Definitions for the Levels of Evidence (1++ to 4) and Grades of Recommendation (A - C, I, and Good Practice Points [GPP]) are given at the end of the "Major Recommendations" field.
Organisation and Evaluation of Stroke Services in New Zealand
Organized Stroke Services
A All District Health Boards must provide organised stroke services.
GPP All people with stroke should have the same degree of access to appropriate stroke services irrespective of where they live, their age, gender, or ethnicity.
Stroke Unit Care
A All people admitted to hospital with stroke should expect to be managed in an area of the hospital designated for people with stroke (i.e. a stroke unit) (Royal College of Physicians, 2002).
A The use of a specialised stroke unit, incorporating comprehensive rehabilitation, is recommended (Adams et al., 2003).
Inpatient Organisation for Different-sized District Health Boards
Large District Health Boards
GPP All people with stroke should be admitted under the care of a designated stroke clinician, in a separate stroke unit or a designated area within a general unit.
GPP The ongoing rehabilitation of all people with stroke should occur in a geographically designated area (i.e. a stroke unit) under the care of a coordinated multidisciplinary team involving stroke specialist clinicians.
GPP If at all possible, the acute AND rehabilitation management should be in the same area (i.e. an integrated acute and rehabilitation stroke unit).
GPP The multidisciplinary team should use written protocols for the management of common problems following stroke and have an ongoing programme of education about stroke for staff, people with stroke, and families.
Medium-sized District Health Boards
GPP All people with stroke should be admitted to a defined area for acute management, in a separate area or a designated area within a general unit. The acute care of all people with stroke should occur in consultation with the hospital's designated stroke clinician(s).
GPP The ongoing rehabilitation of all people with stroke should occur in a geographically designated area (i.e. a stroke unit) under the care of a coordinated multidisciplinary team involving stroke specialist clinicians. It is possible that people with stroke will not be the only patients managed by this team.
GPP The multidisciplinary team should use written protocols for the management of common problems following stroke and have a programme of regular education about stroke for staff, people with stroke, and families.
Small District Health Boards
GPP The acute care of all people with stroke should occur in consultation with the hospital’s designated stroke clinician(s).
GPP The ongoing rehabilitation of all people with stroke should occur under the care of a coordinated multidisciplinary team involving people knowledgeable and enthusiastic about stroke. People with stroke will not be the only patients managed by this team.
GPP The multidisciplinary team should use written protocols for the management of common problems following stroke and have a programme of regular education about stroke for staff, people with stroke, and families.
Scope of Community Services (Diagnostic, Secondary Prevention, and Rehabilitation)
B All District Health Boards should provide a full range of community services to complement inpatient stroke services (Royal College of Physicians, 2002).
Organisation of Community Rehabilitation Services
General Principles
C All people with stroke who are managed at home or discharged from hospital with residual disability should be managed by a team of health professionals knowledgeable in stroke.
A Community rehabilitation can be provided with equal effectiveness from a day hospital or community (i.e. home-based) setting (Royal College of Physicians, 2002).
C There must be a high level of coordination between inpatient and community stroke services within each District Health Board, aiming for seamless management of the person with stroke wherever they are managed.
Specific recommendations for different-sized areas:
Large District Health Boards
GPP A specialist multidisciplinary rehabilitation community team with expertise in the management of stroke should manage all people discharged from hospital following acute stroke and any people with stroke managed at home without hospital admission. Some team members may be "stroke dedicated" (e.g., nurse), while others may have an additional non-stroke caseload (e.g., physician, speech and language therapist).
Medium- and Small-sized District Health Boards
GPP Rehabilitation should be managed as described above for large District Health Boards, but it is likely that most team members will also have a non-stroke caseload.
Rural Communities
GPP The lead stroke clinician should have input on a regular basis to ensure advice and support to all facilities and services involved in stroke care. Local solutions to issues of coordination of community services may be required. These may include inpatient staff having a role in the community and relationships with private providers and general practitioners. The solutions should focus on maintaining and enhancing stroke expertise among available staff to provide the best possible service to people with stroke.
Special Considerations for the Very Old and Very Young
GPP For some very old or already very frail people, issues relating to a stroke may be of less importance than those of accumulated comorbidities so that management in an environment appropriate for these needs (such as a specialised geriatric service) may be preferable to a stroke unit. This will be a clinical decision.
C Younger people with stroke should be managed primarily in a stroke unit rather than in an age-restricted unit with patients with other disabilities (such as head injury).
Services Responsive to Maori
Whanau
GPP For Maori with stroke, whanau wellbeing is the desired outcome. Whanau must be involved in all aspects of stroke management including education, rehabilitation, and discharge planning.
Communication
GPP Communication between Maori with stroke, their whanau, and health professionals must be appropriate. Information developed by Maori that is specific to the needs of Maori and their whanau is the ideal.
Service Providers
GPP Responsiveness of mainstream providers to Maori with stroke and their whanau will be improved when:
- people with stroke and their whanau are informed and supported in an appropriate manner (examples include access to a Maori liaison service, increased support to sustain lifestyle changes and to access outpatient services, and whanau involvement in making decisions, including setting goals)
- local Maori providers are consulted regularly
- barriers to stroke care, including transport and socioeconomic factors, are addressed
Services Responsive to Pacific Peoples
GPP To improve outcomes for Pacific people with stroke it is necessary to:
- recognise the national and cultural diversity within the Pacific community and "tailor" healthcare for the individual
- appreciate the holistic view of health held by Pacific peoples
- involve caregivers, family members, and other members of the community in the management of stroke
- consider the implications of difficult socioeconomic circumstances, especially for compliance
- acknowledge and be open to the use of traditional healing methods
- develop and support Pacific health providers and establish partnerships between these and mainstream health services to ensure streamlined care plans
General Practitioner Care
GPP The general practitioner should take primary responsibility for:
- recognition of stroke syndrome and urgent referral for assessment in hospital or at an outpatient clinic (see pages 6-7 in the original guideline document)
- management of primary prevention of cerebrovascular disease
- management of secondary prevention of cerebrovascular disease
- awareness of resources for people with stroke (e.g., appropriate outpatient clinic, local Stroke Foundation services, educational literature), and how to refer
Stroke Workforce
GPP At both national and District Health Board levels, measures should be taken to increase the numbers and enhance the training of the stroke workforce.
Evaluation of Stroke Services to Improve Performance over Time
Indicators for Stroke Services
GPP The key indicators for stroke services should be:
- Compliance with the recommendations in this section for organised stroke services at a level that matches the volume of people with stroke in the region (Yes/no item)
- Compliance with the recommendation for a named lead clinician responsible for stroke services within the District Health Board (Yes/no item)
- Proportion of all people with stroke admitted to a stroke unit (%) (Target = 95%)
- Proportion of hospital stay spent in a stroke unit (%) (Target = >50%)
- Compliance with the recommendation for written protocols for problems as outlined in the following section (Yes/no item)
- Breakdown by age, gender, ethnicity of all people admitted to hospital with stroke and those who spent any time in the stroke unit (i.e., equity of access, %)
Assessment and Management of Stroke
Assessments
GPP People with stroke should have the initial assessment completed with minimal delay.
GPP The assessments listed below should be undertaken for every person with stroke. Clinicians should, where possible, use validated, reliable instruments.
Early Assessments (The First 48 Hours)
Initial assessments should include the following parameters:
- Level of consciousness (C)
- Swallowing (B)
- Nutrition (B)
- Continence (B)
- Risk factors (see pp. 42 in the original guideline document)
- Hydration (GPP)
- Self-care (GPP)
- Communication (B)
- Appropriate moving and handling of the person with stroke, matched to the level of impairment (C)
- Risk for falling (GPP)
- Risk for developing pressure areas (C)
- Risk for deep vein thrombosis/pulmonary embolism (A)
Assessments Prior to Discharge
To assist rehabilitation planning, information on the following should be obtained as early as possible during the hospital stay:
- Suitability of likely discharge accommodation
- Available supports on discharge
- Mood
- Cognitive status
- Major interests of person with stroke
- Long-term goals
- Work/study/leisure situation
- Cultural/spiritual issues
- Adequacy of information for person and support people
- Driving ability, adequacy of information on driving status on discharge.
Swallowing
B Swallowing should be assessed in all people with stroke as soon as possible (and preferably on admission) by appropriately trained personnel using a simple, validated testing protocol (Royal College of Physicians, 2002).
A Any person with an abnormal swallow should be seen by a speech and language therapist, who should assess the person further and advise the person and staff on safe swallowing techniques and strategies and the consistency of diet and fluids (Royal College of Physicians, 2002).
Written Protocols for Management of Common Problems
C Written protocols should be available for the management of problems that may lead to adverse outcomes, problems that cross professional boundaries, or where consistency of care may be an issue because of changing staff.
Admission to Hospital
GPP All people with a definite or presumptive diagnosis of stroke should be admitted to hospital unless:
- their symptoms have fully resolved or are rapidly recovering so that there is minimal interference with activities of daily living AND urgent outpatient assessment by a specialist stroke service is available OR
- in the opinion of the treating doctor AND the person, or the person’s family, there is unlikely to be any benefit from admission to hospital. This may apply to people who were already severely disabled or suffering a terminal illness prior to the stroke.
Speed of Admission to Hospital
GPP All people with a definite or presumptive diagnosis of stroke should be transferred to hospital urgently.
C Where the local hospital offers acute thrombolytic treatment for ischaemic stroke, and time of stroke onset is known, people with stroke should expect to be admitted to hospital and have initial assessments (including computed tomography [CT]) completed within 3 hours of stroke onset.
Diagnosis of Stroke
B The diagnosis of stroke should always be reviewed by a physician with special expertise in stroke (Royal College of Physicians, 2002).
A Imaging of the brain is required to guide acute intervention (Adams et al., 2003).
C Imaging of the brain should be performed as soon as possible and not more than 48 hours after the onset of symptoms, unless there is a good clinical reason for not doing so (Royal College of Physicians, 2002).
B Brain imaging should be undertaken urgently if:
- there is a deterioration in the person's condition following the onset of symptoms
- subarachnoid haemorrhage is suspected
- hydrocephalus secondary to intracerebral haemorrhage is suspected
- trauma is suspected
- the person is on anticoagulant therapy or has a known bleeding tendency
- the diagnosis is in doubt
- thrombolytic therapy is being considered (Royal College of Physicians, 2002)
C Brain imaging should always be undertaken before anticoagulant therapy or thrombolytic therapy is started.
C All people with a definite or presumptive diagnosis of stroke should have the following investigations:
- full blood count (including platelet count)
- erythrocyte sedimentation rate
- serum urea, creatinine, electrolytes
- blood glucose
- electrocardiogram (SIGN, 2002).
B Chest x-rays should not be undertaken as a routine investigation unless specifically indicated by the patient's symptoms or signs (Adams et al., 2003; Royal College of Physicians, 2002).
Nutrition
A Nutritional support should be considered in any malnourished patient (Royal College of Physicians, 2002).
C Every person with nutritional problems, including dysphagia, who requires food of modified consistency should be referred to a dietitian (Royal College of Physicians, 2002).
C The most suitable posture and equipment to facilitate feeding should be determined (Royal College of Physicians, 2002).
Ischaemic stroke
Acute interventions
Aspirin
A Aspirin 160 to 300 mg should be given as soon as possible after the onset of a stroke in most patients if a diagnosis of intracerebral haemorrhage has been excluded with brain imaging (Adams et al., 2003; Royal College of Physicians, 2002).
A Administration of aspirin within 24 hours of the use of a thrombolytic agent is not recommended (Adams et al., 2003).
Thromobolysis
A Thrombolytic treatment should be administered only in specialist centres by physicians with expertise in the assessment and management of people with acute stroke and where protocols for the use of thrombolysis are in place (Royal College of Physicians, 2002).
Intravenous Thrombolysis
A Thrombolytic treatment with intravenous tissue plasminogen activator (tPA) 0.9 mg/kg (maximum dose 90 mg) may be given to carefully selected people with acute ischaemic stroke if:
- there is a clear history of the time of onset of symptoms
- treatment is given within 3 hours of the onset of symptoms
- intracerebral haemorrhage has been excluded by imaging (Adams et al., 2003; Wardlaw, del Zoppo, & Yamaguchi, 2001)
A The use of intravenous streptokinase or ancrod as an alternative to tPA is not recommended (Adams et al., 2003).
Intra-arterial Thrombolysis
C Carefully selected patients presenting within 0 to 6 hours after the onset of symptoms who have angiographic evidence of a middle cerebral artery occlusion may be treated with intra-arterial thrombolysis. Immediate access to cerebral angiography and expertise with intra-arterial thrombolysis are required.
Heparin
A Intravenous heparin, subcutaneous heparin, low-molecular-weight heparin, and heparinoids are not routinely recommended for the treatment of people with acute ischaemic stroke (Adams et al., 2003; Royal College of Physicians, 2002).
Carotid Endarterectomy
C Carotid endarterectomy is not recommended for people with acute ischaemic stroke (Adams et al., 2003).
Endovascular Treatment
C The use of endovascular treatments, such as angioplasty or stenting, is not recommended for treatment of people with acute ischaemic stroke (Adams et al., 2003).
Other Treatments
A No agents with putative neuroprotective effect can be recommended for the treatment of acute ischaemic stroke (Adams et al., 2003).
B Other treatments, including corticosteroids, calcium antagonists, glycerol, volume expansion, vasodilators, and induced hypertension should not be used unless as part of a randomised controlled trial (Royal College of Physicians, 2002).
B Drugs with a sedative effect should be avoided if possible (Royal College of Physicians, 2002).
Neurological Complications
Brain Oedema and Increased Intracranial Pressure
Corticosteroids
A Corticosteroids are not recommended for the management of cerebral oedema and increased intracranial pressure following an ischaemic stroke (Adams et al., 2003).
Osmotherapy
B Osmotherapy (e.g., intravenous frusemide and intravenous mannitol) and hyperventilation are recommended for selected patients who are deteriorating secondary to increased intracranial pressure (Adams et al., 2003).
Drainage of Cerebrospinal Fluid
C Drainage of cerebrospinal fluid via a ventricular drain or shunt may be used to treat raised intracranial pressure secondary to hydrocephalus (Adams et al., 2003).
Surgical Decompression of Large Cerebellar Infarcts
C Surgical decompression and evacuation of large cerebellar infarcts that are leading to compression of the brainstem and hydrocephalus is recommended (Adams et al., 2003).
Surgical Decompression of Large Cerebellar Hemisphere Infarcts
C Surgical decompression of a large infarct of the cerebral hemisphere which is associated with cerebral oedema and increased intracranial pressure is not routinely recommended. It can be a life-saving measure, but most survivors have severe residual neurological impairment (Adams et al., 2003).
Seizures
C Anticonvulsants after stroke are not recommended unless the person has had at least one seizure. If a person has had a seizure, treatment with an anticonvulsant to prevent recurrent seizures is strongly recommended (Adams et al., 2003).
Medical Complications
Blood Pressure
C A cautious approach should be taken toward the treatment of arterial hypertension in the acute stage (Adams et al., 2003).
C Antihypertensive agents should be avoided unless the systolic blood pressure is >220 mm Hg or the diastolic blood pressure is >120 mm Hg (Adams et al., 2003).
C Patients with elevated blood pressure who are otherwise eligible for treatment with intravenous tPA can have their blood pressure lowered cautiously so that their systolic blood pressure is <185 mm Hg and the diastolic blood pressure is <110 mm Hg (Adams et al., 2003).
C In the exceptional circumstances where blood pressure lowering is required, agents such as labetalol that have a short duration of action and minimal effect on cerebral blood vessels are preferred in the acute stage. Sublingual nifedipine should be avoided (Adams et al., 2003).
Blood Glucose
C Until there are more data to guide treatment, management of hyperglycaemia should be similar to that for other persons with an elevated blood glucose (Adams et al., 2003).
Pyrexia
B Fever should be controlled with the use of antipyretics, such as paracetamol, and treatment of the underlying cause (Adams et al., 2003).
Venous Thromboembolism
Aspirin
A Aspirin 160 to 300 mg/day should be given for the prevention of venous thromboembolism in the absence of any contraindication (Royal College of Physicians, 2002).
Compression Stockings
C Compression stockings should be considered in people with stroke who have weak or paralysed legs once the person’s peripheral circulation, sensation, and the state of the skin have been assessed.
Mobilisation
B Mobilisation should be encouraged as early as possible after the onset of the stroke (Adams et al., 2003).
Prophylactic Anticoagulants
C It is the consensus of the New Zealand stroke guideline development team that prophylactic anticoagulation should not be routinely administered as deep vein thrombosis prophylaxis after stroke. Prophylactic anticoagulation may be considered in immobilised people with stroke who are intolerant of aspirin, are unable to wear compression stockings, or have had a previous venous thrombosis.
Hypoxia
C Supplemental oxygen should be given to hypoxic patients, aiming to maintain oxygen saturation at >95% (Adams et al., 2003).
C Non-hypoxic patients should not be given supplemental oxygen (Adams et al., 2003).
Transient Ischaemic Attacks (TIAs)
C Patients should be assessed as soon as possible after a TIA has occurred and no later than 7 to 14 days after an attack.
C Imaging with CT or magnetic resonance is recommended for patients after a hemispheric TIA, especially if TIAs are recurrent and stereotyped. Brain imaging is not routinely recommended after a vertebrobasilar TIA.
GPP Other investigations should be performed as recommended for patients who have had an ischaemic stroke. Depending on the clinical features, these tests may include ultrasound of the neck vessels, magnetic resonance angiography, transcranial Doppler imaging, digital subtraction angiography, echocardiography, and coagulation studies.
Intracerebral Haemorrhage
Investigations
Coagulation Studies
C A full blood count, bleeding time, prothrombin time, and activated partial thromboplastin time should be performed.
Angiography
C Angiography should be considered for patients with an intracerebral haemorrhage if:
- there is no clear cause for the haemorrhage
- the patient is a surgical candidate, especially a young, normotensive patient who is clinically stable (Broderick et al., 1999).
C Angiography is not required for older, hypertensive patients who have a haemorrhage in the basal ganglia, thalamus, cerebellum, or brainstem and in whom the CT or magnetic resonance imaging does not suggest that the haemorrhage was caused by an underlying vascular lesion (Broderick et al., 1999).
C Magnetic resonance angiography or CT angiography may obviate the need for cerebral angiography in selected patients (Broderick et al., 1999).
Surgical Removal of Intracerebral Haematomas
C Surgical removal of a haematoma may be considered for:
- patients with a cerebellar haemorrhage >3 cm in diameter who are deteriorating secondary to brainstem compression or hydrocephalus
- patients with an intracerebral haemorrhage associated with a structural lesion such as an aneurysm, arteriovenous malformation, or cavernous angioma, if the patient has a chance of a good outcome and the structural vascular lesion is surgically accessible (Broderick et al., 1999)
C Young patients with a moderate or large lobar haemorrhage who are clinically deteriorating may be candidates for surgical removal of a haematoma.
C Surgical removal of a haematoma should not be considered for:
- patients with a small supratentorial haemorrhage (<10 cm3) or a minimal neurological deficit
- patients with Glasgow Coma Scale scores of <4, unless coma is secondary to cerebellar haemorrhage compressing the brainstem
Management of Raised Blood Pressure
C In patients who have an intracerebral haemorrhage, if there is a history of raised blood pressure mean arterial pressure (MAP) should be maintained below 130 mm Hg, where MAP = diastolic blood pressure + 1/3 (systolic blood pressure – diastolic blood pressure) (Broderick et al., 1999).
Secondary Prevention
B All people with stroke or transient ischaemic attack should be assessed for vascular risk factors and be treated appropriately (Royal College of Physicians, 2002).
Lifestyle Factors
C All people with stroke or transient ischaemic attack should be given appropriate advice on lifestyle factors such as not smoking, regular exercise, diet, achieving a satisfactory weight, reducing the use of added salt (Royal College of Physicians, 2002).
Cigarette Smoking
C Cigarette smoking should be discontinued.
Alcohol Consumption
C Excessive alcohol consumption should be discontinued. Mild to moderate use of alcohol (1 or 2 standard drinks per day) is associated with a reduction in stroke rates (Albers et al., 1999).
Physical Activity
A Moderate exercise (30–60 minutes of brisk walking, jogging, cycling, or other aerobic activity at least 3 times per week) is recommended (Albers et al., 1999; Wolf et al., 1999). Medically supervised exercise programmes are recommended for high-risk patients (e.g., those with cardiac diseases) (see http://www.nzgg.org.nz/index.cfm?fuseaction=fuseaction_10&fusesubaction=docs&documentid=22).
Bodyweight
B People who have a body mass index (BMI) >25 (especially those with BMI >30) should commence graduated lifestyle change aimed at weight reduction (Wolf et al., 1999).
Reduction in Blood Pressure
A Blood pressure-lowering treatment is recommended for all people after stroke or transient ischaemic attack unless the person has symptomatic hypotension.
Treatment of Diabetes Mellitus
GPP Diet, oral hypoglycaemics, and insulin should be prescribed as needed to control diabetes (Albers et al., 1999).
Lipid-modifying Treatment
B Treatment with a 3-hydroxy-3-methyl-glutaryl-coenzyme A (HMG-CoA) reductase inhibitor (statin) is recommended for most people following ischaemic stroke or transient ischaemic attack.
Aspirin
A Aspirin is recommended for secondary prevention for all patients after ischaemic stroke or transient ischaemic attack unless there is an indication for anticoagulation or a contraindication to aspirin (Antithrombotic Trialists' Collaboration, 2002).
C CT should be obtained prior to starting aspirin to exclude intracranial haemorrhage.
Clopidogrel
A Clopidogrel is recommended as a safe and effective antiplatelet treatment for the secondary prevention of stroke (CAPRIE Steering Committee, 1996).
Dipyridamole
I There is insufficient evidence to recommend dipyridamole as a first-line treatment for the secondary prevention of vascular events, either as monotherapy or in combination with aspirin.
B Combination treatment with modified-release dipyridamole and aspirin can be used for prevention of non-fatal stroke for patients at high risk of cerebral ischaemic events, including those who have symptomatic cerebral ischaemia while treated with aspirin alone.
B Monotherapy with modified-release dipyridamole is recommended for prevention of non-fatal stroke if aspirin is contraindicated and clopidogrel is unavailable.
Warfarin
A Anticoagulation should be started in every person with ischaemic stroke or transient ischaemic attack and atrial fibrillation (paroxysmal or sustained) unless contraindicated (Royal College of Physicians, 2002).
C Anticoagulation should be considered for all people who have had an ischaemic stroke associated with mitral valve disease, prosthetic heart valves, or myocardial infarction within the preceding 3 months (Royal College of Physicians, 2002).
A Anticoagulation should not be started until intracranial haemorrhage has been excluded by brain imaging (Royal College of Physicians, 2002).
A Anticoagulation should not be used routinely after transient ischaemic attacks or minor ischaemic strokes unless cardiac embolism is suspected (Royal College of Physicians, 2002).
B Anticoagulation following cerebral venous thrombosis appears to be safe and effective, even in the presence of intracerebral haemorrhage (de Bruijn & Stam, 1999; Fink & McAuley, 2001).
Carotid Endarterectomy
A Carotid endarterectomy is recommended for patients with symptomatic severe (70–99%) stenosis of the proximal internal carotid artery (Royal College of Physicians, 2002).
A Carotid endarterectomy should be performed only by specialist surgeons who can demonstrate a complication rate (stroke or death within 30 days) of <7% (Royal College of Physicians, 2002).
A Patients with symptomatic 50 to 69% stenosis of the internal carotid artery should be selected for carotid endarterectomy on a case-by-case basis. The absolute benefit of carotid endarterectomy for patients with a recent transient ischaemic attack or minor stroke and a moderate (50–69%) carotid stenosis is modest. Risk factors that increase the likelihood of benefit from surgery include male sex, increasing age up to 79 years, hemispheric rather than retinal symptoms, plaque surface irregularity, and coexistent intracranial atherosclerotic disease (Cina, Clase, & Haynes, 2002).
A Carotid endarterectomy is not recommended for patients with symptomatic proximal internal carotid artery stenosis less than 50% severity (Royal College of Physicians, 2002).
B Carotid endarterectomy may be considered without digital subtraction cerebral angiography for optimal surgical candidates when good-quality non-invasive imaging is available and a symptomatic high-grade (>70%) stenosis is confirmed both by Doppler ultrasound and by magnetic resonance angiography. Digital subtraction angiography is recommended prior to endarterectomy in all other circumstances, including patients with possible carotid artery occlusion (Barnett & Meldrum, 2000; Kent et al., 1995; Nederkoorn et al., 2002).
Carotid Endarterectomy for Asymptomatic Internal Carotid Artery Stenosis
A Routine carotid endarterectomy is not recommended for unselected patients with asymptomatic carotid stenosis (Chambers, You, & Donnan, 2002).
A Endarterectomy for asymptomatic stenosis must be performed by surgeons with exceptional skill who can demonstrate perioperative complication rates of <2% (Royal College of Physicians, 2002).
Carotid Angioplasty and Stenting
C Carotid angioplasty and stenting should be performed only by an experienced interventionist who can demonstrate a low periprocedural complication rate.
Extracranial-Intracranial Bypass Surgery
A Extracranial-intracranial bypass is not recommended for people with transient ischaemic attacks or minor strokes (Albers et al., 1999).
Early Supported Discharge
A Selected people with stroke can be considered for discharge home as soon as they are able to transfer independently from bed to chair, providing:
- there is a competent caregiver at home
- equivalent rehabilitation input coordinated by a multidisciplinary team can be delivered at home
- adequate support services are available in the community
- there are no environmental impediments (e.g., access to shower and toilet, wheelchair access to the house) (Early Supported Discharge Trialists, 2002).
Rehabilitation Management
When to Start Rehabilitation?
C All people with acute stroke, whether admitted to hospital or not, should have a rehabilitation assessment within the first 24 to 48 hours. The appropriateness and type of rehabilitation intervention will be determined by the results of this assessment.
Who Will Coordinate and Carry Out Rehabilitation?
GPP The rehabilitation team should comprise:
- health professionals with the combined skills to deal with the common issues following stroke and work in a coordinated way to achieve agreed goals
- the person with stroke and their caregivers/family/whanau
How Long Should Input from a Rehabilitation Team Continue and When Should It Stop?
GPP Continuous or intermittent input from a rehabilitation team may be appropriate over long periods of time following stroke, depending on the specific goals being addressed. Withdrawal of rehabilitation team management may occur appropriately when:
- the person with stroke wishes to exit from a formal rehabilitation programme
- no new achievable goals can be identified by the person with stroke and/or their caregivers
How Intense Must Rehabilitation Be?
GPP Local guidelines need to optimise the use of nursing and other trained staff to ensure that every person with stroke is involved in the maximum daily amount of goal-focused activity they can tolerate.
GPP All stroke inpatients should be involved in 7 days per week of goal-focused activity, whether or not this involves a therapist.
Should Community and Inpatient Rehabilitation Be Treated the Same?
GPP Every District Health Board should provide comprehensive rehabilitation services for people with stroke whether they are managed in an inpatient or community environment.
Community Rehabilitation Services
C Local stroke services must decide appropriate types, intensity, and duration of ongoing rehabilitation in the community. There should be appropriate processes to allow for reassessment of need for rehabilitation for all people with stroke.
Specific Rehabilitation Issues
Rehabilitation Interventions
GPP Any rehabilitation intervention needs to be considered within the context of an overall rehabilitation plan for the individual with stroke and the resources available.
Aphasia
B People with aphasia following stroke should be referred to a speech and language therapist for assessment and appropriate management of their communication difficulty (SIGN, 2002).
Care Pathways
A Routine implementation of care pathways for acute management and stroke rehabilitation is not recommended (Kwan & Sandercock, 2002).
Cultural Beliefs
GPP Cultural beliefs may affect rehabilitation of some people whose families may want to "look after" them, possibly rejecting other therapy. It is important that the need for and process of rehabilitation is fully explained in a suitable language/medium, and that culturally appropriate rehabilitation is offered.
Incontinence and Constipation
B Stroke units should have written assessment and management protocols for both urinary and faecal incontinence, and constipation (Royal College of Physicians, 2002).
C Active bowel and bladder management should occur from admission (Royal College of Physicians, 2002).
B Catheters should be used only after full assessment and as part of a catheter management plan using an agreed protocol (Royal College of Physicians, 2002).
C If incontinence persists after 3 weeks in spite of an active bowel and bladder management programme, further tests (urodynamics, anorectal physiology tests) should be considered (Royal College of Physicians, 2002).
C Incontinent inpatients should not be discharged until adequate arrangements for continence aids and services have been arranged at home and the carer has been adequately prepared (Royal College of Physicians, 2002).
C Continence services should cover both hospital and community, to provide continuity of care (Royal College of Physicians, 2002).
Mood Disorders
C People with stroke should be screened for depression and anxiety within the first month, and their psychological state kept under review. A standardized questionnaire (in those who can respond to it) may be used for screening but clinical diagnosis should be confirmed by clinical interview.
B Any person diagnosed with one form of mood disorder should be assessed for other psychiatric comorbidity.
C Mood disorder that is causing persistent distress should be managed by, or with advice from, a clinician experienced in managing mood disorders.
Treatment of Depression
A People with persistently depressed mood (greater than 6 weeks) after stroke should be offered treatment with antidepressant medication.
C Cognitive behavioural psychotherapy should not be routinely offered to people with persistent low mood after stroke.
Prophylactic Antidepressants
I There is insufficient evidence to recommend administration of prophylactic antidepressant medication after a stroke.
Treatment of Emotionalism
A People with severe, persistent, or troublesome tearfulness (emotionalism) following stroke should be offered antidepressant drug treatment, with the frequency of crying monitored to check effectiveness (Royal College of Physicians, 2002).
Movement Reeducation
I No recommendation for a particular form of movement reeducation can be made (Royal College of Physicians, 2002).
Post-stroke (Central) Pain
A Chronic pain post stroke, especially central pain, may respond to tricyclic antidepressant treatment, which should be tried sooner rather than later (Royal College of Physicians, 2002).
C People with intractable pain following stroke should be referred to a specialist in the assessment and management of pain (Royal College of Physicians, 2002).
Shoulder Pain
A Functional electrical stimulation and transcutaneous electrical nerve stimulation post stroke are not recommended (Price & Pandyan, 2002).
B The use of intra-articular corticosteroid injections for treatment of shoulder pain is not recommended (Snels et al., 2000).
B Shoulder strapping to prevent shoulder pain following stroke is not recommended (Hanger et al., 2000).
Spasticity
B Spasticity in the arm or leg following stroke should not be treated routinely with drugs, either orally or by injection (Royal College of Physicians, 2002).
Information and Education for People with Stroke and Their Caregivers
A All people with stroke and their caregivers should be given information, advice, and the opportunity to talk about the impact of illness upon their lives.
A All stroke services should have educational programmes for people with stroke and their families.
Types of Information
B Educational programmes should be flexible enough to accommodate information needs that differ among individuals and between people with stroke and caregivers, and that change over time.
Information Needs of Caregivers
B The specific needs of the caregivers to be given information, to be communicated with, to be involved in decision making, and to be given support should be considered from the outset.
Delivering Information and Education
A Provision of information alone is insufficient.
B Educational programmes should be based on proven adult learning strategies, with active involvement of the person with stroke and caregivers.
I There is insufficient evidence to specify how educational needs are best met.
Leisure and Social Activities after Stroke
B People with stroke should be offered advice on, and treatment aimed at, achieving their desired level of social activities.
C All people with stroke should be provided with access to public or private transport to facilitate participation in leisure and social activities.
I There is insufficient evidence to make any recommendations about leisure and social needs of people with stroke in residential care settings.
Approaches to Therapy
I There is insufficient evidence to recommend how best to improve the leisure and social needs of people with stroke.
Needs of Caregivers
B Caregivers should be given advice on how to maintain their own leisure and social activities while in a caring role.
Sexuality after a Stroke
B The opportunity to discuss issues relating to sexuality should be offered early after a stroke, to both the person and their partner. This should be initiated by the health professionals.
C Pamphlets and other information on sexuality after stroke should be available to all people with stroke.
C Advice about sexuality should cover both physical aspects (e.g., positioning, sensory deficits, erectile dysfunction, drugs) and psychological aspects (e.g., communication, fears, altered roles, and sense of attractiveness).
Risk of Further Stroke during Sex
C People with stroke and their partners should be counselled on the relatively low absolute risk of sexual activity causing a further stroke.
Driving after a Stroke
C All people who have had a stroke who intend to resume driving should be assessed with regard to their ability to drive safely.
C Evaluation of safe driving skills should include a neurological examination by a specialist physician. If there is doubt about the person's ability to drive safely, assessment by a neuropsychologist or specialist occupational therapist is required. If uncertainty still exists, an on-road test should be undertaken.
GPP The Land Transport Safety Authority (LTSA) guidelines should be adhered to. (See summary on page 59 in the original guideline document.)
GPP Adequate training for healthcare workers, resources, technology, and a centre for driving assessments should be available in all District Health Board areas.
GPP Assessment and subsidies for on-road assessment should be accessible to all people with a stroke in New Zealand.
GPP All people unable to drive after a stroke should be advised on alternative means of transport and the availability of disability taxi vouchers (available through the Stroke Foundation).
I There is insufficient evidence on which to recommend strategies which might improve driving performance after a stroke.
Alternative Therapies for Stroke
A Acupuncture is not recommended in addition to standard rehabilitation care in the management of stroke (Sze et al., 2002).
GPP Clinicians should be familiar with the various alternative therapies offered for stroke and be able to comment on the appropriateness of the approach in the context of the nature of the stroke and any comorbidities.
GPP Health professionals should be aware that it is common for Maori and Pacific peoples to use massage, by a family member or traditional healer, as a way of "healing" people with stroke.
I There is insufficient evidence to make any recommendation on the following therapies: conductive education, homoeopathy, herbal medicines, naturopathy, traditional Chinese medicines, music therapy, aromatherapy, snake-venom or remedy for stroke, spider-venom remedy for stroke, hyperbaric oxygen therapy, chelation therapy, magnetic field therapy, reflexology, osteopathy, sound therapy, light therapy.
Definitions:
Rating Scheme for the Strength of the Recommendations
A
The recommendation is supported by good evidence.
B
The recommendation is supported by fair evidence.
C
The recommendation is supported by expert opinion only and/or limited evidence.
I
No recommendation can be made because the evidence is insufficient. Evidence is lacking, of poor quality or conflicting and the balance of benefits and harms cannot be determined.
Good Practice Point (GPP)
Recommended good practice based on the clinical experience of the guideline development group and where guidance is needed.
