Updated stroke management guidelines released

New and updated recommendations for stroke management have been published as part of Australia’s living guidelines for stroke, a summary of which has been published by the Medical Journal of Australia.

In 2018, the Stroke Foundation and Cochrane Australia were awarded funding by the Australian Government (Medical Research Future Fund) to test a model of living guidelines for stroke management. These were the first Australian living clinical guidelines and are the first and only living stroke guidelines worldwide. The latest updated guidelines are available in full at the Stroke Foundation: https://informme.org.au/guidelines/clinical-guidelines-for-stroke-management.

Over 30 new and updated recommendations have been made since 2018. This includes five new strong recommendations:

• For patients with potentially disabling ischaemic stroke who meet perfusion mismatch criteria in addition to standard clinical criteria, the recommended time window for safe administration of alteplase has been extended to 9 hours post-stroke.
• For patients with potentially disabling ischaemic stroke due to large vessel occlusion who meet specific eligibility criteria intravenous tenecteplase (0.25 mg/kg, maximum 25 mg) or alteplase (0.9 mg/kg, maximum of 90 mg) should be administered up to 4.5 hours after the time the patient was last known to be well.
• For patients with ischaemic stroke caused by a large vessel occlusion in the internal carotid artery, proximal middle cerebral artery (M1 segment) or with tandem occlusion of both the cervical carotid and intracranial large arteries, endovascular thrombectomy should be undertaken when the procedure can be commenced between 6 and 24 hours after they were last known to be well if clinical and computed tomography perfusion or magnetic resonance imaging features indicate the presence of salvageable brain tissue.
• In hospitals without onsite 24/7 stroke medical specialist availability, telestroke systems should be used to assist in patient assessment and decision-making regarding acute thrombolytic therapy and possible transfer for endovascular therapy.
• In patients with ischaemic stroke, cholesterol-lowering therapy should target low-density lipoprotein cholesterol < 1.8 mmol/L for secondary prevention of atherosclerotic cardiovascular disease.
   

There are also three updates graded as strong recommendations:

• Aspirin plus clopidogrel should be commenced within 24 hours and used in the short term (first 3 weeks) in patients with minor ischaemic stroke or high risk transient ischaemic attack to prevent stroke recurrence.
• In patients with ischaemic stroke aged under 60 years in whom a patent foramen ovale is considered the likely cause of stroke after thorough exclusion of other aetiologies, percutaneous closure of the patent foramen ovale is recommended.
• For stroke survivors with reduced strength in their arms or legs, progressive resistance training should be provided to improve strength.
   

“Rapid guideline updates as part of a living model are almost certain to have played a significant role by expediting local and state-wide system changes,” wrote the authors of the summary, led by Professor Coralie English, from the University of Newcastle.

“Importantly, living guidelines provide currency of advice. The experience with stroke as well as other guidelines demonstrates that the rigour of the methods does not need to be compromised when living modes are adopted.

“Our model of continual evidence surveillance and timely updates to recommendations is feasible, but sustainability remains a challenge. Now that we have started down this road, the message from guideline end users is that a return to the old model of static updates is no longer acceptable, and ongoing long term investment in living guidelines must be prioritised,” English and colleagues concluded.

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