Stroke Australian Guideline
Stroke Australian Guideline
Stroke Australian Guideline
Disclaimer
This document is a general guide to appropriate practice, to be followed subject to the clinician’s judgement and the patient’s preference in each individual case.
The guidelines are designed to provide information to assist decision-making and are based on the best evidence available at the time development.
These guidelines can be downloaded from the NHMRC website: www.nhmrc.gov.au/publications.
Copies of the document can also be downloaded through the National Stroke Foundation website: www.strokefoundation.com.au.
Funding
The National Stroke Foundation gratefully acknowledges the financial assistance for the consumer consultation process during the guideline develop process
which was provided by the Australian Government Department of Health and Ageing.
About
the National Stroke Foundation
The National Stroke Foundation is a not-for-profit organisation that works with the public, government, health
professionals, patients, carers and stroke survivors to reduce the impact of stroke on the Australian community.
Our challenge is to save 110,000 Australians from death and disability due to stroke over 10 years.
This second edition of the Clinical Guidelines for Acute remains much we can improve on, particularly, access
Stroke Management represents a major undertaking to key effective acute interventions such as stroke
which has significantly updated the first edition in both care units and rt-PA.
methodology and coverage. The current edition has
been expanded with new information covering Evidence from a recent national survey demonstrates
Transient Ischaemic Attack (TIA) assessment and the number of stroke units in Australia is slowly
management, and the economic implications of the increasing.1 However, organised stroke care remains
guidelines. Greater details regarding early the cornerstone of effective stroke care and must
management of ischaemic and haemorrhagic stroke remain the priority for implementation of these
Preface
are also included in this update. It also includes a updated guidelines. Furthermore, for the first time
consumer rating, identifying aspects of care patient data involved in acute stroke care has been
considered to be critical from a patient perspective audited nationally.1 This is an exciting initiative that will
that will complement the evidence ratings for each provide more detailed assessment of the current care
recommendation. provided in acute stroke management and will enable
more targeted quality improvement activities to be
There is a growing evidence base for stroke care with undertaken.
significant new trials for many topics included in these
guidelines including assessment of TIA, Although this edition highlights the advancement in
pharmacotherapy used in secondary prevention knowledge, there still remains much work for
(cholesterol lowering and antiplatelet therapy), surgery researchers, with only 82 of the 148 recommendations
for ‘malignant’ middle cerebral artery infarction to underpinned by Level I or Level II evidence.
name a few. The last four years have also seen a Highlighted areas for further research have been
greater focus on early recognition and faster, more included in this edition.
efficient assessment which has necessitated ongoing
collaboration between emergency service personnel, Finally, we are very grateful for the ongoing support
emergency department staff and specialist stroke unit and time from a wide range of dedicated experts. In
teams. Focus on, and access to, thrombolysis has particular special thanks goes to those involved on the
also advanced since the approval of rt-PA in Australia expert working group who contributed much time and
in 2003. While changes have been made, there effort in developing these guidelines.
Dr Denis Crimmins Assoc Prof Chris Levi Prof Chris Bladin Dr Erin Lalor
Chair, Expert Medical Co-Director, Medical Co-Director, CEO,
Working Group NSF NSF NSF
i
KEY MESSAGES
This second edition of the Clinical Guidelines for Acute included in a preamble to each section. Because of
Stroke Management has been developed to provide a this, the recommendations should be read in
series of evidence-based recommendations related to conjunction with information in the body of the main
acute stroke care. The guidelines should not be seen document. Further information in relation to key
as an inflexible recipe for stroke care; rather, they sections is provided in tables of evidence in the
provide a framework that is based on the best supplement document.
available evidence that can be adapted to local needs,
Unlike previous stroke guidelines, each
resources and individual circumstances. Development
recommendation is given an overall grading based
Key Messages
Grading of Recommendations3
GRADE DESCRIPTION
A Body of evidence can be trusted to guide practice
B Body of evidence can be trusted to guide practice in most situations
C Body of evidence provides some support for recommendation(s) but care should be taken in its application
D Body of evidence is weak and recommendation must be applied with caution
ii
Designations of Levels of Evidence According to Type of Research Question3
Key Messages
among consecutive patients
with a defined clinical
presentation
iv Case series with Study of diagnostic yield Case series, or A cross-sectional Case series
either post-test or (no reference standard) cohort study of study
pre-test/post-test patients at
outcomes different stages
of disease
iii
1. Organisation of Services
> Those identified at low risk (ABCD2 score or = 4) 1.9: Early Supported Discharge
may be managed in the community by a general a) Health services with organised inpatient
practitioner, private specialist or where possible stroke services should provide comprehensive
referred to a specialist TIA clinic and seen within interdisciplinary community rehabilitation and
7-10 days. ( ) support services for people with stroke and their
family/carer. (Grade A; Level I 61-63)
1.3: Organisation of care for rural centres
a) All health services caring for people with stroke b) If interdisciplinary community rehabilitation services
should use networks which link large stroke and carer support services are available, then early
specialist centres with smaller regional and rural supported discharge should be offered for all stroke
centres. (Grade D; Level IV 36, 37, 39, 42) patients with mild to moderate disability.
(Grade A; Level I 61, 62)
b) These networks should assist to establish
appropriate stroke units along with protocols 1.10: Shared care
governing rapid assessment, pathways for direct a) All patients with stroke or TIA should have their risk
communication with stroke specialist centres factors reviewed and managed long term by a
(“telestroke” services), and rapid transfers. general practitioner with input and/or referral to a
(Grade D; Level IV 36, 37, 39, 42) stroke physician for specialist review where
available. (Grade C; Level II 68)
1.4: Care Pathways
All stroke patients admitted to hospital may b) Locally developed protocols and pathways should
be managed using an acute care pathway. be used to efficiently link primary and secondary
(Grade C; Level II 44) care for people with stroke or TIA, including rapid
assessment and referrals, acute management,
1.5: Inpatient care coordinator
direct communication links, efficient discharge
A stroke coordinator may be used to foster services and long term management. ( )
coordination of services and assist in discharge
planning. ( )
iv
2. Pre-Hospital Care
c) Rural practitioners should participate in networks a) Ambulance services, health care professionals
linking them to regional or metropolitan centres with and the general public should receive education
specialty in stroke care. ( ) concerning the importance of early recognition of
stroke, emphasising stroke is a medical emergency.
1.11: Standardised assessment
(Grade C; Level III-3 & IV 39)
a) Clinicians should use validated and reliable
assessment tools or measures that meet the b) Stroke patients should be given a high priority
needs of the patient and guide clinical decision grouping by ambulance services.
(Grade C; Level III-2 83, 84)
Key Messages
making. ( )
b) Clinicians should provide timely and efficient c) Ambulance services should be trained in the use
assessment of patients with acute stroke. Where of validated rapid pre-hospital stroke screening
possible a multidisciplinary assessment should be tools and incorporate such tools into protocols for
undertaken and documented within two days of all pre-hospital assessment of people with
admission. ( ) suspected stroke. (Grade B; Level III-2 86-89 )
c) Assessment findings should be discussed at the team d) Ambulance services should preferentially transfer
meeting and communicated to the patient and suspected patients to a hospital with stroke unit
family/carer in a timely and appropriate manner. ( ) care. ( )
c) Acute stroke patients should have access to b) The following investigations should be undertaken
specialist palliative care services as needed. ( ) routinely for all patients with suspected TIA: full
blood count, electrolytes, renal function, cholesterol
d) People with stroke who are dying, and their
level, glucose level, and electrocardiogram. ( )
families, should have care that is consistent with
the principles and philosophies of palliative care. ( ) c) Patients classified as high risk (ABCD2 >4) should
have an urgent CT brain (‘urgent’ is considered as
1.13: Stroke service improvement
soon as possible, but certainly within 24 hours).
a) All acute stroke services should be involved in Carotid duplex ultrasound should also be
quality improvement activities that include regular undertaken urgently in patients with carotid territory
audit and feedback (‘regular’ is considered at least symptoms who would potentially be candidates for
every two years). (Grade B; Level I 77) carotid re-vascularisation. Patients classified as low
b) Indicators based on nationally agreed standards of risk (ABCD2 4) should have a CT brain and carotid
care should be used when undertaking any audit. ultrasound (where indicated) as soon as possible
Performance can then be compared to similar (i.e. within 48-72 hours). (Grade B; Level I 35, 100, 102
stroke services as described by the National Stroke & Level III-3 99)
Unit Program. ( )
v
3.2: Triage in emergency department prothrombotic screen. These tests should be
a) Diagnosis should be reviewed by a clinician performed as soon as possible after stroke onset,
experienced in the evaluation of stroke. and in selected patients, some of these tests
(Grade C; Level III-3 108, 111) may need to be performed as an emergency
procedure. (✓)
b) Emergency department staff should use a validated
stroke screen tool to assist in rapid accurate
assessment for all people with stroke.
4. Acute Medical and
(Grade C; Level II 112)
Key Messages
Surgical Management
c) Local protocols developed jointly by staff from
pre hospital emergency services, the hospital 4.1: Ischaemic Stroke and TIA
emergency department and the stroke unit should 4.1.2: Thrombolysis
be used for all people with suspected stroke. Such a) Intravenous rt-PA in acute ischaemic stroke
protocols should include early notification by should only be undertaken in patients satisfying
paramedic staff, high priority transportation and specific inclusion and exclusion criteria.
triage, rapid referrals from ED staff to stroke (Grade A; Level I 120, 122)
specialists and rapid access to imaging. (Grade D;
b) Intravenous rt-PA in acute ischaemic stroke should
Level III-3 & IV 39, 83, 85)
be given under the authority of a specialist physician
3.3: Imaging and interdisciplinary acute care team with expert
a) All patients with suspected stroke should have an knowledge of stroke management, experience in
urgent brain CT or MRI (‘urgent’ is considered as the use of intravenous thrombolytic therapy and
soon as possible, but certainly less than 24 hours). with pathways and protocols available to guide
(Grade A; Level I diagnostic study 100) medical, nursing and allied health acute phase
management. Pathways or protocols must include
b) A repeat brain CT or MRI should be considered
guidance in acute blood pressure management.
urgently when a patient’s condition deteriorates. (✓)
(Grade C; Level I 120 & Level IV 123)
c) All patients with carotid territory symptoms who
c) Thrombolysis should only be undertaken in a
would potentially be candidates for carotid
hospital setting with appropriate infrastructure,
re-vascularisation should have an urgent carotid
facilities and networks. (✓)
duplex ultrasound. (Grade B; Level I 102)
d) A minimum set of de-identified data from all
d) Further brain, cardiac or carotid imaging should be
patients treated with thrombolysis should be
undertaken in selected cases including:
recorded in a central register to allow monitoring,
> Patients where initial assessment has not review, comparison and benchmarking of key
confirmed likely source of ischaemic event; outcomes measures over time.
> Patients with a history of more than one TIA; (Grade C; Level IV 126)
> Patients likely to undergo carotid surgery.
4.1.3: Antithrombotic therapy
(Grade B; Level I 100, 102 and Level III-2 116)
a) Aspirin (150-300mg) should be given as soon
3.4: Investigations
as possible after the onset of stroke symptoms
a) The following investigations should be obtained (i.e. within 48 hours) if CT/MRI scan excludes
routinely in all patients – full blood picture, haemorrhage. (Grade A; Level I 160)
electrocardiogram, electrolytes, renal function,
b) The routine use of anticoagulation (e.g. intravenous
fasting lipids, erythrocyte sedimentation rate and/or
unfractionated heparin) in unselected patients
C-reactive protein, and glucose. (✓)
following ischaemic stroke/TIA is not
b) Selected patients may require the following recommended. (Grade A; Level I 157, 158)
additional investigations: angiography, chest
x-ray, syphilis serology, vasculitis screen and
vi
4.1.4: Blood pressure lowering therapy saturation, glucose, and respiratory pattern monitored
a) If extremely high blood pressure (e.g. BP > and documented regularly during the acute phase,
220/120) exists, instituting or increasing the frequency of such observations being determined
antihypertensive therapy may be started, but blood by the patient’s status. (Grade C, Level II 185 and Level
pressure should be cautiously reduced (e.g. by no III-2 186, 187)
more than 10-20%) and the patient observed for 4.3.2: Oxygen therapy
signs of neurological deterioration. (✓)
Patients who are hypoxic should be given oxygen
Key Messages
b) Pre-existing antihypertensive therapy may be supplementation. (✓)
continued (orally or via nasogastric tube) provided
4.3.3: Glycaemic control
there is no symptomatic hypotension or other
reason to withhold treatment. (✓) a) Patients with hyperglycaemia should have their
blood glucose level monitored and appropriate
4.1.5: Surgery for ischaemic stroke
glycaemic therapy instituted to ensure euglycaemia,
a) Selected patients (e.g. 18-60 years where surgery
especially if the patient is diabetic. Hypoglycaemia
can occur within 48 hours of symptom onset) with
should be avoided. (✓)
significant middle cerebral artery infarction should
be urgently referred to a neurosurgeon for b) Intensive, early maintenance of euglycaemia is
consideration of hemicraniectomy. currently not recommended. (Grade B; Level II 198)
(Grade A; Level I 165) 4.3.4: Neuroprotective agents
b) There is currently insufficient evidence to make The use of putative neuroprotectors should only be
recommendations about the use of intracranial used if part of a randomised controlled trial.
endovascular surgery. (Level I 166) (Grade A; Level I&II 199-202)
4.2: Intracerebral haemorrhage (ICH) 4.3.5: Complementary and alternative therapy
a) The use of haemostatic drug treatment with rFVIIa is a) The routine use of the following complementary and
currently considered experimental and is not alternative therapies are not recommended:
recommended for use outside a clinical trial. (Grade
> Acupuncture; (Grade B, Level I 216, 217)
B; Level I 169)
> Ginkgo biloba extract or Dan shen agents;
b) The routine use of surgery is not recommended for (Grade B, Level I 219, 220)
patients with supratentorial haematoma but may be > Reiki therapy; (Grade C, Level II 218)
considered in certain circumstances, including: > Other alternative therapies. (✓)
> stereotactic surgery for patients with deep ICH; b) Health professionals should be aware of different
(Grade C; Level I 181) forms of complementary and alternative therapies
> craniotomy for patients where haematoma is and be available to discuss these with stroke
superficial (<1cm from surface). (Grade C; Level II 180) survivors and their families. (✓)
c) Surgical evacuation may be undertaken for
cerebellar hemisphere haematomas >3cm diameter
in selected patients. (✓) 5. Assessment and Management
of Consequences of Stoke
d) In ICH patients who have a history of hypertension,
mean arterial pressure should be maintained below 5.1: Dysphagia
130 mm Hg. (✓)
a) Patients should be screened for swallowing deficits
4.3 General Acute Stroke Care before being given food, drink or oral medications.
Screening should be undertaken by personnel
4.3.1: Physiological monitoring
specifically trained in swallowing screening. (Grade
Patients should have their neurological status C, Level I 225, 226)
(including Glasgow Coma Scale) and vital signs
b) Patients should be screened within 24 hours of
including pulse, blood pressure, temperature, oxygen
admission. (✓)
vii
c) Patients who fail the swallowing screening should outcomes relating to functional performance in daily
be referred to a speech pathologist for a activities, sensorimotor, perceptual and cognitive
comprehensive assessment. (✓) capacities. (✓)
5.2: Nutrition 5.5: Cognition and perception
a) Close monitoring of hydration status and a) All patients should be screened for cognitive
appropriate fluid supplementation should be used and perceptual deficits using a validated screening
to treat or prevent dehydration. (Grade B; Level I 250) tool. (✓)
Key Messages
b) All patients with acute stroke should be screened b) Patients identified during screening should
for malnutrition. (Grade B; Level II 260) undertake full assessment and management
by an appropriately trained health professional.
c) Those who are at risk of malnutrition, including
(✓)
those with dysphagia, should be referred to a
dietitian for assessment and ongoing management. 5.6: Communication
Assessment of nutritional status should include the a) All patients should be screened for communication
use of validated nutrition assessment tools or deficits using a validated screening tool. (Grade C,
measures. (✓) Level I 293)
d) Nutritional supplementation should be offered to b) Those with suspected communication difficulties
people whose nutritional status is poor or should receive formal assessment by a speech
deteriorating. (Grade A; Level I 252) pathologist. (✓)
e) NG feeding is the preferred method during the first c) Patients with communication difficulties should be
month post stroke for people who do not recover a treated as early and as frequently as possible.
functional swallow. (Grade B; Level II 256) (Grade C, Level I 296 & Level III-2 295)
f) Food intake should be monitored for all people with d) All written health information should be available in
acute stroke. (✓) an aphasia friendly format. (Grade D, Level IV 298)
5.3: Early Mobilisation e) The speech pathologist should advise staff and
family/carers of appropriate communication
a) Patients should be mobilised as early and as
techniques. (Grade C, Level II 299, 300)
frequently as possible. (Grade B; Level II 264)
5.7: Incontinence
b) After assessment the physiotherapist should advise
staff and carers of appropriate mobilising and a) All patients with suspected continence difficulties
transfer techniques. (✓) should be assessed by trained personnel using a
structured functional assessment.
5.4: Early therapy for difficulties with
(Grade B; Level II 301)
Activities of Daily Living (ADL)
b) A portable bladder ultrasound scan can be used to
a) Patients with difficulties in occupational
assist in diagnosis and management of urinary
performance in daily activities should be treated by
incontinence. (Grade B; Level I 302).
an occupational therapist or a specialist
multidisciplinary team that includes an occupational c) Patients with confirmed continence difficulties
therapist (Grade B; Level I 18, 268) should have a continence management plan
formulated and documented. (Grade C; Level II 301)
b) Patients with confirmed difficulties in occupational
performance in personal tasks, instrumental d) The use of indwelling catheters should be avoided
activities, vocational activities or leisure activities as an initial management strategy. (✓)
should have a management plan formulated and
e) A post discharge continence management plan
documented to address these issues. (✓)
should be developed with the patient and carer
c) The occupational therapist should advise staff and prior to discharge and should include how to
carers on techniques and equipment to maximise access continence resources in the community. (✓)
viii
5.8: Mood b) Antiplatelet therapy should be used for people with
a) Patients with suspected altered mood (e.g. ischaemic stroke to prevent DVT/PE. (Grade A;
depression, anxiety, emotional lability) should be Level I 331)
assessed by trained personnel using a c) The following interventions may be used with
standardised scale. (Grade B; Level II & Level III-1 caution for selected people with acute ischaemic
68, 307, 309, 311, 314, 321)
stroke at high risk of DVT/PE:
b) Patients with stroke may be managed using a case > low molecular weight heparin or heparin in
Key Messages
management model after discharge to reduce post prophylactic doses; (Grade B; Level I 331, 334, 335
stroke depression. If used, services should and Level II 336)
incorporate education of the recognition and
> thigh-length antithrombotic stockings.
management of depression, screening and
(Grade C; Level II 331, 338)
assistance to coordinate appropriate interventions
via a medical practitioner. (Grade C; Level II 68, 325) 6.3: Pyrexia
Antipyretic therapy, comprising regular paracetamol
c) Routine use of antidepressants to prevent post-
and/or physical cooling measures, should be used
stroke depression is not currently recommended.
routinely where fever occurs. (Grade C; Level II 212, 344)
(Grade B; Level I 317)
6.4: Pressure care
d) Antidepressants may be used for people with
emotional lability. (Grade B; Level I 315) a) All patients unable to mobilise independently should
have a pressure care risk assessment completed by
e) Patients with depression or anxiety may be treated
trained personnel. (✓)
with antidepressants and/or psychological
interventions to improve mood. (Grade B; Level I 316) b) All those assessed at high risk should be provided
with a pressure relieving mattress as an alternative
to a standard hospital mattress.
6. Prevention and Management
of Complications (Grade B; Level I 345)
ix
> avoiding excessive alcohol. (Grade C; meta- presumed arterial origin should not be routinely
analysis of cohort studies in primary prevention used as there is no evidence of additional benefits
demonstrate link between high alcohol intake over antiplatelet therapy. (Grade A; Level I 412)
and stroke risk 392)
c) The decision to commence anticoagulation therapy
b) Interventions should be individualised and may be should be made prior to discharge. (Grade C; Level
delivered using behavioural techniques (such as III-3 394)
educational or motivational counselling). (Grade A;
d) In patients with TIA, commencement of
Level I 362-366, 395, 396)
Key Messages
x
8. Discharge Planning, Transfer of
Care and Integrated Community Care
Key Messages
f) Carotid endarterectomy is not recommended for discuss their post-discharge needs (e.g. physical,
those with <50% symptomatic stenosis or those emotional, social and financial) with relevant
with <60% asymptomatic stenosis. (Grade A; members of the interdisciplinary team. (✓)
Level I 429, 432)
b) Before discharge all patients should be assessed
g) Carotid angioplasty and stenting should not to determine the need for a home visit prior to
routinely be considered for patients with discharge from hospital. (✓)
symptomatic stenosis. However, it may be
c) If needed, a home assessment should be carried
considered as an alternative in certain
out to ensure safety and community access.
circumstances, that is in patients who meet criteria
(Grade C; Level I 453)
for carotid endarterectomy but are deemed unfit
due to medical comorbidities (e.g. significant 8.3: Carer training
heart/lung disease, age >80yrs), or conditions that Relevant members of the interdisciplinary team should
make them unfit for open surgery (e.g. high or low provide specific training for carers before the person’s
carotid bifurcation, carotid re-stenosis). (Grade B; discharge home. This should include training, as
Level I 437 & Level II 438, 439) necessary, in:
7.8: Patent foramen ovale (PFO) > personal care techniques, communication
a) All patients with an ischaemic stroke or TIA, and a strategies, physical handling techniques, ongoing
PFO, should receive antiplatelet therapy as first prevention and other specific stroke-related
choice. (Grade C; Level II 442) problems; (Grade B; Level II 56)
b) Anticoagulation may also be considered taking into > safe swallowing and appropriate dietary
account other risk factors and the increased risk of modifications. (✓)
harm. (Grade C; Level II 442)
8.4: Care plans
c) Currently there is insufficient evidence to a) People with stroke, their carers, the general
recommend PFO closure. (✓) practitioner, and community care providers should
7.9: Concordance with medication be involved with the interdisciplinary team in the
development of a care plan. (✓)
Interventions to promote adherence to medication
regimes are often complex and should include one or b) Care plans should be used and outline care in the
more of the following: community after discharge, including the
development of self-management strategies,
> information, reminders, self-monitoring,
provision of equipment and support services, and
reinforcement, counselling, family therapy;
outpatient appointments. (✓)
(Grade B; Level I 446-448)
8.5: Discharge planner
> reduction in the number of daily doses;
(Grade B; Level I 446, 447) a) A discharge planner may be used to coordinate a
comprehensive discharge program for people with
> multi-compartment medication compliance device;
acute stroke. (Grade D; Level III-3 457)
(Grade C; Level I 449, 450)
xi
b) The stroke survivor’s general practitioner, other > Urgent CT on admission is the most cost effective
primary health professionals and community strategy for brain imaging in stroke patients. There
service providers should be involved in, and are currently no cost-effectiveness data for the use
informed about, the discharge plans and agreed of MRI in acute stroke.
post-discharge management, as early as possible
> Carer training is cost effective. However, more
prior to discharge. (✓)
information is required to ascertain the implications
8.6: Community rehabilitation for carers.
Rehabilitation in the community is equally effective > Carotid endarterectomy in recently symptomatic
Key Messages
if delivered in the hospital via outpatients, or day patients with high grade carotid stenosis appears
hospital, or in the community, and should be offered highly cost-effective when performed with low
to all stroke patients as needed. perioperative morbidity and mortality but updated
(Grade A, Level I 63, 458, 459) information is needed.
8.7: Post-discharge support > Warfarin is cost effective in selected high risk
a) Contact with and education by trained staff should patients.
be offered for all stroke survivors and carers after
> Blood pressure reduction for secondary stroke
discharge. (Grade C; Level II 53, 54, 57, 59, 60, 463, 468-470)
prevention is cost effective.
b) People with stroke and their carers should be
> The combination antiplatelet therapy of
provided with a contact person (in the hospital or
dipyridamole plus aspirin was consistently found
community) for any post-discharge queries.
to be cost effective compared with aspirin alone.
(Grade D; Level I 471 & Level II 53, 60)
However, there is conflicting evidence for the cost
8.8: Return to driving effectiveness of clopidogrel.
The National Guidelines for Driving and relevant state > Some brief lifestyle change interventions are
guidelines should be followed when assessing fitness cost effective in populations other than stroke
to drive following a stroke or TIA. In general, patients (e.g. brief smoking cessation advice, QUIT
with TIA or minor stroke, especially those found to be lines/phone counselling, physical activity
at high risk, should be advised to delay returning to counselling) and such interventions should be
driving for at least 1- 4 weeks. (✓) applicable to people with stroke.
xii
INTRODUCTION
In Australia, stroke affects approximately 53,000 stroke management. Further information about the
people per year. Around half of these people are consumer perspective is found throughout the
over the age of 75 and as the population ages the document as well as in Appendix A.
number of strokes occurring each year is expected
to increase.4 The burden of stroke goes beyond
Acute stroke care
the measured cost in Australia of $1.3 billion per
annum.5 The impact on individuals, families and the Acute care is characterised by a focus on rapid,
workforce is substantial. Of those who have a thorough assessment and early management.
stroke, approximately a third will die within the first Evidence continues to evolve and highlights the fact
Introduction
12 months, a third will make a complete recovery and that the principles of rehabilitation should be similarly
a third will be left with a disability that causes some applied in the acute setting.6 Rehabilitation is a
reliance on others for assistance with activities of daily proactive, person-centred and goal-oriented process
living. Effective early stroke treatment aims to promote that should begin the first day after stroke. Its aim is
maximum recovery and prevent costly complications to improve function and/or prevent deterioration of
and subsequent strokes. This guideline has been function, and to bring about the highest possible level
developed in response to the burden of stroke on of independence - physically, psychologically, socially
individuals and the community as a whole. This and financially. Rehabilitation is concerned not only
guideline specifically addresses the important aspects with physical recovery but also with reintegration of
of care for people in the acute phase of stroke the person into the community. Furthermore,
recovery and the assessment and management of rehabilitation is a process that aims to maximise
people with transient ischeamic attack (TIA). self-determination and optimise choices for those
with stroke.
The central aspect of rehabilitation is the provision of a
Setting the scene: coordinated program by a specialised, interdisciplinary
a consumer perspective team of health professionals. This rehabilitation team
involves combined and coordinated use of medical,
The process of developing the Clinical Guidelines for
nursing and allied health skills, along with social,
Acute Stroke Management has importantly included
educational and vocational services, to provide
input and advice from stroke survivors and their
individual assessment, treatment, regular review,
family/carer. Their first-hand experience of stroke and
discharge planning and follow-up.
stroke care can contribute much to our understanding
of what we can do that will make a difference to the While the interdisciplinary team recognises the
experience of people as they are recovering from a specialist contribution of each discipline, generally
stroke. However, experience in implementation and no mention has been made of their specific roles
from working with consumers suggests that throughout the document. The following is provided
recommendations that receive the main focus are as a summary of the main aspects of members of
those with the highest levels of evidence, or those that the team:
are more medically driven. Furthermore, many of the > Doctors coordinate comprehensive medical care
aspects of care that consumers consider critical to (including consulting other medical specialists as
their care are unsupported by strong, clear evidence needed), assist stroke survivors and their families in
(e.g. discharge planning). making informed choices and re-adjustments, and
A novel approach has been undertaken during the prevent complications and recurrent stroke. The
development of these guidelines. During this process doctor is often responsible for making sure the best
consumers indicated that almost all topics are viewed available resources and services are offered to
to be extremely important, especially discharge those affected by stroke. An inpatient medical team
planning and transfer of care. Health professionals (commonly a specialist [e.g. in neurology,
should be mindful not only of strength of the evidence rehabilitation or geriatrics], registrar and junior
but also of the needs and opinions of acute stroke medical officers) often work in conjunction with a
patients when implementing the guidelines for acute general practitioner to provide care in hospital and
in the community.
1
> Nurses perform comprehensive nursing
Australian Clinical Guidelines for
assessments and help manage aspects of patient Stroke Management
care including observations, swallowing, mobility,
continence, skin integrity, pain control and Scope of the Guidelines
prevention of complications. Nurses also provide The Australian Clinical Guidelines for Stroke
patient centred care and assist coordination of care, Management have been developed as two
discharge planning, support and education. Nurses documents.
can provide specialist stroke care in the acute,
rehabilitation and community context as well as This document, Clinical Guidelines for Acute Stroke
deliver palliative and terminal nursing care. Management, relates to assessment and early
Introduction
2
intracerebral haemorrhage has been included and paths, integrated care pathways, case management
specifically discussed. Furthermore this guideline has plans, clinical care pathways or care maps). Guidelines
been expanded from the first edition (2003) to include are an overview of the current best evidence translated
a number of new topics, for example, assessment into clinically relevant statements. On the other hand,
and management of TIA. care pathways are seen as a resource which applies
the guidelines in a local setting based on local needs.
Development of the Guidelines
Care pathways are based on best practice guidelines
The Clinical Guidelines for Acute Stroke Management
but provide a local link between the guidelines and
have been developed according to processes
their use.8
prescribed by the NHMRC2 under the direction of
Introduction
an interdisciplinary Expert Working Group (EWG) (see The guidelines and the preambles provide an overview
Appendix A). The draft ‘Additional levels of evidence of the evidence. Those wishing to implement it may
and grades for recommendations for developers of need to find out more information, for example, the
guidelines pilot program 2005-2007’ has been used exact processes involved in use of a particular
to assist in grading the recommendations along with screening tool. Strategies planned to encourage this
specifying levels of evidence.3 Consultation from other transfer of evidence into clinical practice may include,
individuals and organisations was also included in the but are not limited to:
development process in line with NHMRC standards. > distribution via existing networks, key professional
Details about the development methodology and and lay organisations, publications in professional
consultation process are outlined in Appendix A. journals, and electronic access via the internet;
> development and use of decision making tools and
Consumer versions of the Guidelines
summary documents (e.g. care pathways);
Consumer versions of the Clinical Guidelines for Acute
> educational meetings / conferences;
Stroke Management and Clinical Guidelines for Stroke
> use of local opinion leaders;
Rehabilitation and Recovery documents have been
> audit, feedback and reminders;
developed through partnerships between the National
> use of networks.
Stroke Foundation and State Stroke Associations
throughout Australia. Given the different needs of In considering implementation of these Guidelines at a
stroke survivors and their families at different stages of local level, health professionals are encouraged to
recovery, the two Clinical Guideline documents are identify the barriers and facilitators to evidence-based
presented as three books for consumers. These care within their environment to determine the best
books are available through the National Stroke strategy for local needs. Further information regarding
Foundation and State Stroke Associations. implementation is discussed in Appendix A.
3
studies were identified during the development Format
process regarding the impact of interventions for These guidelines are organised in nine sections to
cute stroke. Further discussion about the address issues deemed by the guideline developers
socioeconomic impact of stroke is discussed in as important in acute stroke care. The aim of the
Section 9 of this document. guidelines is to provide a logical framework from
Access is one of the major barriers to equitable pre-hospital care through to discharge and follow up
services and is influenced by geography, culture and in the community.
spiritual beliefs. Particular challenges are therefore The introduction to each topic provides justification
noted for rural and remote services where resources, for the recommendation. The guidelines are then
Introduction
particularly human resources, may be limited. Whilst it presented in a box and are summarised according
is recognised that residents in rural and remote areas to the ‘interim’ NHMRC expanded levels of evidence
may have difficulty accessing health care as readily as which are listed below.3 Each recommendation is
their urban counterparts the aim in all settings must be also graded according to the draft NHMRC grading
to develop local solutions that ensure optimal practice system. The key references for each guideline are
and quality outcomes that are based on the best also included. Where no satisfactory Level I, II, III or IV
available evidence using the available resources. evidence was available but there was sufficient
Careful consideration is also required for the differing consensus, clinical practice points based on expert
needs of people with stroke. Appropriate resources opinion is provided by the EWG. The group tried at all
may be required in a variety of languages and formats times to organise each section as a logical flow from
for people with stroke and their carers. The particular assessment to management. As such the order of the
needs of people from Aboriginal and Torres Strait recommendations in each section is no indication of
Islander and those from culturally and linguistically their importance.
diverse backgrounds also require special attention and
resources.17 Other groups of people (e.g. younger
people with stroke) may also have specific needs that
require particular resources or application of these
guidelines.
cont.
4
Designations of Levels of Evidence According to Type of Research Question3 cont.
Introduction
series with a
control group
iv Case series with Study of diagnostic yield Case series, or A cross-sectional Case series
either post-test or (no reference standard) cohort study of study
pre-test/post-test patients at
outcomes different stages
of disease
Grading of Recommendations3
GRADE DESCRIPTION
A Body of evidence can be trusted to guide practice
B Body of evidence can be trusted to guide practice in most situations
C Body of evidence provides some support for recommendation(s) but care should be taken in its application
D Body of evidence is weak and recommendation must be applied with caution
5
1 ORGANISATION OF SERVICES
The organisation of hospital services to provide stroke planning) and other meetings as needed
unit care is the single most important recommendation (e.g. family conferences);
for acute stroke management. Stroke unit care should > active encouragement of people with stroke and
be the highest priority for clinicians and administrators their carers/family members to be involved in the
to consider. There is overwhelming evidence that rehabilitation process.6, 18
stroke unit care significantly reduces death and A mobile stroke team has been suggested as one
disability after stroke compared with conventional care strategy to improve processes of care for hospitals
in general wards for all people with stroke.6 that do not currently have a dedicated stroke unit.20
Models of stroke care described in the literature One robust systematic review found no clear benefit
Section 1
CONSUMER
1.1 STROKE UNIT CARE GRADE LEVEL RATING
a) All people with stroke should be admitted to hospital and be A Level I 6, 19 9.3/10
treated in a comprehensive stroke unit with an interdisciplinary team.
b) Smaller hospitals should consider models of stroke unit care that
adhere as closely as possible to the criteria for stroke unit care. B Level I 6, 21 –
Where possible, patients should receive care on geographically
discrete units.
6
1.2 Organisation of services for
transient ischaemic attack (TIA)
Organisation of Services
There are various models suggested for organising There are no Australian data to indicate the average
services for those with TIA. Such models include direct waiting times from referral to actually being seen in a
hospital admission to a stroke unit, rapid outpatient clinic. Data from the UK indicate while 78% of
clinics for TIA, or management by a general hospitals have a neurovascular clinic only 34% are
practitioner. seen within 7 days with the average waiting time being
12 days.31 Local services have begun to provide earlier
Admission to hospital
access to special clinics for people with stroke,
While there is very strong evidence for admission to
especially for those assessed as having a lower risk of
hospital and care on a stroke unit for all levels of stroke
stroke. It is vital that any such service should provide
Section 1
severity6 it is unclear if there are benefits for those with
timely access to routine investigations.
TIA and very minor stroke. Analyses undertaken
revealed that mild strokes (presumably including TIA) Management by primary care
did not appear to benefit from stroke unit care The role of the GP in initial assessment and
(compared to general ward) in terms of reduced risk management of TIA and stroke in Australia is unclear.
of death alone or death or institutional care. However, Information collected in one ongoing Australian study
mild stroke patients managed in stroke units reduced found that TIA represents only 0.1% of GP
the risk of being dependent if they survived.6 consultations.32 Furthermore, tests and imaging was
Furthermore, hospital admission to a stroke unit requested in only a small number of contacts for
increased the likelihood of undertaking necessary people with stroke (full blood count 2%; lipid test 1%;
diagnostic tests (e.g. carotid ultrasound, MRI) and had CT brain 2%; Doppler ultrasound of carotid arteries
higher adherence to protocols and processes of care 1%).33 MRI is not available in some areas especially in
consistent with best practice stroke care compared to rural and remote centres34 and GPs are unable to
conventional hospital ward.24 request MRI. Often people will present to the GP
several hours or even days after the event due to
While mild or recovering symptoms are one reason for
underestimation of the need for rapid assessment and
not administering rt-PA initially, there is some indication
management. Given the small numbers of people with
of a correlation between TIA and a subsequent
stroke or TIA who normally present to the GP and the
deterioration in symptoms in a significant minority of
fact that TIA is often over diagnosed, it appears that
cases.25-27 Hence a short hospital admission may
GPs are best placed to provide initial screening and
provide opportunity for administration of rt-PA should
referral to specialist stroke services for full assessment
the patient deteriorate. One study found a policy of
and early management. Long term management of
admission to hospital for 24 hours after TIA is cost
risk factors, however, is the primary role of GPs.
neutral if considering rt-PA alone.28
In conclusion, there is very little direct evidence to
Rapid TIA clinic
guide administrators and clinicians in the most
No robust data were found to determine the outcomes
appropriate organisation of services for people with
of this model of care. One retrospective study in the
TIA. It is clear, however, that whichever model is
UK found that a clinic was cost effective if all relevant
utilised it should focus on rapid assessment and early
investigations had been completed prior to the visit
management and be based on local resources and
allowing informed decisions to be made at a “one
needs. Similar to stroke services, development of
stop” service.29 Another case series reported a rapid
networks between general practitioners and stroke
assessment clinic was useful to screen for patients
centres would enable appropriate use of more
eligible for carotid surgery but found only a small
intensive resources. Access to services should be
number of patients (4.8%) underwent carotid surgery.30
determined on the basis of risk of stroke. While
There is currently no national data for stroke or TIA
recognising its limitations, the ABCD2 tool is a useful
care provided in emergency departments or outpatient
screening tool that should be used to determine high
clinics. Only 5% of hospitals surveyed in 2007 have a
and low risk in patients with TIA (see assessment of
rapid assessment outpatient clinic for TIAs or mild
TIA section 3.1).
stroke. Availability of such services was significantly
more common where there was a stroke care unit.
7
CONSUMER
Organisation of Services
1.3 ORGANISATION OF CARE FOR RURAL CENTRES GRADE LEVEL RATING
a) All health services caring for people with stroke should use D Level IV –
networks which link large stroke specialist centres with smaller 36, 37, 39, 42
Section 1
1.4 Care pathways
Clinical pathways (also known as care pathways or Of the other outcomes reported a large proportion
critical pathways) are defined as a plan of care that demonstrated non significant trends in favour of care
aims to promote organised and efficient pathway intervention.44
multidisciplinary stroke care based on the best
Several subsequent Level III-3 & IV studies have found
available evidence and guidelines.44 Care pathways are
improved efficiency in acute processes primarily
one way of promoting organised and efficient patient
focused on increasing the number of people eligible for
care and hence improve outcomes. The definition,
thrombolysis (e.g. door to CT and door to IV
structure and detail contained within the pathway may
thrombolysis times).46-48 One other Level III-3 study
vary from setting to setting.45
failed to find benefits of an acute pathway when
A robust systematic review on the use of care implemented on a general medical ward.49
pathways found that such interventions can have both
Overall there is a small body of generally consistent
positive and negative effects and concluded that there
evidence that suggests care pathways can improve
was insufficient evidence to justify routine use of care
the process of care in acute stroke management
pathways.44 However, of the three RCTs and 12 non
where a number of investigations are needed in a
RCTs included only one RCT and 7 non RCTs were
short period of time, particularly when thrombolysis is
initiated in the acute phase (three of the non RCTs
considered. In the clinical setting, care pathways can
were initiated in the hyper acute phase in the
provide a useful resource to optimise early stroke care,
emergency department). When the acute trials were
especially in settings without organised stroke care or
considered separately no negative effects were found
where staff are frequently changing.
while benefits of some patient outcomes (reduced
length of stay, fewer readmissions and fewer urinary
tract infections) as well as improved process
outcomes (access to neuroimaging) were found.
CONSUMER
1.4 CARE PATHWAYS GRADE LEVEL RATING
All stroke patients admitted to hospital may be managed using an acute C Level II 44 –
care pathway.
9
1.5 Inpatient care coordinator
The use of an inpatient stroke care coordinator is a case managed care intervention in which one person
one of a number of strategies used to facilitate a coordinates inpatient acute stroke care have been
Organisation of Services
coordinated approach to care. The coordinator is included within the review on inpatient care
generally a member of the team and the role is often pathways.44 The RCT reported a reduction in length of
performed in addition to other clinical or management stay (11v14 days) and therefore lower costs as well as
responsibilities. Exponents of this model suggest that a reduction in returns to emergency departments.
a stroke coordinator is particularly useful for While a care coordinator was only one component of
coordinating services and facilitating the involvement care (usually in combination to protocols or pathways)
of the person with stroke and the carer in care it is logical that such a position aids the organisation of
planning, including planning for discharge or transfer services noted in stroke unit care settings.
of care. One RCT and two lower level trials regarding
Section 1
CONSUMER
1.5 INPATIENT CARE COORDINATOR GRADE LEVEL RATING
Ongoing communication between the members of the meetings.18 While this evidence relates to the total
stroke team is a key element of an organised stroke stroke unit “package” rather than the individual
service. Data from trials included in the Stroke Unit elements of that package, team meetings appear
meta-analysis found that organised stroke units were essential to foster good communication and
characterised by formal weekly meetings of the coordinated services.
multidisciplinary team along with one or more informal
CONSUMER
1.6 TEAM MEETINGS GRADE LEVEL RATING
The multidisciplinary stroke team should meet regularly (at least weekly) C extrapolated –
to discuss assessment of new patients, review patient management and from
goals, and plan for discharge. Level I18
Ongoing communication between the stroke team stroke team (or the whole team) may not occur in
and the family/carer, with early involvement, is also every individual case, however, it is apparent that
a key element of an organised stroke service. organised stroke unit care incorporates processes that
Communication is established through formal and informs and involves the patient and their family in all
informal meetings to discuss assessment results, aspects of care. As such informal meetings should
management plans and to also plan for discharge. occur when stroke team members relay or discuss
Formal family meetings that involve members of the assessment findings or management plans.18
CONSUMER
1.7 FAMILY MEETINGS GRADE LEVEL RATING
The stroke team should meet regularly with the person with stroke and C extrapolated 9.3/10
the family/carer to involve them in management, goal setting and from
planning for discharge. Level I18
10
1.8 Information and education
The provision of information and education is into improved recovery and adjustment for people
Organisation of Services
particularly important for those with stroke and their with stroke and their carers.52 Subsequent trials have
families. However, written information may only be reported mixed benefits from education interventions
provided to a small percentage of patients and in line with conclusions reached by the systematic
family/carers and when provided may not be written reviews. That is, some trials reported psychosocial
in a suitable readability level or design.50 Furthermore, benefits (e.g. reduced anxiety)53-58 or improved
information is often not retained by those with stroke knowledge and/or compliance with treatment59, 60
and their families highlighting the need to provide however, most did not demonstrate any impact on
individualised, flexible and targeted information at functional outcomes and most were based in
different stages of recovery with opportunities rehabilitation units or in the community.
provided to enable interaction with relevant stroke
Section 1
Numerous other trials have assessed interventions
team members.
to educate people with stroke and their family/carer,
The evidence for interventions to improve information particularly after discharge from hospital (see section
and education provision, however, is difficult to 8.7). In most of these trials the intervention was
interpret. Two systematic reviews concluded that multifactorial and it is difficult to gauge the effect of
information provided in an educational context, education or information provision alone. State Stroke
especially an active educational-counselling approach, Associations and the National Stroke Foundation are
improves knowledge better than information provided able to provide written information including consumer
in a booklet or leaflet (which was found to be versions of these guidelines and fact sheets that
ineffective if simply provided alone).51, 52 However, it is could be used as part of a comprehensive
unclear if increased knowledge about stroke translates education program.
CONSUMER
1.8 INFORMATION AND EDUCATION GRADE LEVEL RATING
All stroke survivors and their families/carers should be provided with A Level I 9.4/10
timely, up-to-date information in conjunction with opportunities to learn 51, 52
Early supported discharge (ESD) is a model that links the case.61, 62 ESD predominantly involves people with
inpatient care with community services. ESD services mild to moderate disability and thus this service should
should be considered an extension of stroke unit care target this group of stroke survivors.61, 62 Given the
rather than an alternative to it. A key argument for ESD potential for increased patient satisfaction and reduced
is that the home provides an optimum rehabilitation pressure on acute resources such services should be
environment, since the goal of rehabilitation is to developed to provide comprehensive early supported
establish skills that are appropriate to the home setting. discharge and follow up, particularly in centres where
Stroke survivors have reported greater satisfaction inpatient organised stroke services currently exist as
following ESD than conventional care. development of such services should be the first priority.
Meta-analysis has found that ESD services reduce the To work effectively, ESD services must have similar
inpatient length of stay and adverse events (e.g. elements to those of organised stroke teams (see
readmission rates), while increasing the likelihood of characteristics of stroke units above). Thus ESD should
being independent and living at home.61, 62 Risks relating only be considered where there are adequate
to carer strain might be expected with ESD, but there is community services for rehabilitation and carer support.
too little evidence to demonstrate whether or not this is
11
CONSUMER
1.9 EARLY SUPPORTED DISCHARGE GRADE LEVEL RATING
Organisation of Services
a) Health services with organised inpatient stroke services should A Level I 61-63 –
provide comprehensive interdisciplinary community rehabilitation
and support services for people with stroke and their family/carer.
a) If interdisciplinary community rehabilitation services and carer A Level I 61, 62 8.5/10
support services are available, then early supported discharge
should be offered for all stroke patients with mild to moderate
disability.
Section 1
The organisation of services which link primary care of depression.68 Other studies of post discharge
and hospital and community services is an increasingly support, commonly provided by a specialist nurse, may
important area for good stroke care. While initial also be utilised to improve the link between hospital and
assessment and rehabilitation should be undertaken primary care, however, the sustainability of such a
in an inpatient stroke unit, long term follow up focussing service has not been evaluated. As the general
on secondary prevention and support is undertaken in practitioner (GP) is the hub of community health
general practice. A national survey of risk factors in provision it is important to develop clear links between
general practice found 70% of patients aged over primary and secondary care. Networks have been
30 had one or more risk factors and 34% had two or suggested to improve such a link with several Level 4
more.64 Hypertension was the risk factor with greatest studies showing the benefits of networks for hospital
prevalence (44%), followed by hypercholesterolaemia services (see section 1.3). Such networks could
(43%) and current smoking (17%) and all risk factors collaboratively develop local protocols or pathways for
except smoking were found to increase with age.64 acute management, efficient discharge services and
Studies have also found that there is under treatment long term management. As stroke or TIA
of TIA and stroke risks65-67 and hence there is is less than 0.5% of a typical GP workload 33 and
considerable scope to further improve management. specialist stroke units with educated and skilled staff
have consistently demonstrated improved patient
One RCT found a model of shared care between
outcomes, it would seem sensible for GPs, especially
hospital based stroke specialists and general practice
those in rural centres, to develop such networks with
(using a third party coordinator) demonstrated some
specialist stroke centres. Local divisions of practice are
improvement in the management of secondary
well placed to help facilitate any networks between
prevention and management (including prevention)
stroke specialist centres and local GPs.
CONSUMER
1.10 SHARED CARE GRADE LEVEL RATING
a) All patients with stroke or TIA should have their risk factors C Level II 68 –
reviewed and managed long term by a general practitioner with
input and/or referral to a stroke physician for specialist review
where available.
b) Locally developed protocols and pathways should be used to ✓ – –
efficiently link primary and secondary care for people with stroke
or TIA, including rapid assessment and referrals, acute
management, direct communication links, efficient discharge
services and long term management.
c) Rural practitioners should participate in networks linking them to ✓ – –
regional or metropolitan centres with specialty in stroke care.
12
1.11 Standardised assessment
Complete assessment requires the input from all Any assessment needs to also consider the ability of
Organisation of Services
members of the stroke team. Such assessments are the patient to actually provide informed consent for
foundational to identify deficits, set goals and plan for further management. Such ability maybe
management. While there is some evidence to compromised following stroke (e.g. global aphasia)
suggest a structured assessment helps to identify and all members of the multidisciplinary team must
particular problems 69 there is little direct evidence consider the rights of the patient during any
guiding what should be included and when assessment and management planning.
such assessments should be carried out. It is
There are a large number of assessment tools that
recommended that all assessments occur as soon as
have been developed for use in acute stroke
possible after admission (aiming for within two days of
management (examples include National Institutes of
admission) with the stroke team working together so
Section 1
Health Stroke Scale, Modified Rankin Score,
as not to over burden the patient by duplicating
Scandinavian Stroke Scale). However, given the
questions. Weekend cover and workforce shortages
enormous variety of assessment tools and measures it
are a continual issue for many centres and such issues
is beyond the scope of this guideline to make specific
will reduce the timeliness of assessments. Although
recommendations regarding which measures or tools
reassessment is useful to monitor recovery and assist
should be used in each circumstance. It is important
in planning, the timing of such assessments should
that all staff carefully chose a specific tool based on
consider the needs of the patient along with the
the validity, reliability and availability of such tools and
usefulness of the findings. Communication of
be trained in the use of the chosen tool. It is also
assessment findings to the patient and family/carer
important to balance the use of a detailed assessment
is essential.
(which may take considerable time) with the need to
provide early and active interventions.
CONSUMER
1.11 STANDARDISED ASSESSMENT GRADE LEVEL RATING
Approximately 20% of stroke patients die as a result of acute phase after a severe stroke as it is hard to
the stroke in the first 30 days.70 Palliation can be a predict if a patient will improve or not. Carer support,
complex phase of care and requires careful counselling and multidisciplinary care are basic
consideration and service planning. Issues to consider principles of palliative care and need to be considered.
include linking with specialist palliative care services for Early discussion of prognosis and palliation may be
direct care, intermittent referral, or clinical support on a beneficial for some family members/carers. Practical
needs basis. Other issues to consider include clinical end-of-life issues, such as the use of medical power of
issues such as feeding, hydration and pain attorney and advanced directives, should also be
management. There is often uncertainty during the discussed. Organ donation may be sensitively raised if
13
appropriate. Issues of bereavement may become part from systematic reviews to suggest communication
of the responsibility of the stroke team and formal skills training can have a small beneficial effect on
Organisation of Services
mechanisms should be in place to ensure the behaviour change in health professionals working
patient, their family and caregivers have access to with people with cancer.74, 75 Thus education and
bereavement care, general counselling, information training may be provided to those caring for stroke
and support services. patients and their families to assist in the care of
non-complex patients where specialist services are
Evidence to guide palliative care in stroke is lacking.
not routinely involved.
Only one low level study was identified that developed
and implemented a care pathway for palliative care in People with stroke who are dying, their families and
acute stroke. The study reported improved processes caregivers, should have care that is consistent with
of care based on national standards.71 the principles and philosophies of palliative care in
Section 1
CONSUMER
1.12 PALLIATION AND DEATH GRADE LEVEL RATING
a) A pathway for acute stroke palliative care may be used to improve D Level IV 71 –
palliation for people dying after acute stroke.
b) An accurate assessment of imminent death should be made for ✓ – –
patients with severe stroke or those who are deteriorating.
Any assessment must consider prognostic risk factors along
with the wishes of the patient and their family/carer.
c) Acute stroke patients should have access to specialist palliative ✓ – –
care services as needed.
d) People with stroke who are dying, and their families, should have ✓ – –
care that is consistent with the principles and philosophies of
palliative care.
Stroke unit care has been shown to involve higher improved services.78, 79 However, quality improvement
rates of adherence to key processes of care.24 Thus it activities often use a multifaceted strategy such as
is important to monitor key processes and patient educational meetings, reminders, printed material, or
outcomes to foster improved service delivery. One opinion leaders with or without audit and feedback.77, 80
important strategy to improve quality of care involves
Experience from the National Sentinel Audit of Stroke
the process of audit and feedback. Audit and
in the UK suggests benefits of a cycle of
feedback has been found to produce small to modest
comprehensive audit at least every two years.79
improvements from a large number of wide ranging
However, services may benefit from more frequent
studies.77 Audit and feedback has also been
audit based on a smaller number of key indicators by
successfully used locally and internationally to both
providing the ability to monitor continuous quality
prompt service improvement and demonstrate
improvement activities.
14
CONSUMER
1.13 STROKE SERVICE IMPROVEMENT GRADE LEVEL RATING
Organisation of Services
a) All acute stroke services should be involved in quality improvement B Level I 77 –
activities that include regular audit and feedback (‘regular’ is
considered at least every two years).
b) Indicators based on nationally agreed standards of care should be ✓ – –
used when undertaking any audit. Performance can then be
compared to similar stroke services as described by the
National Stroke Unit Program.
Section 1
15
2 PRE-HOSPITAL CARE
There is growing evidence that good early stroke of a multifaceted strategy and it is difficult to
management can reduce damage to the brain and determine the effect of this strategy alone.
minimise the effects of stroke. Because of this early
> Preferential transportation to known stroke
recognition of stroke the subsequent response of
specialist centres, based on agreed local protocols,
individuals to having a stroke and the timing and
has been suggested in several low level studies.39-41
method by which people are transferred to hospital are
Again, this is one component of a multifaceted
important to ensure optimal outcomes. In this
strategy and it is difficult to determine the effect of
hyperacute phase of care, the ambulance service
this strategy alone. However, there are clear benefits
provides a central, coordinating role. Stroke patients
for admission to a stroke unit. Hence, where
should not only receive a high triage priority but the
practical (e.g. hospitals located within the same
system should facilitate early notification of the
local area), ambulance services should transport
receiving hospital and ensure that the correct hospital
patients with suspected stroke to hospitals with
is selected (i.e. one with organised stroke unit care)
such organised services.
where a choice exists.
> Several validated pre-hospital screening tools have
Studies involving pre-hospital approaches have found:
been developed, for example, the Los Angeles
> Education regarding the signs of stroke and the
Prehospital Stroke Screen or the Melbourne
critical nature of stroke delivered to emergency
Ambulance Stroke Screen (MASS).86-89
medical service staff, emergency department staff
and the general public increased the use of > Specific training for emergency medical services
ambulance transport, decreased admission delays staff improves diagnostic accuracy and reduces
and improved the number of patients receiving pre-hospital delays.39, 83 For example, a one hour
Pre-Hospital Care
thrombolysis.39, 81, 82 While it is unclear how often training session based on the only Australian tool,
education should be provided to improve early the MASS, increased the diagnostic accuracy of
recognition current practice suggested that local pre-hospital emergency service staff from 78 to
services should incorporate such education into 94%.83
routine, ongoing education at least annually. > Pre-hospital initiation by paramedics of intravenous
> High priority by emergency medical services and magnesium sulphate has been shown to be feasible
Section 2
early notification to hospital emergency and safe in one small pilot study90 and a
departments improves efficient acute stroke subsequent RCT is ongoing.
management.83-85 However, this is one component
CONSUMER
2 PRE-HOSPITAL CARE GRADE LEVEL RATING
a) Ambulance services, health care professionals and the general C III-3 & IV 39 9.5/10
public should receive education concerning the importance of early
recognition of stroke, emphasising stroke is a medical emergency.
b) Stroke patients should be given a high priority grouping by C Level III-2 9.6/10
ambulance services. 83, 84
c) Ambulance services should be trained in the use of validated B Level III-2 9.7/10
rapid pre-hospital stroke screening tools and incorporate such 86-89
16
3 EARLY ASSESSMENT AND DIAGNOSIS
The aim of assessment of a patient with suspected was found to predict stroke risk in a retrospective
stroke or TIA is to confirm the diagnosis, identify and prognostic study, however, such changes were only
treat the cause, and guide relevant secondary identified in a small number of cases (4%).99 As with
prevention to prevent complications or stroke ischaemic stroke, CT is useful to exclude differential
reoccurrence. Appropriate diagnosis of stroke and diagnosis that could mimic TIA and should be used
immediate referral to a stroke team is vital given to exclude subdural haematoma or brain tumour and
advances in hyperacute treatments. Strong working should be undertaken early in all patients.100 Magnetic
relationships are required between emergency resonance diffusion weighted imaging (MR-DWI) is the
department staff and the stroke team to improve imaging strategy of choice for patients with suspected
timely assessment and early management. TIA with studies detecting ischaemic changes in
16-67% of those with TIA signifying infarction.101
Section 3 as a whole was given a consumer
rating of 9.7/10. MR-DWI may also assist risk stratification and direct
management; although further large studies are
needed to confirm that an infarction detected by
3.1 Assessment of TIA MR-DWI is a clear prognostic indicator of stroke.101
There are strong similarities between minor ischaemic The presence of symptomatic carotid disease
stroke and TIA and hence principles of assessment increases risk of stroke in patients with TIA.94 Carotid
and management should follow that outlined for investigations should therefore be carried out urgently
people with ischaemic stroke including secondary when an arterial source is suspected and carotid
prevention. This section discusses aspects of care that surgery considered (see section 3.3 and 7.6).102
are specific for people with TIA. The organisation of
Risk factor assessment and stratification
care for people with TIA is discussed in section 1.2.
Five factors have been identified as risks for early
Definition and prognosis
stroke after TIA including age (>60years), diabetes
TIA is defined as “rapidly developed clinical signs of mellitus, longer symptom duration (> 10 mins), motor
focal or global disturbance of cerebral function lasting or speech symptoms of TIA, and high blood pressure
fewer than 24 hours, with no apparent non-vascular (> 140/90mmHg).35
cause” although revision of this definition has been
Two simple risk stratification tools for TIA have been
suggested to shorten the timeframe to 1 hour as TIAs
validated in different populations.35, 103, 104 These two
rarely last longer than this timeframe.91 More recent
risk tools have recently been combined and validated
data have highlighted a higher and earlier risk of
17
Scores 6-7 indicate a high risk (8.1% 2-day risk; 21% simple scoring has been agreed by the working group
of TIA cohorts in validation studies); Scores 4-5 to be used in these guidelines using the ABCD2 tool.
indicate a moderate risk (4.1% 2-day risk; 45% total Hence those with >4 are designated HIGH risk and
TIA cohorts); and 0-3 indicate low risk (1% 2-day risk; those 4 are LOW risk.
34% of TIA cohorts).35 Based on studies looking at the
original ABCD tool, a cut off of 4 has been suggested ABCD2 Tool interpretation103
>4 = HIGH risk; 4 = LOW risk
to differentiate high and low risk103 and this more
a) All patients with suspected TIA should have a full assessment that includes B Level II 35
assessment of stroke risk using the ABCD² tool at the initial point of health
care contact whether first seen in primary or secondary care.
b) The following investigations should be undertaken routinely for all patients – –
with suspected TIA: full blood count, electrolytes, renal function, cholesterol
level, glucose level, and electrocardiogram.
c) Patients classified as high risk (ABCD²>4) should have an urgent CT brain B Level I 35,
(‘urgent’ is considered as soon as possible, but certainly within 24 hours). 100, 102 &
Carotid duplex ultrasound territory symptoms who would potentially Level III-3 99
be candidates for carotid re-vascularisation. Patients classified as low risk
(ABCD² 4) should have a CT brain and cartoid ultrasound (where indicated)
as soon as possible (i.e. within 48-72 hours).
Although there is little direct evidence it is essential to specialist and approximately 20-30% of cases are
undertake a good medical assessment including incorrectly diagnosed as stroke or TIA111 suggesting
Early Assessment and Diagnosis
accurate history and assessment of presenting the need for a close working relationship between
symptoms. Assessment of acute stroke using stroke emergency department staff and stroke
specific scales varies widely. The more commonly specialists.110
used acute assessment scales, for example, the
> Of the diagnostic screening tools specifically used in
National Institutes of Health Stroke Scale (NIHSS), only
emergency departments that have been developed
measure stroke impairment or severity but such scales
to aid the triage process, only the ROSIER scale
have prognostic value.106, 107 Such scales also require
has been adequately studied. The scale has been
experience and formal training and as such, other
found to sensitively identify stroke mimics thereby
tools have been developed for use by staff not as
helping emergency department staff make
familiar with stroke.
appropriate referral to the stroke team.112
Studies aimed at improving the organisation of
> The use of pathways or protocols has been found
services to provide rapid and accurate assessment in
to reduce hospital delays for acute care in several,
emergency departments have found the following:
Section 3
18
> A notification system between emergency medical introducing a small CT unit within the emergency
services staff, emergency department staff and the department for priority imaging.85 While the
stroke team has also been found to reduce proximity of the CT unit was seen as a key
intrahospital delays and improve patient related component in this study it is optimistic to consider
outcomes (those benefiting from receiving this a feasible strategy for most departments.
thrombolysis).39, 83-85
> Education of emergency department staff has
> One non-randomised study reported benefits from also been undertaken as part of a multidimensional
a process of reorganisation of services that included strategy with improvements noted in processes
establishing a nurse led triage team specifically for of care (for example, reduced delays to CT and
neurological patients, improved prenotification by increased numbers receiving thrombolysis).39, 81, 82
ambulance staff of patients eligible for rt-PA, and
b) Emergency department staff should use a validated stroke screen tool to C Level II 112
assist in rapid accurate assessment for all people with stroke.
c) Local protocols developed jointly by staff from pre hospital emergency D Level III-3 &
services, the hospital emergency department and the stroke unit should be IV 39, 83, 85
used for all people with suspected stroke. Such protocols should include
early notification by paramedic staff, high priority transportation and triage,
rapid referrals from ED staff to stroke specialists and rapid access to
imaging.
3.3 Imaging
19
this test. Doppler ultrasound is widely available and (e.g. history of cardiac abnormalities or an abnormal
useful in most centres. Non invasive measures for electrocardiogram where there are no current
symptomatic events were much less accurate for indications for anticoagulation or in patients with
patients with 50-70% stenosis, however, too few stroke of unknown origin after standard diagnostic
data exist and no clear conclusions can be made.102 workup).116 Transthoracic echocardiography (TTE) is
Carotid surgery is most beneficial early after non- less invasive but less sensitive than transesophageal
severely disabling stroke (see section 7.7) and hence echocardiography (TEE) in detecting sources of
carotid imaging should be undertaken as part of the cardiac emboli in patients with TIA or stroke.116 TEE
initial diagnostic workup in selected patients. also appears more useful than TTE in assisting clinical
decision making (i.e. aid decision whether to
C. Cardiac imaging
commence anticoagulation or not).117
Echocardiography may be considered to determine a
potential cardioembolic source in selected patients
a) All patients with suspected stroke should have an urgent brain CT or MRI A Level I
(‘urgent’ is considered as soon as possible, but certainly less than diagnostic
24 hours). study100
b) A repeat brain CT or MRI should be considered urgently when a patient’s ✓ –
condition deteriorates.
c) All patients with carotid territory symptoms who would potentially be B Level I102
candidates for carotid re-vascularisation should have an urgent carotid
duplex ultrasound.
d) Further brain, cardiac or carotid imaging should be undertaken in selected B Level I
cases including: 100, 102and
• Patients where initial assessment has not confirmed likely source of Level III-2116
ischaemic event;
• Patients with a history of more than one TIA;
• Patients likely to undergo carotid surgery.
Early Assessment and Diagnosis
3.4 Investigations
Once clinical diagnosis has been made, investigations diagnose the underlying cause then further
are used to confirm the diagnosis and to determine investigations may be warranted. Many tests exist
the potential cause of the event, specifically if there is a and need to be considered based on individual patient
cardiac or arterial source. Routine investigations needs. For example, thrombophilia screening may
should include full blood count, electrolytes, renal be needed when the clinical history identifies a family
function, cholesterol and glucose levels and history of thrombosis (particularly for those <50 years
electrocardiogram although direct evidence is lacking old). Some tests should be regularly repeated to
Section 3
for each of these investigations. If clinical history, allow for careful monitoring in the acute period (see
imaging and routine investigations do not adequately section 4.3.1).
20
3.4 INVESTIGATIONS GRADE LEVEL
21
4 ACUTE MEDICAL & SURGICAL MANAGEMENT
(see Section 7). further trials are underway (e.g. IST-3, ECASS-III).
4.1.2 Thrombolysis Subsequent phase IV studies have generally
demonstrated similar outcomes to the major phase III
Two systematic reviews have been undertaken
studies.123 Protocol deviation has been identified
to determine the benefits of thrombolysis in acute
across one network of hospitals as a potential reason
ischaemic stroke.120, 121 Four different agents have
for poorer clinical outcomes in routine practice as
been evaluated: streptokinase, recombinant
compared to the outcomes obtained in the treatment
pro-urokinase, recombinant tissue plasminogen
arms of the randomised trials.124 However, an audit
activator (rt-PA) and urokinase. Most of the data are
and quality improvement process in these same
from trials of intravenous thrombolysis involving rt-PA.
hospitals subsequently demonstrated a reduction in
Results found:
protocol violations (50% down to 19.1% following the
> Thrombolysis in all trials and all agents combined quality improvement) and an associated decline in
results in a significant reduction in the composite adverse events from 15.7% to 6.4%.125 Close
end-point of death or disability; monitoring of outcomes, audit and quality
> Thrombolysis (all agents pooled) shows a net improvement activities are, therefore, strongly
benefit, but is associated with a definite risk of recommended for all centres delivering rt-PA. The
intracerebral haemorrhage and increased mortality international “Safe Implementation of Thrombolysis
at the end of 3 or 6 month follow-up. in Stroke” (SITS) register is available to support data
collection, audit and benchmarking across centres
> Heterogeneity between the trials was evident and
and across countries. Recent safety and clinical
no clear evidence for one agent, dose or route was
outcome data from the European arm of the SITS
found. There was indirect evidence that rt-PA may
registry suggests lower adverse events than those
have more benefit and less hazard.
seen in the clinical trials of rt-PA.126 Current Australian
> Therapy appears most beneficial if provided in data are comparable to the international data and are
experienced centres in highly selected patients. shown in the table below.
Widespread use of thrombolytic therapy in routine
Table 1. Safe Implementation of Thrombolysis in Stroke (SITS) register. Summary as of end of June 2007 * 393 total cases entered ** Phase III tPA data122
22
Intravenous rt-PA was licensed by the Australian units have demonstrated an ability to safely administer
Therapeutic Goods Administration for use in acute rt-PA.127, 128 Table 2 outlines the patient selection
Contraindications: ABSOLUTELY Do NOT administer tPA if any of these statements are true:
Section 4
1 Uncertainty about time of stroke onset (e.g. patients awaking from sleep)
2 Coma or severe obtundation with fixed eye deviation and complete hemiplegia.
3 Only minor stroke deficit which is rapidly improving.
4 Seizure observed or known to have occurred at onset of stroke.
5 Hypertension: systolic blood pressure ≥ 185mmHg; or diastolic blood pressure >110mmHg on repeated
measures prior to study.
6 Clinical presentation suggestive of subarachnoid haemorrhage even if the CT scan is normal.
7 Presumed septic embolus.
8 Patient having received heparin with the last 48 hours and has elevated PTT or has a known hereditary
or acquired haemorrhagic diathesis (e.g. PT or APTT greater than normal).
9 INR >1.5.
10 Platelet count is <100,000 uL.
11 Serum glucose is < 2.8mmol/l or >22.0 mmol/l.
RELATIVE Contraindications: If any of the following statements is true, use tPA with caution.
In each situation careful consideration of the balance of the potential risks and benefits must be given:
23
Based on the evidence, intravenous rt-PA therapy is thrombosis seen within 6 hours who are either
beneficial for select patients but should be delivered in not eligible for IV rt-PA or who do not respond to
Acute Medical & Surgical Management
well equipped and skilled emergency departments IV rt-PA) its widespread implementation within
and/or stroke care units with adequate expertise and Australia is currently limited. Further robust,
infrastructure for monitoring, rapid assessment and large studies are needed.
investigation of acute stroke patients. Collaboration
> ultrasound assisted therapy in addition to
between clinicians in pre-hospital emergency services,
intravenous thrombolysis.142-146 This is an evolving
emergency medicine, neurology and neuroradiology is
field and robust evidence is needed before this
recommended to foster prompt identification of
experimental approach could be considered in
potentially eligible patients, expert patient selection
routine clinical care.
along with audit and quality improvement initiatives.
> mechanical thrombolysis.147-153 Recanulisation rates
There are a significant number of other studies (a non
have been found to be similar between trials using
exhaustive number of references are noted below),
the MERCI devise and IV and IA thrombolysis. As
most of which are small Level III or IV studies (only a
with IA thrombolysis the use of mechanical retrieval
few are Level II studies) that have evaluated the
devices is limited to a small number of centres with
following either alone or in combination with
adequate resources and expertise. Further studies
Section 4
intravenous thrombolysis:
are needed (along with appropriate approval) before
> the use of other agents (e.g. tenecteplase, clear recommendations for Australian centres can
reteplase, desmoteplase).130-133 While some agents be made.
appear promising, others have failed to show clear
> anticoagulation or antiplatelet agents.135, 154, 155
benefits. Further data are needed and until so the
use of such agents should only be considered Advanced MR and CT imaging techniques may
within a clinical trial setting. identify ischaemic but potentially viable brain tissue
beyond the 3 hour time window. These techniques are
> intra-arterial (IA) thrombolysis.121, 134-141 Only one
currently under evaluation as a means of selecting
moderate sized RCT has been completed which
patients likely to benefit from intravenous rt-PA and
reported benefits of IA thrombolysis with
other thrombolytic therapies at treatment windows out
prourokinase.140 Many non controlled studies and
to 9 hours after symptom onset. While some of the
a couple of very small RCTs also report benefits
patient selection techniques and other forms of
(either using IA therapy alone or in addition to IV
thrombolysis appear promising, data from large, RCTs
rt-PA). Use of IA thrombolysis requires considerable
evaluating long-term functional outcomes are needed
resources and while it may be promising (particularly
before definitive recommendations can be made.
for basilar artery thrombosis and middle artery
a) Intravenous rt-PA in acute ischaemic stroke should only be undertaken in A Level I 120, 122
patients satisfying specific inclusion and exclusion criteria
b) Intravenous rt-PA in acute ischaemic stroke should be given under the C Level I 120
authority of a specialist physician and interdisciplinary acute care team with & Level IV 123
expert knowledge of stroke management, experience in the use of intravenous
thrombolytic therapy and with pathways and protocols available to guide
medical, nursing and allied health acute phase management. Pathways or
protocols must include guidance in acute blood pressure management.
c) Thrombolysis should only be undertaken in a hospital setting with appropriate ✓ –
infrastructure, facilities and networks.
d) A minimum set of de-identified data from all patients treated with C Level IV 126
thrombolysis should be recorded in a central register to allow monitoring,
review, comparison and benchmarking of key outcomes measures over time.
24
4.1.3 Antithrombotic therapy
Section 4
4.1.3 ANTITHROMBOTIC THERAPY GRADE LEVEL
a) Aspirin (150-300mg) should be given as soon as possible after the onset of A Level I 160
stroke symptoms (i.e. within 48 hours) if CT/MRI scan excludes haemorrhage.
b) The routine use of anticoagulation (e.g. intravenous unfractionated heparin) A Level I 157, 158
in unselected patients following ischaemic stroke/TIA is not recommended.
25
4.1.5 Surgery for ischaemic stroke
Acute Medical & Surgical Management
Hemicraniectomy for ischaemic stroke should be for patients with ‘malignant’ or significant middle
considered for large middle cerebral artery (MCA) artery occlusion an urgent referral to a neurosurgical
infarcts where prognosis is poor, so called “malignant consultant is strongly recommended.
infarction”. A meta-analysis of three RCTs found
One recent robust systematic review failed to find any
benefits (reduced mortality and improved functional
RCTs for the use of angioplasty and stenting for
outcomes for those surviving) of decompressive
intracranial artery stenosis.166 Evidence from case
surgery in conjunction with medical therapy compared
series with three or more cases, demonstrated an
with medical therapy alone.165 Such benefits were
overall perioperative rate of stroke of 7.9%,
seen in selected patients only who fulfilled clear
perioperative death of 3.4%, and perioperative stroke
inclusion criteria (e.g. those between 18- 60 years old
or death of 9.5%. Robust data are required before
who can undertake surgery within 48 hours of
clear conclusions can be made regarding this
symptom onset, with clinical deficits suggesting
intervention.
significant MCA involvement).165 Given the prognosis
a) Selected patients (e.g. 18-60 years where surgery can occur within 48 hours A Level I 165
of symptom onset) with significant middle cerebral artery infarction should be
urgently referred to a neurosurgeon for consideration of hemicraniectomy.
b There is currently insufficient evidence to make recommendations about the – Level I 166
use of intracranial endovascular surgery.
In general the treatment of ICH is similar to that for Mannitol have all failed to demonstrate benefits in patients
ischaemic stroke (e.g. rapid assessment, routine with ICH.172-174
investigations, and prevention of complications). This
While there is consensus that ICH, due to anticoagulation,
section addresses medical and surgical management that
should be urgently reversed there is no clear consensus
is specific for patients with ICH.
about which strategies to choose due to the lack of good
Medical management quality data. 175, 176 Traditional approaches include
administration of prothrombin complex concentrate
Haematoma growth is predictive of mortality and poor
(PCC), fresh-frozen plasma (FFP), or vitamin K (if used in
outcomes after ICH.167 Despite a phase II trial of a
addition to other strategies).175, 176 Off-label use of rFVIIa
haemostatic agent, recombinant activated factor VII
alone or in combination with FFP has also been reported
(rFVIIa), showing reduction in haematoma growth and
in small Level IV studies but is viewed as experimental
reduced disability and mortality at 3 months 168 a
only.177, 178
subsequent trial, the FAST trial, not yet published, while
also showing significant reduction in haematoma growth Management of acute blood pressure is particularly
at 24 hours, did not confirm the earlier findings of a important, however, currently no randomised studies
clinical benefit. At this time the use of rFVIIa in the have been completed to guide treatment. One Level IV
treatment of intracerebral haemorrhage should be study with only 27 patients reported a protocol of keeping
considered experimental and further trials are needed blood pressure below 160/90mmHg was feasible and
before recommendations on the usefulness in routine safe with a low percentage of haematoma growth.179
clinical practice can be made.169 Until more robust data becomes available it is generally
accepted that blood pressure lowering in ICH patients
Neuroprotective agents that have been tested have found
with a history of hypertension is indicated only to keep
no clear benefits in patients with ICH.170 Citicoline has
mean arterial blood pressure (MAP) below 130mmHg
been evaluated in a very small phase I study and further,
(MAP=diastolic BP +1/3(systolic-diastolic BP).
larger studies are needed.171 Corticosteroids, glycerol and
26
Surgical management
a) The use of haemostatic drug treatment with rFVIIa is currently considered B Level I 169
experimental and is not recommended for use outside a clinical trial.
Section 4
b) The routine use of surgery is not recommended for patients with supratentorial
haematoma but may be considered in certain circumstances, including:
• stereotactic surgery for patients with deep ICH; C Level I 181
• craniotomy for patients where haematoma is superficial (<1cm from surface) C Level II 180
c) Surgical evacuation may be undertaken for cerebellar hemisphere haematomas ✓ –
>3cm diameter in selected patients.
d) In ICH patients who have a history of hypertension, mean arterial pressure ✓ –
should be maintained below 130 mm Hg.
This section addresses acute care that is the same for stroke enhances the benefits of conventional stroke
ischaemic and haemorrhagic stroke. Early unit care. However the intensity (e.g. continuous or
physiological changes including hypertension, every 2-6 hours) and duration (e.g. 24-72 hours) of
hypotension, hyperglycaemia, fever, and hypoxia have such monitoring is still unclear and further larger
all been shown to be associated with poor outcomes studies including cost effectiveness data are required.
after stroke and general measures should be initiated However, it is clear that due to the current focus on
to monitor and manage such changes in the acute hyperacute management regular monitoring is
phase.161, 183, 184 needed that reflects individual patient needs as
well as balancing the need for early rehabilitation
4.3.1 Physiological monitoring to commence.
One small RCT185 and two non randomised trials 186, 187
have found that monitoring in the first 2 days after
Patients should have their neurological status (including Glasgow Coma Scale) and C Level II 185
vital signs including pulse, blood pressure, temperature, oxygen saturation, glucose, &
and respiratory pattern monitored and documented regularly during the acute Level III-2
phase, the frequency of such observations being determined by the patient’s status. 186, 187
27
4.3.2 Oxygen therapy
Acute Medical & Surgical Management
One systematic review of hyperbaric oxygen Many centres represented in the stroke unit trials data
therapy concluded that there is insufficient evidence to had management policies for oxygen therapy18 and
demonstrate clear benefits.188 One preliminary study of until further evidence is available there is consensus
normobaric oxygen therapy found short term that in patients found to be hypoxic oxygen therapy
improvements in stroke severity scales but no should be provided.
difference in patient outcomes at 3 months.189
8-83% depending on the cohort and definition.190 and management appear important although evidence is
Observational data indicates that hyperglycaemia scarce. Two pilot studies found glucose infusion to be
fluctuates in the first 72 hours in non diabetic as well as safe and feasible.196, 197 However, a recent large follow up
diabetic patients even with current best practice.191 of one study investigating aggressive maintenance of
Observational data also demonstrates poorer outcomes euglycaemia via glucose-potassium-insulin infusion failed
for non diabetic patients with hyperglycaemia190 and to demonstrate benefits.198 There is consensus that
the prevalence of undetected diabetes ranges from management should be commenced in patients with
16-24% of patients.192, 193 Patients with glucose hyperglycaemia, however, further data are needed to
intolerance after stroke is also common (approximately determine the most appropriate management strategies.
a) Patients with hyperglycaemia should have their blood glucose level monitored ✓ –
and appropriate glycaemic therapy instituted to ensure euglycaemia, especially
if the patient is diabetic. Hypoglycaemia should be avoided.
b) Intensive, early maintenance of euglycaemia is currently not recommended. B Level II 198
28
Acute Medical & Surgical Management
4.3.4 NEUROPROTECTIVE AGENTS GRADE LEVEL
The use of putative neuroprotectors should only be used if part of a randomised A Level I&II
controlled trial. 199-202
Section 4
either acute or subacute stroke care.216, 217 Further
Since complementary medicine may relate to
robust studies are needed.
particular cultural backgrounds or other belief systems,
> Reiki therapy was not found to be beneficial in one health professionals should be aware of, and sensitive
small RCT.218 to, the needs and desires of the stroke survivor and
the family/carer. Health professionals should be willing
> Ginkgo biloba extract and Dan shen agents have
to discuss the effectiveness of therapy and different
some reported benefits, however, trials have
options of care within the context of the current health
care system.
a) The routine use of the following complementary and alternative therapies are
not recommended:
• Acupuncture; B Level I 216, 217
• Ginkgo biloba extract or Dan shen agents; B Level I 219, 220
• Reiki therapy; C Level II 218
• Other alternative therapies. ✓ –
b) Health professionals should be aware of different forms of complementary and ✓ –
alternative therapies and be available to discuss these with stroke survivors
and their families.
29
5 ASSESSMENT AND MANAGEMENT
OF THE CONSEQUENCES OF STROKE
5.1 Dysphagia
Assessment and Management of the Consequences of Stroke
The incidence of dysphagia varies widely, depending comprehensive assessment to thoroughly examine
on the timing and method of evaluation, but is very the patient. However, screening tools have been
common (27–50%) in acute stroke.221 Dysphagia is developed for use by non specialist staff who
also associated with an increased risk of always undertakes essential training prior to using
complications, such as aspiration pneumonia, such tools.225 Overall more methodological robust
dehydration and malnutrition.221 Prompt screening, studies are required to clarify which test is preferred.
accurate assessment and early management are
> The gag reflex is not a valid screen for dysphagia.225
therefore needed to prevent these complications and
promote recovery of functional swallow. > Videofluoroscopic modified barium swallow (VMBS)
study may be considered the reference standard to
Studies involving assessment and management of
confirm swallowing dysfunction and presence of
dysphagia in acute stroke have found:
aspiration, however, several limiting factors have
> The adherence to a formal dysphagia screening been noted including: the relatively complex, time
protocol reduces the incidence of pneumonia in consuming and resource intensive nature of the
acute stroke patients.222, 223 Another study test; small exposure to radiation; and patients may
implementing evidence based acute care involving have difficulty sitting upright in a chair for the test. In
dysphagia screening, referral and assessment addition, the results of the test can be difficult to
demonstrated improved process and patient interpret and variation among individual raters may
outcomes.224 Further studies, however, are occur.227 There is currently no agreed criterion for
needed to clarify what are the key factors that when a VMBS study is required and local policies
improve outcomes including which screening tool is should be developed that take into consideration
most useful. local resources and the potential limitations noted
above.
> Three systematic reviews were all unable to
Section 5
conclude which screening tool used for bedside > Fiberoptic endoscopic evaluation of swallowing
assessment was most useful due to variability in the (FEES) has also been used as a reference standard
studies.225-227 While most tests had sensitivities of in studies assessing screening tools230-232 and has
70-90% some were much lower, with the lowest been found to have similar sensitivity and specificity
reported to be 42%.225, 227 Specificity was almost compared with VMBS.234 FEES is portable (possibly
always lower with ranges from 22-67% in one allowing more immediate access and time saving),
review225 and 59-91% in another.227 Screening requires less staff and is therefore cheaper, and
should be undertaken routinely before providing reduces radiation exposure.234 While speech
food or drink to patients. Ideally such screening pathologists currently coordinate and conduct
would be undertaken within the first 24 hours of VMBS studies, FEES can only be conducted by
hospital admission. specialists with recognised training and
credentialing and as such it is not yet commonly
> Subsequent studies of bedside clinical screening
available in Australia.
have demonstrated similar sensitivities with other
bedside tests.228-233 The best was found to be the > One recent robust trial found more patients
50ml water swallow test in combination with receiving a behavioural intervention (i.e. swallowing
oxygen saturations (with sensitivity reported compensatory strategies plus dietary modification,
between 87-100%).228, 230, 232 either high or low intensity therapy) returned to a
normal diet at 6 months or recovered swallowing at
> Screening tests are used to identify patients with
6 months, than those receiving usual care.221 While
possible dysphagia. Screening tools may also be
this study suggests potential benefits for more
used by a speech pathologist as part of a
30
intense therapy, further high quality trials are Stroke Rehabilitation and Recovery. No other
needed. This study strengthens rather than alters significant studies were found and readers are
the recommendations for management of those directed to that document for details regarding
with dysphagia outlined in the Clinical Guidelines for management strategies.
a) Patients should be screened for swallowing deficits before being given food, C Level I 225, 226
drink or oral medications. Screening should be undertaken by personnel
specifically trained in swallowing screening.
b) Patients should be screened within 24 hours of admission. ✓ –
c) Patients who fail the swallowing screening should be referred to a speech ✓ –
pathologist for a comprehensive assessment.
5.2 Nutrition
Dehydration is common after stroke due to status.
consequences of stroke such as swallowing impairment,
Studies relating to hydration and nutrition post stroke
immobility and communication difficulties. Malnutrition is
have found the following:
also common with Australian data indicating that 16-19%
of patients are malnourished on admission.235, 236 Previous > Suboptimal fluid intake leads to negative outcomes 242,
243 and is particularly problematic in people with
observational studies have shown that dehydration and
malnutrition increases in the first week of hospitalisation dysphagia.244, 245 As a result it may be necessary to
and are associated with poor outcomes post stroke, increase fluid intake via the intravenous, subcutaneous
including increased complications and mortality, a fact or enteral route (using a nasogastric [NG] tube or
confirmed by more recent studies.235-237 percutaneous endoscopic gastrostomy [PEG]). There
is no clear evidence to suggest one route is more
Section 5
Currently there is no universally accepted gold standard
beneficial than the other when addressing adequate
for the assessment of nutritional status in the acute stroke
hydration levels.246
patient. Malnutrition is typically diagnosed based on
objective nutrition parameters (biochemical, > There are very few robust observational studies found
anthropometric or immunological markers), for example that report nutritional intake of acute hospitalised
serum albumin, weight or skin folds, however, these are stroke patients. The identified studies suggest that
imperfect measures which are impacted by factors nutritional intake is suboptimal.247, 248 Furthermore,
secondary to stroke. Validated nutritional screening tools there is suggestion that the nutritional needs of those
have also been developed and should be used in patients with haemorrhagic strokes may be higher than
with acute stroke on admission and at regular intervals previously calculated and therefore these patients may
throughout admission. This would appear logical given be at particular risk of malnutrition.249
the poor prognosis of those with malnutrition. A number > Simple strategies such as making fluid accessible,
of validated nutrition assessment tools, including the offering preferred fluids and providing supervision
Subjective Global Assessment (SGA) along with the during meals have been found to increase fluid intake
associated patient generated SGA, Malnutrition in elderly people who are able to take fluids orally.250, 251
Screening Tool (MST), Malnutrition Universal Screening
> One systematic review found oral nutritional
Tool (MUST) and Mini Nutritional Assessment (MNA), have
supplementation of patients deemed to be
been used in studies of acute hospitalised patients
undernourished at baseline reduces infectious
including those with stroke. 235, 236, 238-241 Such validated
complications and mortality when compared with
tools should be used alone or in addition to objective
placebo/standard care.252 A subsequent RCT of oral
nutritional parameters in the assessment of nutritional
liquid supplementation in addition to a normal hospital
31
diet reduced non-elective readmissions to hospital in a > There is conflicting evidence for the preferred method
generalised population. Only 2.3-5.5% of those of enteral feeding for those with dysphagia. In by far
included were stroke patients.253 Given the the largest and most robust study, NG tube feeding in
observational data regarding poorer outcomes it is the first month after stroke was associated with
considered good practice for staff to monitor food increased functional recovery and was more likely to
Assessment and Management of the Consequences of Stroke
intake along with fluid intake to maximise nutrition and be associated with normal feeding 6 months after
outcomes for people with acute stroke. stroke when compared with PEG feeding.256 Three
other much smaller studies reported benefits of PEG
> A prospective observational study also found early
feeding compared with NG feeding.257-259 Given the
nutritional support (via tube feeding) improved
FOOD trial paper is almost 10 times larger than other
outcomes compared to standard care for severe
trials and much more robust, it is prudent to base
stroke patients.254, 255 The FOOD trial found no
decisions on the data from this study suggesting NG
significant difference in death and disability or
is preferred in the acute phase for those requiring
incidence of pneumonia for patients provided with
enteral feeding.
early NG enteral feeding compared with intravenous or
subcutaneous fluids (without nutrition).256 However, > Implementation of locally developed evidence-based
there was a non significant trend for those who guidelines for nutritional support using opinion leaders
received early NG tube feeding to have a reduced risk and educational programmes linked to audit and
of death but an increased likelihood of being severely feedback improved adherence to guidelines by staff
disabled.256 Unfortunately this trial was underpowered and reduced patient complications (infections).224
to detect such changes.
a) Close monitoring of hydration status and appropriate fluid supplementation B Level I 250
should be used to treat or prevent dehydration.
b) All patients with acute stroke should be screened for malnutrition. B Level II 260
c) Those who are at risk of malnutrition, including those with dysphagia, should ✓ –
be referred to a dietitian for assessment and ongoing management.
Section 5
32
of very early versus delayed mobilisation after stroke is Due to the early risk of falls and potential for manual
currently underway 266 as is the large AVERT Phase III handling issues for both the patient and staff an early
trial which is testing whether very early mobilisation assessment by a physiotherapist and appropriate advice
(within 24 hours of stroke onset) reduces death and communicated to the stroke team, especially to nursing
disability, reduces complications after stroke, improves staff, is prudent.
Assessment and management of occupational period. Included studies have been undertaken during
performance in daily activities fall into two areas: subacute care in hospital or in the community with very
little data in the acute phase of care although early OT
> Occupational performance in basic self-maintenance
involvement was typical of units described in the stroke
tasks such as showering, toileting, dressing, and
unit trialist collaboration.18
eating.
Based on assessment findings, interventions targeting
> Occupational performance in domestic and
specific areas such as occupational performance in daily
Section 5
community tasks such as home maintenance tasks,
activities, upper limb function, cognition, perception and
management of financial affairs and community
participation in the community including driving should be
access, including driving.
tailored to each patient. No recent studies have been
A recent robust systematic review found patients who found that alter the recommendations for such topics
receive occupational therapy interventions reduce the outlined in the Clinical Guidelines for Stroke Rehabilitation
likelihood of a poor outcome and increase personal and Recovery and readers are directed to that document
activity of daily living scores.268 It is unclear what specific for details.
factors contribute to this benefit especially in the acute
a) Patients with difficulties in occupational performance in daily activities should be B Level I 18, 268
treated by an occupational therapist or a specialist multidisciplinary team that
includes an occupational therapist.
b) Patients with confirmed difficulties in occupational performance in personal ✓ –
tasks, instrumental activities, vocational activities or leisure activities should
have a management plan formulated and documented to address these issues.
c) The occupational therapist should advise staff and carers on techniques and ✓ –
equipment to maximise outcomes relating to functional performance in daily
activities, sensorimotor, perceptual and cognitive capacities.
33
5.5 Cognition and perception
Cognitive and perceptual impairment commonly involves significant number of screening and assessment tools
attention, memory, orientation, language, executive used for neglect but there is no universally agreed gold
functions, neglect, apraxia and agnosia. Cognitive and standard.275, 278, 279 This may account for the low numbers
perceptual impairment and dementia are common after of patients found to be assessed in the acute phase of
stroke (up to 60% have cognitive impairment and up to care in one overseas audit.280 However, as neglect is
Assessment and Management of the Consequences of Stroke
30% develop dementia within the first 12 months) 269-272 associated with increased falls risk and poor functional
and there is overlap between these impairments making outcome, screening should be carried out in all patients
it hard to delineate between them. and those identified followed up with a comprehensive
assessment.279
Early screening for cognitive impairment is important
although no gold standard currently exists.273, 274 Non Correspondingly, apraxia is a relatively common cognitive
linguistic tests should be considered where impairment, particularly after a stroke affecting the left
communication deficits are present as language based hemisphere. As with neglect, there are a number of
assessments are inadequate in these patients.274 A more screening and assessment tools used to detect the
detailed assessment conducted by a trained team presence of apraxia, however, there is no universally
member (e.g. occupational therapist, neuropsychologist, agreed gold standard.281, 282 The presence of apraxia
or speech pathologist) can clarify the type of impairments may have a significant effect on the capacity to complete
and guide the team in providing the most appropriate functional activities, therefore, screening should be
rehabilitation interventions. Adequate screening and completed on all patients. Those identified with a
assessment for cognitive impairment is important to diagnosis of apraxia should be followed up by
determine a patient’s capacity to participate in the comprehensive evaluation and intervention.283-286
recovery process and make important decisions (i.e. post
Assessment and treatment on a stroke unit was found to
discharge accommodation and follow up, financial
improve outcomes for those with perceptual difficulties
decisions) and should assist the stroke team to care
compared with care provided on a conventional ward.287
and communicate with the person with stroke and
Specific management of cognitive and perceptual deficits
their family/carer.
is outlined in the Clinical Guidelines for Stroke
Neglect is the most common cognitive impairment Rehabilitation and Recovery, and no significant research
reported in 20-40% of acute stroke patients (more has been undertaken in the last few years that changes
Section 5
commonly in those with right-sided lesions), however, the recommendations. Little research has been
the exact incidence is hard to ascertain due to variability undertaken in the acute period and it is unclear if
in studies and a lack of inclusion of patients with outcomes are improved with early treatment. Further
communication deficits.275-277 Currently there are a studies are needed.
a) All patients should be screened for cognitive and perceptual deficits using a ✓ –
validated screening tool. (Consensus opinion)
b) Patients identified during screening should undertake full assessment and ✓ –
management by an appropriately trained health professional.
5.6 Communication
Communication deficits after stroke are common with aphasia.289 The prognosis for recovery from aphasia
aphasia, the most common deficit, found in 30% of is generally moderate to good with most patients
first-ever ischemic strokes.288 Other communication improving and approximately 40% having a full
disorders post stroke includes dyspraxia and dysarthria. recovery within one year post stroke.290, 291
There is a higher mortality rate for people with
34
The first step in planning management for people with shortcomings and small numbers.294 It is also noted
aphasia is the identification and diagnostic process. The that during the acute phase, therapy often focuses
presence of aphasia may be determined through a on dysphagia and communication therapy is often
screening process prior to a full assessment that will delayed. However, evidence from reviews of RCT
guide management. An audiology assessment may also and non randomised trials seems to indicate that
Section 5
not within the scope of this guideline to discuss these supportive communication techniques.299, 300
tests in detail it is noted that all detailed assessment However, even if carers are not formally trained in
tools are normally administered and interpreted by a specific techniques it is good practice for speech
speech pathologist trained in the use of such tools. pathologists to advise them on the communication
deficits found on assessment and strategies to
> Evidence for therapy for communication deficits is
improve communication between the patient and
limited with most trials having methodological
their family/carer.
a) All patients should be screened for communication deficits using a validated C Level I 293
screening tool.
b) Those with suspected communication difficulties should receive formal ✓ –
assessment by a speech pathologist.
c) Patients with communication difficulties should be treated as early and as C Level I 296 &
frequently as possible. Level III-2 295
d) All written health information should be available in an aphasia friendly format. D Level IV 298
e) The speech pathologist should advise staff and family/carers of appropriate C Level II 299, 300
communication techniques.
35
5.7 Incontinence
Dysfunction of the bladder and/or bowel is common > One robust systematic review301 noted two particular
soon after stroke and may be caused by a combination studies that demonstrated benefits. One study found
of stroke-related impairments (e.g. weakness, cognitive a structured functional approach to assessment and
or perceptual impairments). Incontinence is associated management, compared with a traditional
with complications (e.g. depression) and prolonged neurodevelopmental approach in early rehabilitation
Assessment and Management of the Consequences of Stroke
recovery and is a major factor for many patients and increased the likelihood of being continent at
their carers.301 discharge. The other study demonstrated benefits of
care provided by a specialist continence nurse
Urinary Incontinence
compared with GP care once in the community.301
Several types of urinary incontinence occur after stroke This review found trials of physical, behavioural,
and hence assessment is important to identify distinct complementary and anticholinergic drug interventions
aetiology to enable commencement of targeted were inconclusive and more robust data are needed to
interventions. Methods of diagnostic assessment have guide continence care after stroke.301
been described as a five step sequential process:302
> A second systematic review focused on behavioural
1. clinical history-taking, including history of incontinence approaches to manage urinary incontinence. This
before the stroke, nature, duration and reported review found only modest evidence of the benefits for
severity of symptoms and exacerbating factors urge suppression along with pelvic floor exercises,
including diet, fluid and medications; however, more robust data are needed.303
2. validated scales that measure the severity of Faecal Incontinence
symptoms and impact of symptoms on quality of life;
Faecal incontinence has been found to occur in 30% of
3. physical examination, including abdominal, perineal acute stroke patients however only 11% are incontinent
(pelvic floor strength), rectal, neurological and at 3-12 months post stroke.304 Toilet access and
measurement of body mass index (BMI); constipating drugs are two modifiable risk factors after
4. simple investigations, including urinalysis, midstream stroke. Constipation is also common post stroke as is
specimen of urine (MSSU), measurement of post void reported to be up to 66% in one community based
residual volume (PVRV), provocation stress test, study.304 The research base for management for faecal
frequency–volume charts and pad tests; incontinence and constipation is extremely limited and is
Section 5
36
5.7 INCONTINENCE GRADE LEVEL
a) All patients with suspected continence difficulties should be assessed by B Level II 301
trained personnel using a structured functional assessment.
5.8 Mood
Mood is frequently affected following a stroke. useful for anxiety).307-312 It is not always clear what
Depression is the most common mood disturbance contribution the physical symptoms of stroke make to
with a meta-analysis of observational studies finding the total score on a rating scale.313 Scales specifically
approximately one third of patients have depression for people with aphasia have also been developed.314
after stroke.305 Depression is common in the acute,
Treatment options include pharmacological therapy, or
medium and long term.305 Anxiety and emotionalism
psychological therapy, which includes counselling and
may also occur, either separately or in combination.
problem-solving interventions. The heterogeneity and
While some people with mood disturbances may
methodological shortcomings of trials make it difficult
recover spontaneously over a few months, others may
to reach conclusions on interventions to prevent or to
have problems that persist despite active
Section 5
manage depression after stroke.315, 316 While most
interventions.305 Physical disability, stroke severity and
studies focussed on prevention of depression start early
cognitive impairment are reported to predict depression,
after stroke, studies for treating depression are almost
however, methodological limitations to current studies
always in the subacute and chronic phases of recovery.
do not allow for accurate predictive models to be
Studies have found the following:
developed.306
> Routine prophylactic use of pharmacotherapy was
Assessment can be difficult due to the complex
not effective in preventing depression, however,
interaction of stroke specific deficits (especially aphasia
individual psychotherapy improved scores on mood
or cognitive impairments) and the normal adjustment
scales, but it is unclear if it prevents post-stroke
needed to a potentially devastating situation.
depression.317 Subsequent small studies have found
Assessment of abnormal mood may occur via
conflicting results for routine pharmacotherapy and
psychiatric interview using standard diagnostic criteria
further large robust studies are needed.318, 319
such as the Diagnostic and Statistical Manual of Mental
Subsequent studies of psychotherapy have reported
Disorders (e.g. DSMIV), psychiatric rating scales (e.g.
benefits in terms of improved mood and life
Hamilton Depression rating scale, Geriatric depression
satisfaction.320, 321
scale) or a self-rating mood scale (e.g. Patient Health
Questionnaire 9-item depression scale [PHQ-9]). Rating > A robust systematic review found pharmacotherapy
scales and single simple screening questions have been improved scores on mood scales, but clear benefit in
found to have adequate sensitivity but generally lack remission of post-stroke depression and
specificity and hence are useful for screening rather improvement of functional outcomes has not been
than to diagnose depression (although they are not as shown.316 Subsequent trials have also failed to
demonstrate consistent, clear benefits.322-324
37
> One systematic review found pharmacotherapy was of Although depression is common, there remain many
benefit to people with emotionalism.315 challenges regarding assessment and management.
For example, there are no clear data to suggest how long
> Case management models of care that focused on
therapy should continue after a stroke, at what dosage,
education, screening, management and links with
what rate of side effects may be expected or what is the
Assessment and Management of the Consequences of Stroke
a) Patients with suspected altered mood (e.g. depression, anxiety, emotional B Level II &
lability) should be assessed by trained personnel using a standardised scale. Level III-1
68, 307, 309,
311, 314, 321
b) Patients with stroke may be managed using a case management model after C Level II 68, 325
discharge to reduce post stroke depression. If used, services should
incorporate education of the recognition and management of depression,
screening and assistance to coordinate appropriate interventions via a medical
practitioner.
c) Routine use of antidepressants to prevent post-stroke depression is not B Level I 317
currently recommended.
d) Antidepressants may be used for people with emotional lability. B Level I 315
Section 5
e) Patients with depression or anxiety may be treated with antidepressants B Level I 316
and/or psychological interventions to improve mood.
38
6 PREVENTION AND MANAGEMENT
OF COMPLICATIONS
Cerebral oedema in the infarcted or peri-lesional brain > One robust systematic review found corticosteroids
tissue often leads to early deterioration and death.327 have no benefit and may cause harm and are
therefore not recommended.328
Studies to reduce cerebral oedema and raised
intracranial pressure have found the following: > Another robust systematic review found
osmotherapy using glycerol reduces short term
> A recent meta-analysis of RCTs found benefits
mortality but no long term differences were noted
(reduced mortality and improved functional
and hence its use should be considered in selected
outcomes for those surviving) of decompressive
cases (e.g. while assessing use of decompressive
surgery in conjunction with medical therapy
surgery).172
compared with medical therapy alone (see also
section 4.1.5).165 Given the prognosis for patients > Hyperventilation has not been rigorously tested in
with ‘malignant’ or significant middle artery stroke but short term effects have been found in
occlusion, mainly due to the effect of cerebral patients with traumatic brain injury.329
oedema, an urgent referral to a neurosurgical
consultant is recommended.
a) Selected patients (e.g. 18-60 years with potential for surgery to occur within A Level I 165
48 hours of symptom onset) with significant middle cerebral artery infarction
DVT and the associated complication of PE, are introduction of preventive measures, haemorrhagic
Section 6
significant risks in the first few weeks post stroke with stroke and cryptogenic ischaemic stroke.331 While
PE accounting for 5% of deaths after stroke (third there is often a high number of DVTs found in studies
most common cause).330 Risk factors reported in the (15-80%), many of these are asymptomatic. Clinically
literature include reduced mobility, stroke severity, age, apparent incidence is low for both DVT (<1-10%) and
dehydration, increasing time between stroke and the PE (<1-6%).331
39
> In high-risk populations, duplex or triplex ultrasound symptomatic VTE, intracranial haemorrhage, major
techniques are useful to confirm or rule out extracranial haemorrhage and mortality.331, 334, 336, 337
suspected DVT (sensitivity 91-92%, specificity
> The routine use of low molecular weight heparin or
94%).332 However, use of the Wells Score to
standard heparin in unselected patients is not
categorise the risk and the D-Dimer prior to
recommended as the risks offset the benefits.
ultrasound has been found to be the most cost
LMWH may be more effective than UFH although
effective testing strategy.332
the risk of bleeding also appears to be higher.
> There is limited evidence to guide treatment The benefits of prophylactic UFH or LMWH may
decisions in patients with acute ischaemic or outweigh the risks for certain subgroups, for
haemorrhagic stroke, who may be at particularly example, those with leg paresis, who are immobile,
high risk of bleeding complications related to those with a prior history of DVT or PE, those with
anticoagulant therapy.333 an inherited thrombophilic tendency or those who
are morbidly obese.331 LMWH may be more
> Observational data suggests acute stroke patients
convenient to administer (often once a day dosing),
spend significant time inactive.261 Early mobilisation
but dosing precautions (such as for patients with
is not supported by direct evidence, however,
renal failure) should prophylactic anticoagulant
studies of stroke unit care that encourage early
therapy be considered.
mobilisation have been found to have lower rates
of DVT18 and early mobilisation has been identified The evidence for physical methods of preventing
as one of the most important factors contributing DVT is less clear:
to better outcomes with stroke unit care (see
> Two systematic reviews concluded there is currently
Section 5.3).264
insufficient evidence of the effectiveness of physical
> Hydration, similarly, has not been evaluated in trials, methods to prevent DVT.331, 338 One trial of note
but studies have found dehydration to be strongly included in the more recent review assessed the
associated with DVT 242 and early hydration, a use of intermittent pneumatic compression (IPC) in
component of stroke unit care, could be expected conjunction with elastic stockings. The study
Prevention and Management of Complications
to provide some protection against DVT. reported a reduced incidence of asymptomatic DVT
for patients with ICH in an ICU setting. However, the
> Routine antiplatelet therapy (using aspirin) has
study was too small to detect clinical/symptomatic
modest benefits for acute ischaemic stroke and has
DVT differences in the groups and a higher number
also been shown to have modest preventative
discontinued treatment in the intervention group.339
qualities for DVT (NNT>300) and PE prophylaxis
(NNT>1000).331 > Graduated compression (antithrombotic) stockings
do reduce the incidence of post-surgical DVT,338, 340,
> Heparin and low molecular weight heparin (LMWH)
341 but the evidence for people with stroke is
have both been shown to prevent DVT and PE after
inconclusive.338 Potential benefits in those at high
ischaemic stroke.331, 334, 335 Evidence from these
risk of DVT need to be weighed up against risks,
studies also demonstrated that early use of such
which include acute limb ischaemia (especially in
treatment is consistently associated with increased
stroke survivors with diabetes), peripheral
risk of cerebral haemorrhage when used in the first
neuropathy, and peripheral vascular disease.
few days or weeks after the onset of ischaemic
Results of the ongoing CLOTS trial should further
stroke.331, 334
assist therapy decisions in this area.
> LMWH is at least as effective as unfractionated
heparin (UFH) in preventing DVT, and may be more
Section 6
40
6.2 DEEP VENOUS THROMBOSIS (DVT) AND PULMONARY EMBOLISM (PE) GRADE LEVEL
a) Early mobilisation and adequate hydration should be encouraged with all acute ✓ –
stroke patients to help prevent DVT and PE.
b) Antiplatelet therapy should be used for people with ischaemic stroke to A Level I 331
prevent DVT/PE.
c) The following interventions may be used with caution for selected people with
acute ischaemic stroke at high risk of DVT/PE:
• low molecular weight heparin or heparin in prophylactic doses; B Level I 331,
334, 335 &
Level II 336
• thigh-length antithrombotic stockings. C Level II 331, 338
6.3 Pyrexia
Pyrexia is associated with poorer outcomes after acute phase rather than specifically responding to
stroke.342 The most common causes of pyrexia are pyrexia (see section 4.3.4). Paracetamol and physical
chest or urinary infections.343 A number of trials have cooling for those with pyrexia have been found to be
evaluated different techniques for reducing body modestly effective therapies to reduce temperature in
temperature as a means of neuroprotection in the acute stroke.212, 344
Antipyretic therapy, comprising regular paracetamol and/or physical cooling C Level II 212, 344
measures, should be used routinely where fever occurs.
Pressure ulcers are defined as “areas of localised There is no evidence that the use of risk assessment
damage to the skin and underlying tissue due to scales reduces the incidence of pressure ulcers.346
pressure, shear or friction”.345 One large multicentre
Four main strategies for the treatment of pressure
trial reported 1% of patients developed pressure ulcers
ulcers not specific to stroke involve:
during acute stroke admission.260 Age, stroke severity,
immobility, incontinence, nutritional status and 1. local treatment of the wound using wound
diabetes are contributing risk factors. The skin of those dressings and other topical applications;
deemed at high risk should be examined initially and 2. pressure relief using beds, mattresses or cushions,
reviewed as regularly as needed based on individual or by repositioning the patient;
factors.
Section 6
41
Evidence for such interventions includes the following: > One systematic review was not able to draw any
firm conclusions on the effect of enteral and
> There is insufficient research evidence to guide
parenteral nutrition on the prevention and treatment
decisions about which dressings or topical agents
of pressure ulcers.349 One subsequent trial of
are most effective in pressure ulcer management.348
nutritional support reported no difference in
> One systematic review found foam alternatives to complications of pressure sores for those receiving
the standard hospital mattress were shown to nutritional supplementation.260 However,
reduce the incidence of pressure ulcers in people at supplementation was only recommended in the
risk.345 However, included trials varied greatly in small number of patients with malnutrition and
quality and comparisons were difficult. The relative further large trials would be needed to confirm
merits of alternating and constant low pressure or deny any benefits of nutritional support in
devices, and of the different alternating pressure this subgroup.
devices or seat cushions for pressure ulcer
> There is not enough evidence to clearly determine
prevention are unclear. Sheepskin overlays appear
if physical therapies are beneficial.347, 348
promising based on one trial of orthopaedic
patients. Air filled vinyl boots (with integral foot A management plan is useful for those assessed at an
cradle) were found to be ineffective or even harmful increased risk of developing pressure ulcers. Such a
(i.e. increased pressure sores).345 plan needs to be tailored to each individual situation in
response to identified risk factors. Careful monitoring
> No evidence was found for the effects of
should also be incorporated with the frequency
repositioning as a pressure relieving strategy.
determined by individual factors.
a) All patients unable to mobilise independently should have a pressure care risk ✓ –
assessment completed by trained personnel.
Prevention and Management of Complications
b) All those assessed at high risk should be provided with a pressure relieving B Level I 345
mattress as an alternative to a standard hospital mattress.
6.5 Pain
Pain from any cause can affect people with stroke However, it is important to note that during the acute
due to reduced movement as a result of the stroke, phase, particular emphasis should directed at
pre-existing disease or stroke specific pain (central prevention of post stroke shoulder pain, including the
post-stroke pain). No recent studies have been found prevention of shoulder subluxation, as shoulder pain
that alter the recommendations outlined in the Clinical once present can be particularly problematic and no
Guidelines for Stroke Rehabilitation and Recovery and clear interventions currently exist.7
readers are directed to that document for details.
6.6 Falls
Section 6
Falling is common in acute hospital settings. No information regarding generic guidelines for falls
recent studies have been found that alter the prevention and management in the elderly is also
recommendations outlined in the Clinical Guidelines for available 350 and should be considered for acute stroke
Stroke Rehabilitation and Recovery and readers are patients.
directed to that document for details. Further
42
7 SECONDARY PREVENTION
7.1 Behaviour change to prevent another stroke has been given a Consumer Rating of 9.7/10.
7.2 -7.8 Medical or surgical treatments to prevent another stroke has been given a Consumer
Secondary Prevention
Rating of 9.6/10.
7.9 Concordance with medication to prevent another stroke has been given a Consumer
Rating of 9.6/10.
A person with stroke has an accumulated risk of cessation in general populations and should be
subsequent stroke of 43% over 10 years with an provided via an individualised approach either in a
annual rate of approximately 4%.351 The rate of strokes group or on a one-to-one basis.362-365 One good
after TIA is significantly higher (up to 20% after example of such behavioural therapies involves
Section 7
3 months) suggesting greater opportunities to prevent telephone counselling, which improved smoking
stroke after TIA.35 Secondary prevention therefore cessation rates particularly when three or more call
relates to both stroke and TIA. Data from overseas backs are made.366
highlight the current underutilisation of secondary
> Diet has an impact on a number of risk factors and
prevention strategies for people with stroke and TIA.35,
can provide additional benefits to pharmacological
352, 353 Long term management of risk factors is the
interventions in people with vascular disease.
primary role of GPs and good communication
Reducing dietary salt in people with cardiovascular
between secondary and primary care is important
disease (especially in those with high blood
(see section 1.10 Shared care).
pressure) modestly reduces blood pressure and
may therefore be beneficial to prevent stroke.367-371
7.1 Behaviour change A meta-analysis of cohort studies found a diet high
in fruit and vegetables (>5 servings per day)
Evidence on behaviour change strategies targeting
reduced the risk of stroke.372 Similarly, a diet that is
lifestyle factors to prevent recurrence of stroke is
low in fat but high in fruit and vegetables has been
limited and often derived from cohort studies of
shown to be effective in risk reduction for those with
primary prevention.
cardiovascular disease.370, 373-375 Similar dietary
> Smoking increases the risk of both ischaemic and modification has also been shown to be beneficial
haemorrhagic stroke due to vascular narrowing and for those with dyslipidemia 376-378 and obesity (to
changes in blood dynamics.354-356 While no RCTs assist in controlling hypertension).379 Supplementary
have been conducted, observational studies have antioxidants and vitamins, however, have not been
found the risk from smoking decreases after found to reduce stroke.380-382 One recent large
quitting with the risk disappearing altogether after RCT of a general dietary intervention (intended to
5 years.357, 358 Several Cochrane systematic reviews be low in fat and high in vegetables, fruits and
have been undertaken related to different therapies grains) in women 50-79 years old noted a
for smoking cessation. Nicotine replacement significant reduction in diastolic blood pressure and
therapy is beneficial and doubles the chances of low-density lipoprotein cholesterol.383 However, no
smoking cessation.359 Some antidepressants (i.e. difference in stroke incidence or coronary heart
bupropion and nortriptyline but not selective disease was found. The authors suggested a more
serotonin reuptake inhibitors) aid long-term smoking individual, targeted approach may be needed.383
cessation.360 Varenicline (a nicotine receptor partial Recommendations for dietary intake are available
agonist) has recently been developed for long-term from other guidelines and provide useful information
smoking cessation with a threefold success rate based on cardiovascular disease and general
compared with non drug quit attempts.361 populations.384, 385
Varenicline has also been found to be more
> There is strong evidence from meta-analysis of
beneficial than the antidepressant bupropion.361
cohort studies that exercise has a protective effect
A number of behavioural therapies delivered by
on stroke.386-388 However, for secondary stroke
different health professionals in different settings
prevention, there is currently a lack of direct
have demonstrated modest effects for smoking
43
evidence on interventions to increase fitness.389 secondary prevention, including lifestyle
Exercise has clear benefits for reducing interventions, while in hospital lead to improved
hypertension in at-risk people 390 and improving rates of adherence both prior to discharge and
Secondary Prevention
glycemic control for those with type 2 diabetes.391 3 months after discharge.393, 394 Every stroke
Thus increasing exercise, particularly aerobic survivor was given lifestyle advice and good
exercise, could be expected to reduce the risk of adherence was achieved regarding diet (78%),
further stroke. exercise (70%) and smoking cessation (83% of
previous smokers had quit).394 Other educational
> Excessive alcohol consumption increases the risk of
interventions have also reported improved
stroke,392 so reducing alcohol levels could be
adherence to dietary advice. 59, 60 Systematic
expected to modify the risk of further strokes.
reviews have also found behaviour techniques,
However, light alcohol intake was found to be
Section 7
a) Every person with stroke should be assessed and informed of their risk factors
for a further stroke and possible strategies to modify identified risk factors.
The risk factors and interventions include:
• smoking cessation: nicotine replacement therapy, bupropion or nortriptyline A Level I
therapy, nicotine receptor partial agonist therapy and/or behavioural therapy 359-361, 363-366
should be considered;
• improving diet: a diet that is low in fat (especially saturated fat) and sodium, A Level I 367-369,
but high in fruit and vegetables should be consumed; 372, 376 & II
370, 373-375
prevention demonstrate strong link between low exercise and stroke risk
• avoiding excessive alcohol. (meta-analysis of cohort studies in primary) C 392
prevention demonstrate link between high alcohol intake and stroke risk
b) Interventions should be individualised and may be delivered using behavioural A Level I 362-366,
techniques (such as educational or motivational counselling). 395, 396
High blood pressure is the major risk factor for both combined vascular events including myocardial
first and subsequent stroke. In general effective blood infarction.398 Reducing blood pressure is particularly
pressure management requires that blood pressure is important for patients who have diabetes where levels
maintained below acceptable limits (i.e. lower than should be below 130/85 mm Hg.397 Currently the most
140/90 mm Hg).397 However, reduction in blood direct evidence available in secondary stroke
pressure, irrespective of initial blood pressure, has prevention is for the use of an ACE inhibitor or for
been shown to reduce the recurrence of stroke and combination therapy with an ACE inhibitor and a
44
diuretic.398 A subsequent trial compared an angotensin rather than secondary prevention (see section 4.1.4).
receptor blocker (ARB) with a calcium antagonist. However, two recent small studies in those with mild
Both agents were found to reduce blood pressure, stroke or TIA without major carotid disease, found
Secondary Prevention
although the ARB was significantly more effective in blood pressure lowering therapy (with an angiotensin
reducing mortality and all cardiovascular and II receptor antagonist or ACE inhibitor) was safe when
cerebrovascular events, including all recurrent commenced 2-4 days after stroke, although follow
events.399 It is noted that in this study only 1/3 used up was short (2 weeks).400, 401 Another study found
monotherapy for blood pressure lowering and of the a program of initiating secondary prevention
2/3 using combination therapy 46% were using a medications, including blood pressure lowering
diuretic and 33% were using a Beta blocker with no therapy, while in hospital lead to improved rates of
difference in combination therapy between groups.399 adherence both prior to discharge and 3 months
Section 7
Only approximately 3% of patients commenced after discharge.394
therapy within 1 week and no subgroup analysis was
Lifestyle change including diet and exercise, by
performed for this aspect.
themselves or in conjunction with pharmacotherapy,
The timing of commencing therapy remains unclear. can also be used to reduce blood pressure (see
Hyperacute therapy (within first 48 hours) is discussed section 7.1).
separately as it relates to acute medical treatment
a) All patients after stroke or TIA, whether normotensive or hypertensive, should A Level I 398
receive blood pressure lowering therapy, unless contraindicated by
symptomatic hypotension.
b) Commencement of new blood pressure lowering therapy may occur prior to B Level II 400, 401
discharge or within the first week after stroke or TIA. & Level III-3 394
There is evidence from 21 RCTs in 23,000 patients Aspirin at lower doses (75-150mg) is just as
with previous ischaemic stroke or TIA that, compared effective as higher doses (300-1300mg) and is
with control, antiplatelet therapy significantly reduces associated with a lower risk of gastrointestinal
the risk of subsequent serious vascular events adverse effects.402 The lowest therapeutic dose of
including stroke, MI or vascular death (17.8% aspirin remains unclear, but the DUTCH TIA trial
compared with 21.4%).402 Antiplatelet therapy may showed that in more than 3,000 patients with TIA,
have adverse effects, particularly a small risk of 30 mg was as effective as 283 mg in preventing
haemorrhage, but the benefits outweigh the risks.403 serious vascular events.405
Although the benefits of antiplatelet therapy are well
> Combination therapy with extended release
known and treatment can commence soon after
dipyridamole (200mg bd) plus aspirin is more
stroke (see section 4.1.3), under treatment is
effective than aspirin alone (relative risk reduction
common.404
[RRR] 18%).406 The main adverse effect of
The evidence for antiplatelet therapy indicates: combination therapy is headache (34% ceased
medication compared with 17% for aspirin alone
> Aspirin remains the most readily available, cheapest
over 5 years).406
and most used anti-platelet agent. Aspirin reduces
the risk of serious vascular events by about 13% in > Dipyridamole alone at any dose is no more effective
patients with previous ischaemic stroke or TIA.405 than aspirin.407
45
> Clopidogrel (75mg) is modestly more effective than or with aspirin failure. Because it can cause
aspirin in the prevention of major vascular events neutropenia and thrombocytopenia, careful
(RRR 8.7%).402 monitoring is required after commencement.
Secondary Prevention
a) Long term antiplatelet therapy should be prescribed to all people with A Level I 402
ischaemic stroke or TIA who are not prescribed anticoagulation therapy.
b) Low dose aspirin and modified release dipyridamole should be prescribed to 406, 411
all people with ischaemic stroke or TIA who do not have concomitant acute
coronary disease.
c) Aspirin alone or clopidogrel alone may be used for people who do not tolerate 402
aspirin plus dipyridamole therapy. Clopidogrel alone should be used for those
who are intolerant of aspirin or in whom aspirin is contraindicated.
d) The combination of aspirin plus clopidogrel is not recommended in the A Level II 408, 409
secondary prevention of cerebrovascular disease in patients who do not have
acute coronary disease or recent coronary stent.
There is evidence from robust systematic reviews method and variable aspirin dosage. Another trial of
involving a number of RCTs against the routine use warfarin (INR 2-3) compared to aspirin (1300mg) for
of anticoagulant therapy in people with those with significant intracranial artery stenosis was
non-cardioembolic ischaemic stroke or TIA.157, 412 also stopped early due to safety concerns for those
Two subsequent studies of note have been reported receiving warfarin.414
in the last few years confirming this conclusion. One
However, in people with non-rheumatic atrial fibrillation
trial comparing oral coagulation (INR 2-3) and aspirin
and a recent TIA or minor ischaemic stroke, the
(30-325mg) found no difference in outcomes and was
benefits of anticoagulants outweigh the risks and
stopped early due to results of the other arm of the
anticoagulants are more effective than antiplatelet
trial which found aspirin inferior to combined aspirin
therapy for long-term secondary prevention.119, 415
and dypridomole.413 However, this trial was not
They should therefore be prescribed unless there is a
sufficiently powered to detect benefits of
major contraindication (e.g. poor compliance, major
anticoagulation compared with aspirin and other
bleeding risk).
issues have been raised including the open trial
46
There remains uncertainty about the ideal time to while all were still adhering to this therapy at 3 months
commence therapy and no clear data are available to post discharge.394 In patients with TIA, anticoagulation
inform this decision. Trials generally enrolled patients therapy should be commenced as soon as imaging
Secondary Prevention
after 1 or 2 weeks to reduce the risk of haemorrhage has excluded intracerebral haemorrhage or a stroke
(only 12% of patients in the recent ESPRIT trial were mimic as the cause of the symptoms. Aspirin or other
enrolled within 1 week). One Level III-3 trial antiplatelet therapy should be used between acute
commenced appropriate anticoagulation prior to event and time when anticoagulation is commenced.
discharge from acute hospital care in 100% of cases
Section 7
a) Anticoagulation therapy for long-term secondary prevention should be used in A Level I 119, 415
all people with ischaemic stroke or TIA who have atrial fibrillation, cardioembolic
stroke from valvular heart disease, or recent myocardial infarction, unless a
contraindication exists.
b) Anticoagulation therapy for secondary prevention for those people with A Level I 412
ischaemic stroke or TIA from presumed arterial origin should not be routinely
used as there is no evidence of additional benefits over antiplatelet therapy.
c) The decision to commence anticoagulation therapy should be made prior to C Level III-3 394
discharge.
d) In patients with TIA, commencement of anticoagulation therapy should occur ✓ –
once CT or MRI has excluded intracranial haemorrhage as the cause of the
current event.
There is conflicting evidence regarding the link safety profile and are not associated with liver
between elevated cholesterol and stroke subtypes, as toxicity.420, 421 One study reported higher rates of
epidemiology studies suggest that higher cholesterol is adherence for statin therapy commenced prior to
associated with a higher risk of ischaemic stroke but a discharge from hospital.422
lower risk of haemorrhagic stroke.416 However, trials of
Lifestyle change strategies involving dietary
cholesterol lowering interventions have not
modification have been shown to lower cholesterol
demonstrated increased rates of haemorrhagic
levels in those with cardiovascular risks and should
strokes.417 Two large RCTs have now demonstrated
be used as an alternative, or in addition, to
that statin therapy is beneficial for people with stroke
pharmacotherapy (see section 7.1) Currently the
or TIA.382, 418 While the earlier Heart Protection Study
Pharmaceutical Benefits Scheme (PBS) states that
failed to demonstrate reductions in secondary stroke
dietary advice and interventions should be undertaken
events, the more recent SPARCL study has
either prior or alongside drug therapy to reduce
demonstrated a modest reduction in subsequent
cholesterol and be reviewed annually. Systematic
stroke events with a statin.418 Meta Analysis of trials
reviews including a wide range of patient groups have
demonstrate that benefits occur within 12 months
found benefits in behavioural interventions (e.g.
of commencing therapy and are related to low-density
motivational counselling or dietary counselling)
lipoprotein (LDL) cholesterol reduction.417, 419
delivered by specialist or trained clinicians, to positively
Meta-Analysis also suggest statins have a good
change dietary patterns and lower cholesterol.395, 396
47
7.5 CHOLESTEROL LOWERING GRADE LEVEL
Secondary Prevention
a) Therapy with a statin should be used for all patients with ischaemic stroke B Level II 382, 418
or TIA.
b) Patients with high cholesterol levels should receive dietary review and B Level I 395, 396
counselling by a specialist, trained clinician.
Diabetes and glucose intolerance post stroke have prevention measures for stroke recurrence. Evidence
been found to be independent risk factors for for the management of diabetes is primarily based on
subsequent strokes.195, 423, 424 Hyperglycaemia in the primary prevention. Important aspects of care include
first few days after stroke is very common and levels careful blood pressure control, aggressive cholesterol
fluctuate (see section 4.3.3). However, assessment of control and glycemic control with behavioural (e.g. diet
glucose tolerance after stroke or TIA would allow and exercise) and pharmacotherapy. National
identification and subsequent management for guidelines for the management of diabetes are
patients with undiagnosed diabetes or glucose available and relevant recommendations should be
intolerance, hence providing additional secondary followed.425-428
All acute stroke patients should have their glucose monitored. Patients with ✓ –
glucose intolerance or diabetes should be managed in line with national guidelines
for diabetes.
48
asymptomatic stenosis <60%.432 Careful selection of Carotid angioplasty and stenting
patients considered at high risk of stroke is therefore
Endovascular surgery has been explored as an
needed to justify surgery in those with asymptomatic
Secondary Prevention
alternative to CEA, particularly in selected patients
stenosis.432
(significant heart or lung disease, >80 years, high or
It is important that centres undertaking CEA low carotid bifurcation or carotid re-stenosis after
participate in ongoing, independent and systematic CEA). One systematic review found a reduction in
audits of surgical complication rates 433 as this often cranial neuropathies with no other difference in
determines the balance between benefits and harms, benefits between the two approaches.437 Two of the
particularly for those with 50-69% stenosis. The five trials included in the review were stopped early
evidence suggests low complication rates are needed raising safety concerns. Two subsequent trials have
(<6%) in patients with 70-99% stenosis to achieve net not added significant clarity to the debate. One trial
Section 7
benefits. So extremely low rates (<3%) are suggested reported similar results to the review with no difference
where centres are considering CEA for patients with between treatments.438 However, the other trial was
symptomatic stenosis of 50-69% or asymptomatic stopped early due to safety concerns in those
stenosis 60-99%.429, 432 undergoing stenting.439
Treatment with antiplatelet therapy (predominantly While many factors that may account for the
aspirin monotherapy) either commencing prior to or inconsistencies have been discussed, further trials and
after CEA has been shown to reduce stroke analysis are needed before endovascular surgery can
reoccurrence although no effect was found for other be routinely considered compared with CEA or if any
outcomes.434 Combination therapy of clopidogrel and particular subgroup should undergo one or the other
aspirin has been found to be beneficial using surrogate treatment. Two ongoing trials will assist in answering
markers in two studies, however, no patient outcomes such questions: the International Carotid Stenting
have been reported 435, 436 and further studies are Study (ICSS) and the Carotid Revascularisation
needed. Endarterectomy versus Stenting Trial (CREST).
a) Carotid endarterectomy should be undertaken in patients with non disabling A Level I 429, 430
carotid artery territory ischaemic stroke or TIA with ipsilateral carotid stenosis
measured at 70-99% (NASCET criteria) if surgery can be performed by a
specialist surgeon with low rates of perioperative mortality/morbidity.
b) Carotid endarterectomy should be undertaken in select patients (considering A Level I 429, 430
age, gender and comorbidities) with non disabling carotid artery territory
ischaemic stroke or TIA with ipsilateral carotid stenosis measured at 50-69%
(NASCET criteria) if surgery can be performed by a specialist surgeon with very
low rates of perioperative mortality/morbidity.
c) Carotid endarterectomy may be undertaken in highly select patients A Level I 429, 430
(considering age, gender and comorbidities) with asymptomatic carotid
stenosis of 60-99% if it can be performed by a specialist surgeon with very low
rates of perioperative mortality/morbidity.
d) Eligible patients should undergo carotid endarterectomy as soon as possible A Level I 431
after the event (ideally within 2 weeks).
e) Carotid endarterectomy should only be performed by a specialist surgeon B Level I 429
at centres where outcomes of carotid surgery are routinely audited.
f) Carotid endarterectomy is not recommended for those with <50% symptomatic A Level I 429, 432
stenosis or those with <60% asymptomatic stenosis.
cont.
49
7.7 CAROTID SURGERY cont. GRADE LEVEL
Secondary Prevention
g) Carotid angioplasty and stenting should not routinely be considered for patients B Level I 437 &
with symptomatic stenosis. However, it may be considered as an alternative in Level II 438, 439
certain circumstances, that is in patients who meet criteria for carotid
endarterectomy but are deemed unfit due to medical comorbidities
(e.g. significant heart/lung disease, age >80yrs), or conditions that make them
unfit for open surgery (e.g. high or low carotid bifurcation, carotid re-stenosis).
Section 7
Patent foramen ovale (PFO) is more common in those death rates over 2 years were found.442 Warfarin use
with cryptogenic stroke, especially those <55 years.440 was found to have higher rates of minor bleeding.442
While much debated, PFO has not been found to
No RCT has compared surgical closure to standard
increase the risk of subsequent stroke or death in
medical care and Level IV data are conflicting. One
cryptogenic stroke, however, it may increase such
systematic review involving 10 studies suggests
risks if present in combination with an atrial septal
surgery is beneficial compared to medical care,441
aneurysm.440
however, 3 other subsequent studies failed to find
Two systematic reviews 440, 441 have identified only any difference in stroke recurrence and reported non
one RCT 442 for medical management that compared significant increase in harms.443-445 Until clear evidence
warfarin (INR 1.4-2.8) to aspirin (325mg). The study exists from RCTs no recommendation can be made
was not designed to evaluate superiority between on the surgical closure of PFO.
agents, however, no differences in recurrent stroke or
a) All patients with an ischaemic stroke or TIA, and a PFO, should receive C Level II 442
antiplatelet therapy as first choice.
b) Anticoagulation may also be considered taking into account other risk factors C Level II 442
and the increased risk of harm.
c) Currently there is insufficient evidence to recommend PFO closure. ✓ –
Failure to take prescribed medication is a major barrier family therapy, support and reminders, and complex
to optimal secondary prevention. or combined interventions were useful in promoting
adherence to prescription regimes.446-448
Three robust reviews have found only modest effects
for interventions to improve adherence with > Education alone or informing people about adverse
medications in people with chronic illness, although drug effects did not change adherence.448
the interventions were not tested specifically in the
> The use of multi-compartment packaging or other
stroke population. Studies have found the following:
reminder packing strategies to promote adherence
> Simplification of drug dose regimens, has conflicting evidence. One systematic review
information/education, motivation, counselling, found benefits of compliance among non-adherent
50
adults living at home with diabetes, however, no to establish secondary incidence, commencing
benefits were noted for those with hypertension.449 strategies early may be a key to improving
However, the other more robust review found medication adherence and improve secondary
Secondary Prevention
improvements in number of pills taken in four of the prevention along with regular follow up.
five included studies, but only modest clinical
The available studies suggest there is no single
benefits were reported in one of the three trials for
intervention that is proven to work across all patients,
those with hypertension.450
conditions and settings. Hence, specific interventions
> One study found a program of initiating tailored should be tailored to each individual’s situation after
secondary prevention medications while in hospital stroke. Information specific to general practice has
lead to improved rates of adherence both prior to been developed and provides further practical
discharge and 3 months after discharge.394 While advice.451 However, further studies specific to stroke
Section 7
only small numbers are reported, making it difficult are needed.
51
8 DISCHARGE PLANNING, TRANSFER OF CARE
AND INTEGRATED COMMUNITY CARE
and efficient use of limited hospital resources. The evidence suggested that organised stroke unit
While it is known that the transfer of responsibility for care is most effective when a number of weeks of
management from inpatient to the community can be rehabilitation are offered.6, 19 Furthermore, all patient
difficult, insufficient attention and resources are often types benefit from rehabilitation (probably more so
provided for this process. One group that is of those who are severely affected by stroke).6 If the
particular concern is younger stroke survivors (i.e. <65 acute stroke services are unable to provide necessary
years) who may require residential care post- ongoing rehabilitation then alternative rehabilitation
discharge. Whilst the ideal discharge outcome may in services, ideally on a stroke rehabilitation unit, need to
fact be to an inpatient rehabilitation facility this is not be considered and organised. While prognostic
always feasible in all geographical locations. Careful studies have described different attributes that impact
consideration needs to be given to discharge on rehabilitation and recent imaging can predict the
destinations (other than a rehabilitation facility) to amount of damage and areas where recovery may be
ensure the person is in appropriate accommodation possible there is no generic criteria for selecting those
and is able to receive necessary services.452 who require ongoing, active rehabilitation. Hence, the
Discharge planning relies on effective communication decision as to who should be provided with continued
between team members, the person with stroke, inpatient or outpatient rehabilitation is a complex
family/carers, and community service providers decision that requires input from the whole stroke
including general practitioners. Important aspects of team taking into consideration the needs and wishes
care during this phase including team meetings, family of those with stroke and their families.
meetings, information/education and shared care have Often rehabilitation will be undertaken in a different
been discussed under organisation of care and should part of the hospital or a different site altogether.
also be considered when planning discharge or Evidence for hospital based rehabilitation is still
transfer of care (see Sections 1.5, 1.6, 1.7 & 1.10). consistent with that in the Clinical Guidelines for Stroke
Other important aspects of care to consider during Rehabilitation and Recovery that describes high level
acute care include return to work, leisure and sexuality. evidence for inpatient rehabilitation care and
While such topics should be discussed with relevant community rehabilitation services.
Section 8
CONSUMER
8.1 INPATIENT REHABILITATION GRADE LEVEL RATING
A pre and/or post-discharge needs assessment discussed and management incorporated into any
examines, for example, the social, emotional, physical discharge plan (e.g. monitoring of mood). The
and financial needs of the person with stroke and circumstances and capacity of the carer and family
his/her family/carer. Assessment of discharge needs should also be explored, ideally with the person with
should start as soon as possible after admission. Any stroke, to identify any community care supports
cognitive or behavioural issues identified should be needed. The needs assessment should identify who
52
requires a home visit. Factors to consider include the on the effectiveness of pre-discharge home visits for
reported environmental barriers at home, specific people with stroke, or indeed for older people
CONSUMER
8.2 PRE-DISCHARGE NEEDS ASSESSMENT GRADE LEVEL RATING
a) Before discharge, people with stroke and their carers should have ✓ – 9.5/10
the opportunity to identify and discuss their post-discharge needs
(e.g. physical, emotional, social and financial) with relevant
members of the interdisciplinary team.
b) Before discharge all patients should be assessed to determine ✓ – –
the need for a home visit prior to discharge from hospital.
c) If needed, a home assessment should be carried out to ensure C Level I 453 –
safety and community access.
Section 8
8.3 Carer training
Carers often report feeling inadequately trained, poorly activities related to care, including personal care
informed, and dissatisfied with the extent of support techniques, communication, physical handling and
available after discharge. Evidence from a recent, high transfers, ongoing prevention of functional decline and
quality trial suggests that carers benefit from other specific stroke-related problems.56
undertaking training prior to discharge in a range of
CONSUMER
8.3 CARER TRAINING GRADE LEVEL RATING
53
8.4 Care plans
A care plan is normally completed prior to discharge needed, especially when changing settings or care.
and identifies appropriate management strategies to A formal family meeting or conference is often used
Discharge Planning, Transfer of Care and Integrated Community Care
guide care after the stroke survivor returns to the to develop such a plan.
community. Care plans are based on the needs
Evidence for discharge planning (one component of
identified in the pre-discharge assessment, and are
the total care planning process) is unclear.456 This
useful in building self-management strategies for those
suggests care plans are often one component of a
with stroke. All team members, including the person
complex service delivery (e.g., early supported
with stroke, the family/carer, the general practitioner,
discharge or inpatient integrated pathway). In many of
and community-based service providers are ideally
the trials it is difficult to determine the evidence for this
involved in developing and documenting an agreed
specific component.
plan that takes into account the complex adjustments
CONSUMER
8.4 CARE PLANS GRADE LEVEL RATING
a) People with stroke, their carers, the general practitioner, and – 9.7/10
community care providers should be involved with the
interdisciplinary team in the development of a care plan.
b) Care plans should be used and outline care in the community after – 9.7/10
discharge, including the development of self-management
strategies, provision of equipment and support services, and
outpatient appointments.
management and future management plans remains systematic reviews were identified, however, neither
an important part of good stroke care. Discharge review provided clear conclusions.44, 456
planning may be coordinated by one member of the
Any person coordinating discharge should provide the
team (e.g. inpatient care coordinator) or it may be
person with stroke and their family/carer with
undertaken by someone who coordinates discharges
appropriate information regarding the details of any
for multiple teams (or the whole hospital). One lower
community services, possible waiting times, costs and
level trial involving a comprehensive discharge
contact details prior to discharge. Good pre-discharge
planning program for people with craniotomy or
care planning addresses these communication issues
stroke, coordinated by a discharge planner, reduced
and supports effective transfer of care.
length of stay and readmissions, but did not change
CONSUMER
8.5 DISCHARGE PLANNER GRADE LEVEL RATING
54
8.6 Community rehabilitation
Often rehabilitation will need to continue after Rehabilitation and Recovery which described high
discharge (either as part of an early supported level evidence for community rehabilitation services
discharge program or general community for people with stroke. The needs identified by the
CONSUMER
8.6 COMMUNITY REHABILITATION GRADE LEVEL RATING
Rehabilitation in the community is equally effective if delivered in the A Level I 63, 9.4/10
hospital via outpatients, or day hospital, or in the community, and should 458, 459
The level of services available following discharge from information to people with stroke and their families.
hospital can be poor, and people with stroke and their The evidence is difficult to interpret and no one service
families often report being dissatisfied with the has been shown to be clearly beneficial. Studies
information, support services and therapy available.460 suggest modest advantage when providing tailored
education although no clear functional benefits have
A number of follow-up services have been evaluated
been found and further studies are needed. A simple
including:
approach often incorporated into other
> social work;461, 462
multidimensional interventions is the use of telephone
> specialist nurse support;53, 54, 57, 59, 60, 463
contact after discharge. While one recent systematic
Section 8
> the Stroke Transition After Inpatient Care (STAIR)
review failed to demonstrate consistent benefits from a
program;464
range of non stroke populations,471 two stroke related
> stroke family care worker;465
studies involving 3 telephone calls from a nurse in the
> mental health worker;466
first 3-5 months post discharge provided some
> home visits by physician or physiotherapist;467 and
benefits.53, 60 As the early post discharge period is
> stroke family support organisers.468-470
consistently reported by stroke survivors and their
Such services are usually multidimensional and can family/carers to be a difficult time, the provision of
include emotional and social support, assistance with simple and relevant services appears important.
referral to other services, and the provision of
CONSUMER
8.7 POST-DISCHARGE SUPPORT GRADE LEVEL RATING
a) Contact with and education by trained staff should be offered for C Level II 53, 54, 57 –
all stroke survivors and carers after discharge. 59, 60, 463, 468-470
b) People with stroke and their carers should be provided with a D Level I 471 & –
contact person (in the hospital or community) for any post-discharge Level II 53, 60
queries.
55
8.8 Return to driving after stroke or TIA
The issue of returning to driving can be confusing and and the person has had a 6 month period free of
the topic is often raised by the patient or their attacks.472
Discharge Planning, Transfer of Care and Integrated Community Care
CONSUMER
8.8 RETURN TO DRIVING GRADE LEVEL RATING
The National Guidelines for Driving and relevant state guidelines should ✓ – 9.7/10
be followed when assessing fitness to drive following a stroke or TIA.
Section 8
56
9 COST AND SOCIOECONOMIC IMPLICATIONS *
Introduction
This section presents a review of the cost and extension to the work recently prepared for assessing
socioeconomic implications of providing evidence the potential economic implications of the Stroke
based stroke care supported by the recommendations Rehabilitation and Recovery Guidelines.7
contained within this guideline. The Guidelines project
There are two important points to keep in mind
officer conducted a separate systematic review for this
when reviewing the data presented in relation to
section. The search strategy included a focus on cost-
cost-effectiveness. Firstly, an intervention can be
effectiveness studies that considered both the costs
cost-effective without being cost saving and secondly
and health outcomes associated with an intervention.
what constitutes a cost-effective intervention is a value
The key search terms used were consistent with those
judgement. In previous Australian policy decisions,
used for the previous searches with adjustments made
$30,000-$50,000 per Disability Adjusted Life Year
to focus on economic implications. The search
(DALY) recovered has been considered to represent
strategy used is available from the NSF. Overall, 1,438
value-for-money in the health sector.473
potential papers were identified with reference to the
primary subjects (recommendation headings) in this Evidence related to socioeconomic implications is
guideline. The abstracts were scrutinised for omissions sparser than the cost-effectiveness evidence. Where
and appropriate papers were retrieved and reviewed. relevant references to socioeconomic implications
As the breadth of topics was wide and the methods were identified these will be highlighted. Overall, we
used quite disparate, a narrative review was deemed know that there are disparities between people with
the most appropriate way to summarise the cost and different socioeconomic status. Socioeconomic status
socioeconomic evidence. There was also a preference and its definition can vary depending on both the
to include studies undertaken in Australia, therefore if wealth of a country and that of the individuals within
similar work had been undertaken elsewhere this was that country. In addition, the socio-economic status of
often discarded, unless the results were relevant to the countries and individuals does not tend to shift readily.
findings in Australia. This is because it is often difficult The most disadvantaged people in society in terms of
to extrapolate from international studies to the occupational status, level of education and financial
Australian context given differences in health services resources tend to have the greatest burden of health
provision and funding, target populations and risks which cluster and accumulate over time.474
interventions, such as drug dosages. Evidence suggests that socioeconomic factors appear
been conducted. Therefore, evidence and discussion potential expected benefits of prevention interventions,
for the main (strongest) recommendations in this as these may be over or underestimated for different
guideline will be provided. This review is also an populations.
* Prepared by Dominique Cadilhac and Helen Dewey, National Stroke Research Institute
57
9.1 Organisation of care
9.1.1 Stroke Unit Care Currently, only 19% of public hospitals report providing
stroke unit care 480 and there is clustering of stroke units
To date there has been one systematic review identified
in large urban centres. Stroke units improve outcomes for
that included three studies comparing the costs and
people with stroke (see section 1.1). Further economic
outcomes of stroke units to that of general wards.476
modelling work has predicted that if access to stroke
All three studies were based in Europe (UK, Sweden
units was improved to 80% from a baseline of 25%, then
and Germany) and included costs of community and
more than 8,374 DALYs could be recovered.481 Although
outpatient care. All three studies found modest cost
this literature does not specifically indicate the real costs
savings (3-11%) using stroke unit care, however, the
of setting up a stroke unit, there is evidence that health
figures failed to reach significance. The authors concluded
services should be organised to provide stroke unit care
that there was “some” evidence for the costs to be at
and that considerable gains in terms of health benefits
least equivalent to conventional care.
could be achieved.
More recently, an Australian prospective cohort study
9.1.2 Care Pathways and Clinical Practice
comprising 468 patients from Melbourne has been
Guidelines
published.477 The investigators determined that care
delivered in geographically localised units was cost- The effectiveness of care pathways in stroke management
effective compared with general medical wards or mobile is variable and the effects on length of stay and costs
stroke (inpatient) teams and that the additional cost in are inconclusive.44, 482 To date there has not been a cost-
providing stroke units compared with general medical effectiveness study for care pathways in stroke, but there
wards was found to be justified given the greater health is evidence that the setting of use may be important.
benefits in terms of delivering best practice processes of
The study (pre-post audit design) conducted by Read
care and avoiding severe complications. When compared
and Levy (2006) has shown that implementation of
to general medical care costs ($12,251), costs for mobile
pathways in regional Queensland can assist in improving
teams were significantly higher ($15,903 p=0.024), but
adherence to important processes of care, such as early
borderline for stroke units ($15,383 p=0.08). This was
access to allied health, improved use of antithrombotic
primarily explained by the greater use of specialist medical
agents in eligible cases at discharge and estimation of
services. The incremental cost-effectiveness of stroke unit
blood glucose levels.483 Similar studies conducted in
over general wards was $AUD9,867 per patient achieving
Victoria have also indicated improved adherence to some
thorough adherence to clinical processes and
important processes of care with use of care pathways or
Cost and Socioeconomic Implications
There was an additional lifetime cost of $1,288 per study indicates that greater adherence to important
DALY recovered, or alternatively $20,172 per stroke clinical processes of care occur more often in stroke units
averted or $13,487 per premature death averted. and there is also a reduction in severe complications,
It was determined that the stroke unit intervention which when these measures are used as proxies of health
was cost-effective given the small additional costs outcome indicate that these units are more cost-effective
per extra unit of benefit gained.479 than other care modalities.477 In SCOPES, hospitals with
58
stroke units that used care pathways were more likely lower using this ESD model in comparison to inpatient
to complete them.24 In most studies it is difficult to stroke unit care, but ESD was found to be cheaper.
separate out the specific benefits of care pathways A separate randomised controlled trial of unselected
from other aspects of organised services, such as hospital cases undertaken in Norway has also indicated
team meetings and experienced staff. Therefore, the that an early supported discharge program provided
fundamental conclusion from this review is that organised after 2 weeks in a stroke unit (as an alternative to inpatient
management for stroke that provides evidence-based rehabilitation) offered a cost neutral or cheaper option
clinical care, with or without care pathways, should over a 12 month period. In particular, ESD was more
be cost-effective. cost-effective in cases of moderate stroke, rather than
very mild or severe stroke.486
9.1.3 Early Supported Discharge (ESD)
Data specific to the Australian context was included in the
One systematic review identified eight trials evaluating
previous review and warrant further discussion. The data
the economic implications of ESD compared with
from a meta-analysis of ESD (12 trials, N=1277, search
conventional care.476 Two studies were conducted in
date March 2001) were used to apply costs from the
Australia with the remainder from Hong Kong (one),
Australian health system.487 Hospital costs were taken
Canada (one), Sweden (two) and the UK (two). All but
from the Australian National Hospital Cost Data for
one of the studies compared ESD using home-based
1998/1999, domiciliary rehabilitation costs were taken
services to conventional services (noted to be either
from a single study of domiciliary rehabilitation care
hospital rehabilitation or mix of hospital and community
(Adelaide stroke study) and costs related to other
rehabilitation). Of the eight studies included, six studies
community services were taken from the Australian
were noted as having medium or high methodological
Department of Health and family Services Report,
quality. These studies reported a trend for reduced costs
1996/1997.487 Using a cost minimisation analysis (i.e.
of between 4-30% with ESD, however, this cost saving
health outcomes were found to be equivalent) ESD was
was found to be statistically significant in only one of
found to be 15% lower regarding overall mean costs
the six studies. The authors concluded that there was
($A16016 v $18350). Cost estimates were based over a
“moderate” evidence that ESD services provided care
12-month period and did not include any indication of set
at modestly lower total costs than conventional care.
up costs. It was highlighted that the included studies were
However, the heterogeneity of the ESD care provided
all based in urban centres confirming the view that ESD
was noted along with the uncertain impact of ESD care
should only be considered where appropriate resources
59
9.2 Specific interventions for the
management of stroke
for Australia suggests that the treatment is cost-effective performed to assess the diagnostic accuracy. The
and the incremental cost/DALY lifetime benefit of treating addition of magnetic resonance angiography slightly
one additional first-ever case of stroke with aspirin as increased effectiveness but at disproportionately high
an acute therapy is about $1,847.490 In contrast to other costs.492 A more recent detailed cost-effectiveness study
Level I recommendations in this guideline that have been of the assessment of carotid stenosis conducted in the
compared using the same economic model, this result UK provided evidence that non-invasive assessment of
was less favourable to the cost-effectiveness results of carotid stenosis, including use of ultrasound as the first
stroke units ($1,390), warfarin as primary and secondary or repeat test, could be used in place of intra-arterial
prevention and intravenous rt-PA (these later two angiography to select patients who are likely to benefit
interventions being highly effective and cost saving). from carotid endarterectomy. However, the findings
Although not cost saving, it should be noted that both from the economic model were sensitive to the accuracy
stroke unit care and aspirin within 48 hours could be of non-invasive testing and to the cost and timing
applied to many more patients than rt-PA and warfarin. of surgery.102
Further, the stroke unit intervention represents a 9.2.4 Rapid assessment clinics and management
composite of these interventions as they are not
Section 9
60
9.2.5 Carer training real world situation. Nevertheless, it is very likely that
carotid endarterectomy in recently symptomatic patients
One study was identified that assessed the economic
with high grade carotid endarterectomy is highly cost-
outcome of training carers.493 Evidence was based on one
effective when performed with low perioperative morbidity
RCT conducted in the UK. The study has been discussed
and mortality.496
previously (see section 8.3). Costs were based at 2001-2
prices and included health and other formal care costs Pharmacological therapies
as well as informal costs. Providing carer training during
Moodie (2004) has investigated the cost-effectiveness of
inpatient rehabilitation reduced total costs (mean saving
anti-thrombotic (warfarin) treatment for people with
of £4043), primarily reflecting savings due to earlier
atrial fibrillation as a primary and secondary prevention
discharge from inpatient care, while also improving health
measure.479 This investigator determined that 1,851
outcomes. No difference in QALYs in carers were found,
DALYs could be recovered with a cost/DALY saved of
however, the authors suggested that this was likely to be
$480. This finding was based on the 1997 Australian
influenced by the insensitivity of the outcome measure
population modelled using MORUCOS, an economic
used (EuroQol five-dimensional questionnaire).
model with resource utilisation data derived from the
Since the burden of providing both formal and informal North East Melbourne Stroke Incidence Study. One
care after stroke in Australia is significant,494 inpatient published systematic review has identified three studies
rehabilitation services in Australia should be encouraged assessing the cost-effectiveness of anticoagulation for
to introduce formal carer training as part of their care. primary prevention in people with atrial fibrillation (AF).497
Further cost-effectiveness studies in this area are Warfarin was more cost-effective than aspirin for people
needed that include appropriate assessment of the with two or more stroke risk factors, in addition to those
impact on carers. with chronic non-valvular AF in one study. Warfarin was
also found to be cost-effective for people with only one
9.2.6 Stroke prevention
other stroke risk factor costing US$8000 per QALY.
There are few economic evaluation studies available However, warfarin use for people with no other stroke risk
for secondary prevention based on Australian data in factors, apart from AF, was not cost effective with costs
stroke. The majority of the literature related to the cost of US$370,000 per QALY. A second study confirmed
effectiveness of prevention interventions relates to these findings. The third study found anticoagulation for
carotid surgery and pharmacological therapies, which AF caused by mitral stenosis to be cost effective with
pointed to significant differences in the estimated costs studies predicted costs in the UK, USA and France over a
and benefits between these studies and among the period of 2 years, 5 years or over a lifetime. The
included partial economic evaluations. An important combination therapy of dipyridamole plus aspirin was
observation is that the use of trial data about peri- found to be cost effective compared with aspirin alone in
operative morbidity and mortality is likely to overestimate all five studies. However, there was conflicting evidence for
the benefits of carotid endarterectomy when applied in the
61
the cost effectiveness of clopidogrel. Two studies points for treatment do not discriminate well between
reporting no cost effectiveness using clopidogrel.502, 503 those who will and will not have an event. Murray et al
Two other studies found clopidogrel was cost effective (2003) showed that combination pharmacological
and reported ICERs of US$31,200 and US$26,580 per treatment for people with a 35% risk of a cardiovascular
QALY saved.501, 504 event over 10 years was cost-effective and would result
in the recovery of 63 million DALYs worldwide.515 There
An economic model based on data obtained in the Heart
has been one recent comparative evaluation of five
Protection Study has provided evidence that cholesterol
international guidelines from English speaking countries
lowering using simvastatin 40mg daily is cost-effective,
including Australia using the treatment recommendations
not only among the population of patients enrolled in this
within these guidelines and modelled for ‘best practice’.
trial (aged 40-80 years with coronary disease, other
It was reported that the cost per cardiovascular event
occlusive arterial disease or diabetes) but also for people
prevented was lowest in older patients and very high in
with an annual risk of major vascular events of 1% or
those aged less than 35 years. It was also expressed that
more, independent of the age of commencement of
clinical practice guidelines that used ‘absolute risk’ criteria
statin treatment.505 Cost-effectiveness estimates remained
as the principle determinant of treatment, were more
favourable when proprietary (£4.87) versus generic
cost-effective than those recommending management for
simvastatin (£29.69) prices were assumed. Simvastatin
thresholds of single risk factors.514 In consideration of risk
treatment was cost saving or cost less than £2500 per life
assessment, all persons who have experienced a stroke
year gained across the range of scenarios assessed.505
or TIA would be considered at high risk of another
Lifestyle (non-pharmacological) prevention vascular event. Therefore, use of anti-platelet therapy,
interventions cholesterol lowering and BP lowering in eligible high-risk
Cost-effectiveness studies undertaken for lifestyle patients could be considered cost-effective.
changes are limited in that they have not been Conclusions
undertaken for stroke specifically and most consider
In conclusion, there is good evidence of cost-
primary prevention measures. However, in the available
effectiveness for the most clinically effective and important
studies, smoking cessation has been reported to cost
stroke prevention and treatment strategies recommended
between £270-1500 per QALY saved depending on the
in this guideline. In particular, the findings from a recent
intervention (e.g. advice from GP or nicotine replacement
modelling exercise in the Australian setting indicate that
strategies).506 The use of quit lines or telephone
Cost and Socioeconomic Implications
62
APPENDIX A: Guideline development process report
Apendix A
responsible for the development of these guidelines:
> Reviewing the framework of existing guidelines;
Dr Alan Barber > Identifying, reviewing and classifying relevant
Neurologist, Auckland City Hospital literature;
Dr Christopher Beer > Developing the draft clinical guidelines;
Senior Lecturer, University of Western Australia and > Providing feedback gained through the consultation
Geriatrician/Clinical Pharmacologist Royal Perth and process;
Mercy Hospitals and Swan Health Service > Developing a plan for communication, dissemination
and implementation; and
Prof Justin Beilby
> Developing recommendations for periodically
Executive Dean, Faculty of Health Sciences and
updating the guidelines.
Professor of General Practice, University of Adelaide
All members of the working group completed and
Assoc Prof Julie Bernhardt
signed a declaration of potential conflicts of interest
Physiotherapist, National Stroke Research Institute
with development of these guidelines. Most had no
Prof Christopher Bladin perceived conflicts. The reasons provided for potential
Neurologist, Box Hill Hospital conflicts primarily involved receiving money from non
commercial and commercial organisations specifically
Ms Brenda Booth
for undertaking clinical research. This was expected
Consumer, Working Aged Group with Stroke, NSW
given the expertise of members of the working group
Dr Julie Cichero in clinical research. Only a small number of members
Speech Pathologist, Private Practice had received financial support from commercial
& University of Queensland companies for providing consultancy or lecturing.
Ms Louise Corben Additional expertise and significant input was gratefully
Occupational Therapy, Monash Medical Centre received from the following people:
& Bruce Lefroy Centre Murdoch Children's
Ms Anne Parkhill
Research Institute
Information Manager, Aptly
Dr Denis Crimmins (chair) Independent consultant who undertook the systematic
Neurologist, Gosford Hospital database searches during the process.
Dr Richard Gerraty Ms Dominique Cadilhac
Neurologist, Alfred Hospital and Monash University Manager Public Health Division, National Stroke
Mr Kelvin Hill Research Institute
Manager, Guidelines Program, National Stroke
Foundation
63
Assoc Prof Helen Dewey The questions generally queried the effects of a
Guideline Development Process Report
Neurologist and Associate Director, specific intervention and were developed in three
National Stroke Research Institute and the parts: the intervention, the population and the
Austin Hospital outcomes. An example is “What is the effect of
Consultants from the National Stroke Research anticonvulsant therapy on reducing seizures in people
Institute who were responsible for writing section 9 with post-stroke seizures?” In this example,
(Economic and socioeconomic implications) of these anticonvulsant therapy is the intervention, reduction of
guidelines. post-stroke seizures is the outcome, and the
population is people with post-stroke seizures.
Additional people who kindly contributed to the
guidelines development process during the appraisal Finding relevant studies
and drafting process included:
For this guideline searching, there could be no single
Dr Michael Briffa search coverage for all 89 questions: some sections
Palliative Care Specialist, Royal Adelaide Hospital of the guidelines need updating only from 2003, some
are topics not previously addressed in the guidelines,
Prof Stephen Davis
some have already been well researched by other
Neurologist, Royal Melbourne Hospital
reputable guidelines authorities while some have no
Apendix A
?
64
d) If the search was for an update only to NSF or For brevity, search strategies are not included here
Apendix A
8 133 225 1931 4441 130
9 23 3 185 24 –
10 15 2208 949 1171 –
A total of 28,656 potential articles resulted. Neurology), and Archives of Physical Medicine and
A systematic process for choosing relevant articles Rehabilitation. For a number of topics a general
occurred. At first, relevant systematic reviews were internet search was then undertaken (using the
initially identified. Where no systematic review was “google” search engine). Finally, where possible,
found, primary studies were then searched. This initial experts in the field were contacted to review the
process was conducted by one member of the identified studies and suggest other new studies not
working group and revealed 1341 articles. Final identified. Hand searching continued until May 2007
decision to include and review articles was made by and significant studies were included.
two members of the working group after abstracts
In addition to the initial searches the economic
were scrutinised. Reference lists of identified articles
literature was searched with a total of 1484 references
and other guidelines were then used to identify further
retrieved after deduplication (see table 4). Again one
trials. The table of contents of a number of key
person sorted these and selected 70 potentially
journals for the last 6 months was also conducted.
relevant articles. These abstracts were scrutinised for
The following journals were chosen: Stroke,
omissions by two people and appropriate papers were
Cerebrovascular Disease, Lancet (and Lancet
retrieved and reviewed (n=30).
65
Appraising and selecting studies Summarising and synthesising the evidence
Guideline Development Process Report
A standardised appraisal process was used based on Details of relevant studies were summarised in
that outlined by Scottish Intercollegiate Guidelines evidence tables which form a supplement to this
Network (SIGN). Where available, appraisals already document. The supplement is available for download
undertaken by the Stroke Therapy Evaluation Program from the NSF website (www.strokefoundation.com.au).
(STEP) team were used to avoid duplication. The
For each question the evidence was collated using the
standardised appraisal form assesses the level of
draft NHMRC “Assessing the body of evidence form”.
evidence (design and issues of quality), size of effect,
The recommended grading matrix was used to guide
relevance, applicability (benefits/harms) and
the strength or grading of the recommendation. For
generalisability of studies. Examples of completed
each question, the working group discussed and
checklists can be found on the STEP website
agreed on draft recommendations. The body of
(www.effectivestrokecare.org). Where Level I or II
evidence matrix along with the draft recommendation
evidence was unavailable the search was broadened
gradings are shown below.
to include lower levels of evidence. Evidence for
diagnostic and prognostic studies was also appraised
using the SIGN methodology.
Apendix A
Consistency all studies consistent most studies consistent some inconsistency evidence is
and inconsistency may genuine uncertainty inconsistent
be explained around clinical question
66
Consultation hyperglycaemia, aspects of thrombolysis, faecal
Apendix A
prevention and these sections were reviewed and Several prompted questions were also asked and the
updated. Additional information was also included response noted in table 5.
regarding assessment and management of
Given the small sample size each response was Prof Stephen Davis
checked for clarifying comments if noted “No” and Neurologist, Royal Melbourne Hospital
these were followed up where possible. All the & Melbourne University
recommendations with Level I evidence or those
Prof Anthony Cross
graded as an ‘A’ were checked and modified to ensure
On behalf of ACEM, Scientific committee Consumer
the recommendations were actionable. The
Stroke Association, ACT
sequencing of the recommendations was also
reviewed and modified where appropriate. Prof Mark Nelson
GP, University Tasmania
The following professional organisations and
individuals who were involved during the consultation Prof Nicholas Glasgow
process included: GP, Australian National University
67
Ms Bronwyn Thomas Ms Rosemary Bryant
Guideline Development Process Report
Principal Project Officer, Clinical Practice Improvement On behalf of members of the National Blood Pressure
Centre, QLD Health and Vascular Disease Advisory Committee (NBPVDAC)
Dr Glen Adams, Marian Gandy, & Dr Paul Slade Consumer Involvement
Briston-Myers Squibb Pharmaceuticals
Stroke guidelines are often large, complex documents
Dr Brian Draper which provide significant challenges for consumers.
Hospital Chair, Faculty of Psychiatry of Old Age Specific challenges in this patient population include a
typically older age and stroke specific impairments
Ms Lisa-Jane Moody
both of which have been found to reduce patient's
Audiology Dept, Geelong Hospital
reading ability, concentration and cognitive function.
Ms Lisa Allwell & Prof David Clarke However, consumer input has been a key component
Beyondblue: the national depression initiative in the development process of the current guidelines.
Ms Lisa Hopper, Cristie Field, Kelly Carter A consumer was included in the EWG and has been
Speech Pathology, Gosford Hospital involved in every phase of the development process,
Ms Jo James including the development of the clinical questions to
Dietitian, Flinders Medical Centre guide the literature searching. In addition a number of
consumer organisations were specifically sent the draft
Ms Colette Bennett
document and asked to provide any comments
Diabetes Centre, St Vincent’s Hospital (Sydney)
reflecting the views of consumers. Finally a two part
Ms Nicole Pond, Brigid Horan, Julie Elliot, structured consultation process was also undertaken
Sharon Lawrence, Perryn Carroll, by an independent team from the University of
Jenny Pomplun & Renae Hamilton Queensland on behalf of the National Stroke
Hunter New England Health Hospitals Foundation to understand the views of consumers on
the current document. The first phase discovered the
Ms Sarah Whitney, Kate Hanrahan,
views of consumers on the best process to engage
Kate Schuj & Danielle Buckley
consumers and receive feedback on the guidelines.
Royal Prince Alfred Hospital
Based on the results of this qualitative data,
Dr Owen Davies consumers from a wide range of locations, stroke
Repatriation General Hospital, Flinders Medical Centre severities, carer/survivor mix, and other demographics
Dr Ashish Soman & Dr Gordon Hirsch were collected.
Sanofi-Aventis Australia/NZ
68
A total of 44 consumers were involved in two different important to consumers. The average ratings
Apendix A
Table 6: Consumer consultation of modified acute stroke topics
QUESTION RATING (/10)
1. Organisation of Stroke care
1.1 Care for stroke patients should take place in ‘stroke units’. 9.3
1.2 The ‘stroke unit team’ should meet regularly with the stroke patient and their
family or carer. This meeting helps to involve the stroke patient and their family
or carer in managing and planning care. 9.3
1.3 Stroke patients may be managed at home if special health services and health
professional support is available. These services and support mean some
stroke patients can leave hospital earlier and recover successfully at home. 8.5
2. Getting to hospital
2.1 Health professionals and the public should get education about how to 9.5
recognise stroke early. That education needs to make it clear that stroke is a
medical emergency.
2.2 Stroke needs to be considered a medical emergency. It needs to be given a 9.6
high priority by ambulance services.
2.3 Ambulance staff should be trained to recognise stroke (for example, they should 9.7
use an easy and standard test).
3. Arriving at hospital 9.7
4. Early treatment 10
5. General treatment including prevention and management of complications 9.8
6. Preventing another stroke
6.1 Stroke patients are to be given information about healthy lifestyle and how to 9.7
risk reduce risk factors.
6.2 Medical treatments (including drugs or surgery) are to be used when 9.6
appropriate to help prevent another stroke.
6.3 Medical drugs are given for a reason. They work best when taken properly. 9.6
Health professionals should help stroke patients and their families with medical
drugs. For example, they should make sure the right drugs are taken at the right time
and in the right way.
cont.
69
Table 6: Consumer consultation of modified acute stroke topics cont.
Guideline Development Process Report
7.5 Health professionals should provide training for family/carers before the 9.5
stroke survivor leaves hospital.
7.6 Stroke survivors and their families/carers should be given information and 9.7
advice about driving again after a stroke.
70
A systematic review of the above dissemination and These include:
Apendix A
workbook); and
be supported by existing resources and networks.
> various networks including Stroke Services NSW,
QLD Stroke collaborative and other state and local
networks.
71
APPENDIX B: Priorities for Research
72
GLOSSARY AND ABBREVIATIONS
Activities of daily living: The basic elements of Family support / liaison worker: A person who
personal care such as eating, washing and showering, assists stroke survivors and their families to achieve
grooming, walking, standing up from a chair and using improved quality of life by providing psychosocial
the toilet. support and information, referrals to other stroke
service providers.
Activity: The execution of a task or action by an
individual. Activity limitations are difficulties an Impairment: A problem in the structure of the body
individual may have in executing activities. (e.g. loss of a limb) or the way the body or a body part
functions (e.g. hemiplegia).
Agnosia: The inability to recognise sounds, smells,
objects or body parts (other people’s or one’s own) Infarction: Death of cells in an organ (e.g. the brain or
despite having no primary sensory deficits. heart) due to lack of blood supply.
Aphasia: Impairment of language, affecting the Inpatient stroke care coordinator: A person who
production or comprehension of speech and the ability works with people with stroke and with their carers to
to read and write. construct care plans and discharge plans and to help
coordinate the use of health care services during
Apraxia: Impaired planning and sequencing of
recovery in hospital.
movement that is not due to weakness,
incoordination, or sensory loss. Interdisciplinary team: The entire rehabilitation team,
made up of doctors, nurses, therapists, social
Atrial fibrillation: Rapid, irregular beating of the heart.
workers, psychologists etc.
Augmentative and alternative communication:
Ischaemia: An inadequate flow of blood to part of the
Non-verbal communication, e.g. through gestures or
body due to blockage or constriction of the arteries
by using computerised devices.
that supply it.
Deep vein thrombosis: Thrombosis (a clot of blood)
Neglect: The failure to attend or respond to, or make
in the deep veins of the leg, arm, or abdomen.
movements towards one side of the environment.
Disability: A defect in performing a normal activity or
Participation: Involvement in a life situation.
action (e.g. inability to dress or walk).
Participation restrictions: are problems an individual
Dysarthria: Impaired ability to produce clear speech
may experience in involvement in life situations.
due to the impaired function of the speech muscles.
Percutaneous endoscopic gastrostomy (PEG): A
Dysphagia: Difficulty swallowing.
form of enteral feeding in which nutrition is delivered
Dysphasia: Reduced ability to communicate using via a tube that is surgically inserted into the stomach
language (spoken, written or gesture). through the skin.
Dyspraxia of speech: Inability to produce clear Phonological deficits: Language deficits
Glossary and Abbreviations
speech due to impaired planning and sequencing of characterised by impaired recognition and/or selection
movement in the muscles used for speech. of speech sounds.
Emotionalism: An increase in emotional behaviour - Pulmonary embolism: Blockage of the pulmonary
usually crying, but sometimes laughing that is outside artery (which carries blood from the heart to the lungs)
normal control and may be unpredictable as a result of with a solid material, usually a blood clot or fat, that
the stroke. has travelled there via the circulatory system.
Enteral tube feeding: Delivery of nutrients directly into Rehabilitation: Restoration of the disabled person to
the intestine via a tube. optimal physical and psychological functional
Executive function: Cognitive functions usually independence.
associated with the frontal lobes including planning, Risk factor: A characteristic of a person (or people)
reasoning, time perception, complex goal-directed that is positively associated with a particular disease or
behaviour, decision making and working memory. condition.
73
Stroke unit: A section of a hospital dedicated to IV: Intravenous
comprehensive rehabilitation programs for people with
LMWH: Low molecular weight heparin
a stroke.
M/A: Meta analysis
Stroke: Sudden and unexpected damage to brain
cells that causes symptoms that last for more than 24 MAP: Mean arterial blood pressure
hours, in the parts of the body controlled by those MCA: Middle cerebral artery
cells. It happens when the blood supply to part of the
MBS: Modified barium swallow
brain is suddenly disrupted, either by blockage of an
artery or by bleeding within the brain. MR-DWI: Magnetic resonance diffusion weighted
imaging
Task-specific training: Training that involves repetition
of a functional task or part of the task. MRI: Magnetic Resonance Imaging
Transient ischaemic attack (TIA): Stroke-like NG: Nasogastric
symptoms that last less than 24 hours. While TIA is
NHMRC: National Health and Medical Research
not actually a stroke, it has the same cause. A TIA may
Council
be the precursor of a stroke, and people who have
had a TIA require urgent assessment and treatment to NNT: Numbers needed to treat
prevent stroke. OBS: Observational study
OT: Occupational therapist
Abbreviations PE: Pulmonary embolism
AAC: Augmentative and alternative PEG: Percutaneous endoscopic gastrostomy
communication
QALYs: Quality adjusted life years
ADL: Activities of daily living
RCT: Randomised controlled trial
AF: Atrial fibrillation
rFVIIa: recombinant activated factor VII
CEA: Carotid endarterectomy
rt-PA: Recombinant tissue plasminogen activator
CEMRA: Contrast enhanced magnetic resonance
RRR: Relative risk reduction
angiography
SR: Systematic review
CT: Computed tomography
STAIR: Stroke transition after inpatient care
DVT: Deep vein thrombosis
STEP: Stroke Therapy Evaluation Program
ESD: Early supported discharge
TIA: Transient ischaemic attack
Glossary and Abbreviations
74
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