological conditions, and anti-seizure drugs should be selected based upon specific patient characteristics.
  • Prophylactic use of anti-seizure drugs is not recommended.
Imaging
  • Routine use of brain MRI in all patients with AIS is not cost-effective and is not recommended for initial diagnosis or to plan subsequent treatment.
  • In some patients with AIS, the use of MRI might be considered to provide additional information for initial diagnosis or to plan subsequent treatment, although the effect on outcomes is uncertain.
  • For patients with nondisabling (mRS score 0-2) AIS in the carotid territory who are candidates for CEA or stenting, noninvasive imaging of the cervical vessels should be performed routinely within 24 hours of admission.
  • In patients with AIS, routine noninvasive imaging by means of CTA or MRA of the intracranial vasculature to determine the presence of intracranial arterial stenosis or occlusion is not recommended to plan subsequent secondary preventive treatment.
  • In some patients with AIS, noninvasive imaging by means of CTA or MRA of the intracranial vasculature to provide additional information to plan subsequent secondary preventive treatment may be reasonable, although the effect on outcomes is uncertain
Cardiac
  • People with stroke or TIA should be investigated with transthoracic echocardiography if the detection of a structural cardiac abnormality would prompt a change of management and if they have: clinical or ECG findings suggestive of structural cardiac disease that would require assessment in its own right, or unexplained stroke or TIA, especially if other brain imaging features suggestive of cardioembolism are present.
  • Cardiac monitoring is recommended to screen for atrial fibrillation and other potentially serious cardiac arrhythmias that would necessitate emergency cardiac interventions. Cardiac monitoring should be performed for at least the first 24 hours.
  • The clinical benefit of prolonged cardiac monitoring to detect atrial fibrillation after AIS is uncertain.
  • In some patients with AIS, prolonged cardiac monitoring to provide additional information to plan subsequent secondary preventive treatment may be reasonable, although the effect on outcomes is uncertain.
  • Routine use of echocardiography in all patients with AIS to plan subsequent secondary preventive treatment is not cost-effective and is not recommended.
  • In selected patients with AIS, echocardiography to provide additional information to plan subsequent secondary preventive treatment may be reasonable.
Acute Ischaemic stroke Cerebellar and Cerebral Oedema
  • Acute stroke services should have protocols for the monitoring, referral and transfer of patients to regional neurosurgical centres for decompressive hemicraniectomy, surgical management of intracranial haemorrhage and the management of symptomatic hydrocephalus including external ventricular drain insertion
  • Ventriculostomy is recommended in the treatment of obstructive hydrocephalus after a cerebellar infarct. Concomitant or subsequent decompressive craniectomy may or may not be necessary on the basis of factors such as infarct size, neurological condition, degree of brainstem compression, and effectiveness of medical management.
  • Decompressive suboccipital craniectomy with dural expansion should be performed in patients with cerebellar infarction causing neurological deterioration from brainstem compression despite maximal medical therapy. When deemed safe and indicated, obstructive hydrocephalus should be treated concurrently with ventriculostomy.
  • When considering decompressive suboccipital craniectomy for cerebellar infarction, it may be reasonable to inform family members that the outcome after cerebellar infarct can be good after sub-occipital craniectomy.
Management of ICH
  • Patients with ICH in association with vitamin K antagonist treatment should have the anticoagulant urgently reversed with a combination of PCC and IV vitamin K.
  • Patients with ICH in association with dabigatran treatment should have the anticoagulant urgently reversed with idarucizumab.
  • Patients with ICH in association with factor Xa inhibitor treatment should receive urgent treatment with 4-factor PCC.
ICH and BP
Patients with primary ICH who present within 6 hours of onset with a systolic blood pressure above 150mmHg should be treated urgently using a locally agreed protocol for blood pressure lowering to a systolic blood pressure of 140 mmHg for at least 7 days, unless:
  • the Glasgow Coma Scale score is 5 or less;
  • the haematoma is very large and death is expected;
  • a structural cause for the haematoma is identified;
  • immediate surgery to evacuate the haematoma is planned.
ICH and Hydrocephalus
  • Patients with ICH should be admitted directly to a HASU for monitoring of conscious level and referred immediately for repeat brain imaging if deterioration occurs.
  • Patients with ICH who develop hydrocephalus should be considered for surgical intervention such as insertion of an external ventricular drain.

Abbreviations:

  • ICH intracranial haemorrhage
  • middle cerebral artery (MCA)
  • Acute ischaemic stroke (AIS)
  • prothrombin complex concentrate (PCC) Reference Author Outcome

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