The recommendations that follow are those from the guideline's executive summary; detailed recommendations can be found in the original guideline document. Each recommendation is rated based on the level of the evidence and the grades of recommendation. Definitions of the grades of the recommendations (A, B, C, Good Practice Points) and level of the evidence (Level I-Level IV) are presented at the end of the Major Recommendations field.
Service Delivery
A - Acute inpatient care for patients admitted to hospital with a stroke should be organised as a multidisciplinary stroke service based in designated stroke units. (Grade A, Level Ia)
C - Hospitals and general practitioners should agree on a local admissions policy and a local protocol for referral to specialist assessment clinics for those not requiring hospital admission. (Grade C, Level IV)
Assessment and Investigation
C - A full medical assessment should be undertaken and multidisciplinary assessment considered for all patients with acute stroke or transient ischaemic attack (TIA) to define the nature of the event, the need for investigations, further management, and rehabilitation. (Grade C, Level IV)
C - Written local protocols should be available, setting out indications for both routine and more specialised investigations which the clinical situation may merit. (Grade C, Level IV)
C & GPP - All patients with acute stroke should undergo brain scanning (computed tomography [CT] or magnetic resonance imaging [MRI]) as soon as possible (Grade C, Level IV), preferably within 24 hours (GPP). A local protocol for more urgent scans should be made available. (GPP)
C - All patients with acute stroke or TIA should have the following investigations: electrocardiogram (ECG), chest x-ray, full blood count, serum urea and electrolytes, blood glucose, and lipids. (Grade C, Level IV)
B - A swallowing assessment should be undertaken at home or in hospital as part of the clinical assessment of stroke. (Grade B, Level III)
Immediate Management
A - The routine use of drugs to limit neural damage, including the administration of corticosteroids, neuroprotectants, plasma volume expanders, barbiturates, and streptokinase, is of no proven benefit and should be discouraged. (Grade A, Levels Ia & Ib)
A - Antiplatelet therapy, normally aspirin, should be prescribed immediately in patients who have sustained an ischaemic stroke. (Grade A, Levels Ia & Ib)
A - Mild and moderately elevated blood pressure should not routinely be lowered in the acute phase of stroke as this may worsen outcome. (Grade A, Level Ia)
C - Urgent neurosurgical assessment should be available for selected patients, such as those with large cerebellar infarcts or haemorrhage or acute hydrocephalus, and for selected cases of cerebral haemorrhage. (Grade C, Level IV)
C - Patients receiving anticoagulants or recent thrombolytic therapy or those with bleeding diastheses require urgent correction of coagulation defects. Thrombolytics, anti- platelet therapy, and anticoagulants should be discontinued. (Grade C, Level IV)
C - Measures should be taken to combat fever in acute stroke patients. Stroke patients with fever should be fully investigated for possible sources of infection and started on early antibiotic therapy if appropriate. (Grade C, Level IV)
C - Reasonable glycemic control should be maintained in all acute stroke patients. (Grade C, Level IV)
C - Measures should be instituted to prevent complications after acute stroke, such as infections, decubitus ulcers, deep venous thrombosis, and depression. (Grade C, Level IV)
Secondary Prevention
A - Antiplatelet therapy should be continued on the long term for the secondary prevention of recurrent stroke and other vascular events in patients who have sustained an ischaemic cerebrovascular event. (Grade A, Levels Ia & Ib)
A - Warfarin should be considered for use in stroke and TIA patients with non-valvular atrial fibrillation. (Grade A, Level Ia)
C - Warfarin should also be considered after cardioembolic stroke or TIA from valvular heart disease and recent myocardial infarction. (Grade C, Level IV)
A – Patients with moderate or severe internal carotid artery ipsilateral to a carotid TIA or non-disabling ischaemic stroke should be considered for carotid endarterectomy by an experienced surgeon. (Grade A, Level Ia & 1b)
A - Blood pressure lowering should be considered for patients after the acute phase of stroke. (Grade A, Level Ia)
A - Cholesterol lowering should be considered for patients after the acute phase of stroke. (Grade A, Level Ib)
C - The control of risk factors such as diabetes mellitus and cigarette smoking should be initiated once the initial event has stabilised. (Grade C, Level IV)
Rehabilitation
A - All stroke patients should be assessed for rehabilitation potential, and rehabilitation therapy started as soon as the patient's condition permits. (Grade A, Level Ib)
A - Stroke patients should be rehabilitated in a stroke rehabilitation unit. Where this is not available, rehabilitation should be provided in a generic rehabilitation ward. (Grade A, Level Ia)
Definitions:
Grades of Recommendations
Grade A (evidence levels Ia, Ib): Requires at least one randomised controlled trial as part of the body of literature of overall good quality and consistency addressing the specific recommendation.
Grade B (evidence levels IIa, IIb, III): Requires availability of well conducted clinical studies but no randomised clinical trials on the topic of recommendation.
Grade C (evidence level IV): Requires evidence obtained from expert committee reports or opinions and/or clinical experiences of respected authorities. Indicates absence of directly applicable clinical studies of good quality.
Good Practice Points: Recommended best practice based on the clinical experience of the guideline development group.
Levels of Evidence
Level Ia: Evidence obtained from meta-analysis of randomised controlled trials.
Level Ib: Evidence obtained from at least one randomised controlled trial.
Level IIa: Evidence obtained from at least one well-designed controlled study without randomisation.
Level IIb: Evidence obtained from at least one other type of well-designed quasi-experimental study.
Level III: Evidence obtained from well-designed non-experimental descriptive studies, such as comparative studies, correlation studies, and case studies.
Level IV: Evidence obtained from expert committee reports or opinions and/or clinical experiences of respected authorities.
