The levels of evidence supporting the recommendations (I-IV) and grades of recommendations (A-D and clinical practice points [CPP]) are defined at the end of the "Major Recommendations" field.
The original guideline document also includes a consumer rating that identifies aspects of care considered to be critical from a patient perspective.
Cerebral Oedema
Selected patients (e.g., 18-60 years with potential for surgery to occur within 48 hours of symptom onset) with significant middle cerebral artery infarction should be urgently referred to a neurosurgeon for consideration of hemicraniectomy. (Grade A; Level I [Vahedi et al., 2007])
Corticosteroids are not recommended for management of patients with brain oedema and raised intracranial pressure. (Grade A; Level I [Qizilbash, Lewington, & Lopez-Arrieta, 2001])
Osmotherapy and hyperventilation may be trialled while a neurosurgical consultation is undertaken, or for patients with deteriorating condition due to raised intracranial pressure. (Grade C; Level I for potential short term benefit of glycerol [Righetti et al., 2004]; Level IV for hyperventilation [Hofmeijer, Van Der Worp, & Kappelle, 2003])
Deep Venous Thrombosis (DVT) and Pulmonary Embolism (PE)
Early mobilisation and adequate hydration should be encouraged with all acute stroke patients to help prevent DVT and PE. (CPP)
Antiplatelet therapy should be used for people with ischaemic stroke to prevent DVT/PE. (Grade A; Level I [Andre, De Freitas, & Fukujima, 2007])
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. (Grade B; Level I [Andre, De Freitas, & Fukujima, 2007; Sandercock, Counsell, & Stobbs, 2005; van Dongen et al., 2004] and Level II [Sherman et al., 2007])
- Thigh-length antithrombotic stockings. (Grade C; Level II [Andre, De Freitas, & Fukujima, 2007; Mazzone et al., 2004])
Pyrexia
Antipyretic therapy, comprising regular paracetamol and/or physical cooling measures, should be used routinely where fever occurs. (Grade C; Level II [Dippel et al., 2003; Mayer et al., 2004])
Pressure Care
All patients unable to mobilise independently should have a pressure care risk assessment completed by trained personnel. (CPP)
All those assessed at high risk should be provided with a pressure relieving mattress as an alternative to a standard hospital mattress. (Grade B; Level I [Cullum et al., 2004])
Definitions:
Levels of Evidence
Level |
Intervention |
Diagnosis |
Prognosis |
Aetiology |
Screening |
I |
A systematic review of Level II studies |
A systematic review of Level II studies |
A systematic review of Level II studies |
A systematic review of Level II studies |
A systematic review of Level II studies |
II |
A randomised controlled trial |
A study of test accuracy with: an independent, blinded comparison with a valid reference standard, among consecutive patients with a defined clinical presentation |
A prospective cohort study |
A prospective cohort study |
A randomised controlled trial |
III-1 |
A pseudo-randomised controlled trial (i.e., alternate allocation or some other method) |
A study of test accuracy with: an independent, blinded comparison with a valid reference standard, among consecutive patients with a defined clinical presentation |
All or none |
All or none |
A pseudo-randomised controlled trial (i.e., alternate allocation or some other method) |
III-2 |
A comparative study with concurrent controls:
- Non-randomised experimental trial
- Cohort study
- Case-control study
- Interrupted time series without a parallel control group
|
A comparison with a reference standard that does not meet the criteria required for Level II and Level III-1 evidence |
Analysis of prognostic factors amongst untreated control patients in a randomised controlled trial |
A retrospective cohort study |
A comparative study with concurrent controls:
- Nonrandomised, experimental trial
- Cohort study
- Case-control study
|
III-3 |
A comparative study without concurrent controls:
- Historical control study
- Two or more single arm study
- Interrupted time series without a parallel control group
|
Diagnostic case-control study |
A retrospective cohort study |
A case-control study |
A comparative study without concurrent controls:
- Historical control study
- Two or more single arm study
|
IV |
Case series with either post-test or pre-test/post-test outcomes |
Study of diagnostic yield (no reference standard) |
Case series or cohort study of patients at different stages of disease |
A cross-sectional study |
Case series |
Grading of Recommendations
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 |
Clinical Practice Points |
CPP |
Recommended best practice based on clinical experience and expert opinion |