Note from the Scottish Intercollegiate Guidelines Network (SIGN) and National Guideline Clearinghouse (NGC): In addition to these evidence-based recommendations, the guideline development group also identifies points of best clinical practice in the full-text guideline document.
The grades of recommendations (A-D) and levels of evidence (1++, 1+, 1-, 2++, 2+, 2-, 3, 4) are defined at the end of the "Major Recommendations" field.
Management of Suspected Stroke or Transient Ischaemic Attack (TIA)
Systems of Care
B - Emergency medical services should be redesigned to facilitate rapid access to specialist stoke services.
Pre-Hospital
Pre-Hospital Assessment
C - Standard assessment scales such as face arm speech test (FAST) or Melbourne acute stroke scale (MASS) are recommended for pre-hospital assessment to:
- Increase the accuracy of the initial stroke diagnosis
- Assist with more rapid diagnosis
- Speed up consideration for treatment
- Assist with more rapid referral to specialist services
In-Hospital
In-Hospital Assessment
C - Standard assessment scales such as recognition of stroke in the emergency room (ROSIER) are recommended for emergency department staff to:
- Increase the accuracy of the initial stroke diagnosis
- Assist with more rapid diagnosis
In-Hospital Care
A - Stroke patients requiring admission to hospital should be admitted to a stroke unit staffed by a coordinated multidisciplinary team with a special interest in stroke care.
B - Patients with TIA and minor stoke, who are at high risk of early recurrence, should undergo specialist assessment and begin treatment promptly.
Integrated Care Pathways
B - The routine implementation of care pathways for acute stroke management or stroke rehabilitation is not recommended where a well organized multidisciplinary model of care exists.
Telemedicine Consultation
B - In areas without a local stroke specialist, telemedicine consultation should be considered to facilitate treatment in patients eligible for thrombolysis.
Assessment, Diagnosis and Investigation
Clinical Assessment
Risk of Recurrence
C - The ABCD (age, blood pressure, clinical features and duration of symptoms) score should be used to identify patients who are at highest risk of recurrent stroke to allow very rapid investigation and treatment.
Assessment of Degree of Dependency
C - Impairment scales should be considered to help discussion of likely outcomes after stroke with patients and carers.
Brain imagining for Suspected Acute Stroke or TIA
Timing of Imaging
A - All patients with suspected stroke should have brain imaging immediately on presentation.
Modality of Imaging
B - Computed tomography (CT) scanning is recommended for most patients in the acute phase of stroke.
B - Magnetic resonance imaging (MRI) with diffusion weighted and gradient echo sequences is recommended (where available and practical) for the diagnosis of acute stroke syndromes in patients who:
- Are not severely ill, especially where either neurological deficit is mild and clinical likelihood is that the lesion is small or lies in the posterior fossa or
- Present late (after one week)
Who Should Interpret the Brain Scan?
C - Unenhanced CT brain scans for detection of early changes of infarction should be interpreted by personnel trained and experienced in stroke radiology.
D - Medical personnel trained and experienced in stroke radiology should interpret CT and MRI brain scans from all time frames.
Carotid Evaluation
Carotid Imaging in Patients with Carotid Territory TIA or Stroke and/or Retinal Event
A - All patients with non-disabling acute stroke syndrome /TIA in the carotid territory who are potential candidates for carotid surgery should have carotid imaging.
C - Initial carotid imaging with duplex ultrasound or alternative should be performed rapidly once a diagnosis of ischaemic stroke or TIA in the carotid territory is made.
C - Corroborative imaging is recommended to confirm and more accurately grade carotid disease if duplex carotid ultrasound is abnormal.
C - Non-invasive angiographic carotid imaging (CE-MRA) should be performed and interpreted by radiologists specifically trained and with specialist interested in vascular imaging.
Cardiac Imaging
B - The routine use of echocardiography with contrast media for evaluation of patients with stroke is not recommended.
B - Echocardiography should be considered in patients with:
- Clinical findings and/or baseline investigations suggesting cardiac disease
- Cryptogenic stroke
Diagnostic Tests
C - The routine requesting of thrombophilia screens, antiphospholipid antibodies, other auto-antibodies or homocysteine levels is not recommended.
Treatment of Ischaemic Stroke
Thrombolysis
Intravenous Thrombolysis
A - Patients admitted with stroke within four and a half hours of definite onset of symptoms, who are considered suitable, should be treated with 0.9 mg/kg (up to maximum 90 mg) intravenous recombinant tissue plasminogen activator (rt-PA).
A -
- Onset to treatment time should be minimised.
- Systems should be optimised to allow the earliest possible delivery of intravenous rt-PA within the defined time window.
A - Streptokinase should not be used for treatment of patients in the acute phase of stroke.
Intra-Arterial Thrombolysis
B - Intra-arterial thrombolysis may be considered for patients with proximal middle cerebral artery occlusion or basilar artery occlusion that presents beyond four and a half hours.
B - Treatment should be delivered within six hours of symptom onset in patients with middle cerebral artery occlusion.
Antiplatelet Agents
Aspirin
A - Aspirin 300 mg daily should be commenced within 48 hours of ischaemic stroke and continued for at least 14 days.
Anticoagulants
Fibrinogen-Depleting Agents
A -
- The routine use of anticoagulants (unfractionated heparin [UFH], low molecular weight heparins [LMWHs], heparinoids, oral anticoagulants, direct thrombin inhibitors, fibrinogen-depleting agents) is not recommended for the treatment of acute ischaemic stroke.
- Anticoagulants are not recommended in patients with progressing stroke.
A - In patients at high risk of venous thromboembolic disease LMWH should be considered in preference to UFH.
D - Following administration of intravenous (IV) thrombolysis, heparin should not be given in any form for 24 hours.
C - For patients in atrial fibrillation following stroke, anticoagulation with warfarin can be introduced early in patients with minor stroke or TIA, but should be deferred for two weeks after onset in those with major stroke.
Decompressive Surgery
A - For individuals aged up to 60 years who suffer an acute middle cerebral artery (MCA) territory ischaemic stroke complicated by massive cerebral oedema, surgical decompression by hemicraniectomy should be offered within 48 hours of stroke onset.
Mechanical Reperfusion
Clot Retrieval
C - Mechanical clot retrieval devices, when used by experienced interventional neuroradiologists, may be considered in patients:
- Ineligible for thrombolytic drug therapy
- Who have failed to improve clinically or recanalise following intravenous thrombolysis
Transcranial Doppler and Thrombolysis
B - Transcranial Doppler (TCD) ultrasound at lower (kilohertz) frequencies is not recommended.
Treatment of Primary Intracerebral Haemorrhage
Haematoma Evacuation
A - Routine surgical evacuation by craniotomy is not recommended for supratentorial primary intracerebral haematoma.
B - If surgical evacuation of primary intracerebral haematoma is considered:
- Minimally invasive procedures including stereotaxy-guided evacuation should be considered as an alternative to craniotomy
- Early intervention (within eight hours of symptom onset) is recommended
Reducing Raised Intracranial Pressure
Corticosteroids
B - Corticosteroids should not be used for treatment of primary intracerebral haemorrhage.
Mannitol
B - Intravenous mannitol should not be used routinely for treatment of raised intracranial pressure in patients with primary intracerebral haemorrhage.
Other Causes of Stroke
Cerebral Venous Thrombosis
Anticoagulants
C - Intravenous UFH or subcutaneous LMWH followed by warfarin therapy should be considered in patients with cerebral venous thrombosis.
Extracranial Cervical Arterial Dissection
Anticoagulants and Antiplatelets
D - In patients with extracranial cervical arterial dissection consider treatment with either:
- Anticoagulation for three to six months
- Antiplatelet agents
Endovascular Stenting
D - Endovascular stenting is not routinely recommended for extracranial cervical arterial dissection or cervical artery pseudo-aneurysms.
Physiological Monitoring and Intervention
Physiological Intervention
Fluid Replacement Therapy
B - To prevent iatrogenic hyperglycaemia, intravenous saline infusion is preferable to glucose containing preparations.
A - Haemodilution is not recommended as a routine treatment in acute stroke with the possible exception of patients with polycythaemia.
C - For patients in whom intravenous fluids are not appropriate, subcutaneous fluids can be used to maintain plasma osmolality within the normal range.
Blood Pressure Management
A - Blood pressure should not be actively managed as a routine in patients in the acute phase of ischaemic stroke.
Blood Glucose Management
B - Routine use of insulin regimens to lower blood glucose in patients with moderate hyperglycaemia after acute stroke is not recommended.
C - Patients with hyperglycaemia (random blood glucose > 7 mmol/L) should be formally assessed (by oral glucose tolerance test [OGTT]) to exclude or confirm a diagnosis of impaired glucose tolerance or diabetes.
Feeding
A - Early placement of a nasogastric feeding tube should be considered in patients identified as unable to take adequate oral intake.
A - Routine use of nutritional supplements is not recommended.
Supplementary Oxygen Therapy
A - Hyperbaric oxygen therapy for patients with acute ischaemic stroke is not recommended outwith the setting of a clinical trial.
Management of Pyrexia
C - Increased body temperature should be investigated and antipyretic medications may be administered to assist in lowering the body temperature.
Early Mobilisation
A - Early mobilisation, including positioning in bed, sitting on the edge of the bed, or standing up should be considered for patients within the first three days after a stroke.
Physical Therapy
D -
- Patients' suitability for early, active rehabilitation should be considered.
- Healthcare professionals managing patients in the acute phase of stroke should consider how to actively engage patients throughout the day.
Active Positioning
C -
- Patients should be placed in an upright sitting position, if their medical condition allows.
- Hypoxia inducing positions (or left side or slumped in a chair) should be avoided.
Preventing Recurrent Stroke in Patients with Ischaemic Stroke or TIA
Antiplatelet Agents
Combination Therapy
A - Low-dose aspirin (75 mg daily) and dipyridamole (200 mg modified release twice daily) should be prescribed after ischaemic stroke or TIA for secondary prevention of vascular events.
B - Dose titration of dipyridamole may help to reduce the incidence of headache.
A - Clopidogrel (75 mg daily) monotherapy should be considered as an alternative to combination aspirin and dipyridamole after ischaemic stroke or TIA for secondary prevention of vascular events.
A - The combination of aspirin and clopidogrel is not recommended for long term secondary prevention is ischaemic stroke or TIA.
Statins
A - A statin should be prescribed to patients who have had an ischaemic stroke, irrespective of cholesterol level.
A - Atorvastatin (80 mg) should be considered for patients with TIA or ischaemic stroke.
A - Other statins (such as simvastatin 40 mg) may also be considered as they reduce the risk of major vascular events.
A - Statin therapy for prevention of further vascular events post-haemorrhagic stroke is not recommended routinely unless the risk of further vascular events outweighs the risk of further haemorrhage.
Anticoagulants
Patients with Non-Cardioembolic Ischaemic Stroke
A - Anticoagulation is not recommended for preventing recurrent stroke in patients with non-cardioembolic ischaemic stroke.
Patients with Non-Rheumatic Atrial Fibrillation and Ischaemic Stroke
A - Patients with ischaemic stroke or TIA who are in atrial fibrillation should be offered warfarin with target international normalized ratio (INR) 2.0-3.0.
B - In the absence of contraindications and patient preference for alternative treatment, warfarin should be offered routinely to elderly patients (>75 years) with ischaemic stroke or TIA who are in atrial fibrillation.
Antihypertensives
A - All patients with a previous stroke or TIA should be considered for treatment with an angiotensin-converting enzyme (ACE) inhibitor (for example, perindopril) and thiazide (for example, indapamide) regardless of blood pressure, unless contraindicated.
D - Patients with hypertension should be treated to <140/85 mm Hg (<130/80 mm Hg for patients with diabetes).
Patent Foramen Ovale and Stroke
B - Patients with cryptogenic stroke and patent foramen ovale (PFO) should be treated with antiplatelet therapy to reduce the risk of recurrence.
D - Transcatheter closure of PFO may be considered for patients with recurrent cryptogenic stroke on optimal medical management.
Preventing Recurrent Stroke in Patients with Primary Intracerebral Haemorrhage
Blood Pressure Reduction
A - Lowering blood pressure (non-acutely) following intracerebral haemorrhage (ICH) using a combination therapy of ACE inhibitor and thiazide diuretic should be considered to prevent further vascular events.
Antiplatelet Agents
B - The use of aspirin following ICH is not recommended to prevent further vascular events when the risk of recurrence is low.
C - The use of aspirin following ICH may be considered when there is a high risk of cardiac ischaemic events.
Anticoagulants
D - Anticoagulation therapy following ICH is not recommended.
Statins
A - Statin therapy after haemorrhagic stroke is not routinely recommended unless the risk of further vascular events outweighs the risk of further haemorrhage.
Carotid Intervention
Carotid Endarterectomy
Symptomatic Carotid Artery Disease
A - All patients with carotid artery territory stroke (without severe disability, modified Rankin scale [mRS] ≤2) or transient ischaemic attack should be considered for carotid endarterectomy as soon as possible after the index event.
A - Carotid endarterectomy (on the internal carotid artery ipsilateral to the cerebrovascular event) should be considered in all:
- Male patients with a carotid artery stenosis of 50-99% (by North American Symptomatic Carotid Endarterectomy Trial [NASCET] method)
- Female patients with a carotid artery stenosis of 70-99%
B - For all patients, carotid endarterectomy should be performed as soon as the patient is stable and fit for surgery, ideally within two weeks of event.
B - There is no justification for withholding carotid endarterectomy from older patients who are considered fit for surgery.
A - All patients undergoing carotid endarterectomy should receive optimal medical therapy in addition to surgery.
Asymptomatic Carotid Artery Disease
A - Carotid endarterectomy (CEA) should be considered for asymptomatic patients with high grade carotid stenosis and no ipsilateral event for at least six months.
B - CEA should only be performed by operators with a low (<3%) perioperative stroke or death rate.
Carotid Surgery Technique
A - Patch angioplasty should be used as the closure method in all carotid endarterectomies performed by conventional methods.
A - Changing surgical technique from conventional carotid endarterectomy to eversion method is not recommended.
A - The choice of anaesthetic technique for patients undergoing surgery should be made by the individual operator/anaesthetist.
Carotid Angioplasty and Stenting
A - Carotid angioplasty and stenting is not recommended outwith ongoing randomised controlled trials.
Periprocedural Antiplatelet or Antithrombotic Therapy
A - Standard antiplatelet treatment should be given after CEA.
Promoting Lifestyle Changes
Altering Dietary Fat Intake
A - Diets low in total and saturated fats should be recommended to all for the reduction of cardiovascular risk.
Reducing Dietary Salt
A - People with hypertension should be advised to reduce their salt intake as much as possible to lower blood pressure.
Fruit and Vegetable Consumption
C - Increasing fruit and vegetables consumption is recommended to reduce risk of stroke or TIA.
Vitamin Supplements
B - Vitamin supplementation is not recommended in patients following ischaemic stroke.
Weight Reduction
B - Patients and individuals at risk of cardiovascular disease, who are overweight, should be targeted with interventions designed to reduce weight, and to maintain this reduction.
Smoking
B - All people who smoke should be advised to stop and offered support to help facilitate this in order to minimise cardiovascular and general health risks.
Exercise
B - Lifelong participation in programmes of exercise after stroke should be encouraged.
Provision of Information
Providing Information and Support
Information Needs of Patients and Carers in the Acute Phase of Stroke
D - Each patient should be individually assessed on his or her readiness to receive information.
D - Healthcare professionals should take a patient's age, gender, educational status and communication support needs into account when assessing their need for information.
A - Information should be offered to patients and carers in a variety of formats, including easy access.
D - Information should be tailored to the phase of the patient's journey.
D - Information should be repeated and re-offered at appropriate intervals.
Support Needs of Carers in the Acute Phase of Stroke
D - Healthcare professionals should actively involve carers and find out what support they need.
A - Caregivers should be offered ongoing practical information and training individualized for the needs of the person for whom they are caring.
D - Carers' support needs should be addressed prior to patient discharge.
Definitions:
Grades of Recommendations
Note: The grade of recommendation relates to the strength of the evidence on which the recommendation is based. It does not reflect the clinical importance of the recommendation.
A. At least one meta-analysis, systematic review, or randomised controlled trial (RCT) rated as 1++ and directly applicable to the target population; or
A body of evidence consisting principally of studies rated as 1+, directly applicable to the target population, and demonstrating overall consistency of results
B. A body of evidence including studies rated as 2++, directly applicable to the target population, and demonstrating overall consistency of results; or
Extrapolated evidence from studies rated as 1++ or 1+
C. A body of evidence including studies rated as 2+, directly applicable to the target population and demonstrating overall consistency of results; or
Extrapolated evidence from studies rated as 2++
D. Evidence level 3 or 4; or
Extrapolated evidence from studies rated as 2+
Good Practice Points: Recommended best practice based on the clinical experience of the guideline development group
Levels of Evidence
1++: High quality meta-analyses, systematic reviews of randomised controlled trials (RCTs), or RCTs with a very low risk of bias
1+: Well-conducted meta-analyses, systematic reviews, or RCTs with a low risk of bias
1-: Meta-analyses, systematic reviews, or RCTs with a high risk of bias
2++: High quality systematic reviews of case control or cohort studies
High quality case control or cohort studies with a very low risk of confounding or bias and a high probability that the relationship is causal
2+: Well-conducted case control or cohort studies with a low risk of confounding or bias and a moderate probability that the relationship is causal
2-: Case control or cohort studies with a high risk of confounding or bias and a significant risk that the relationship is not causal
3: Non-analytic studies (e.g., case reports, case series)
4: Expert opinion
