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The European Stroke Organization - ESO - Executive Committee and Writing Committee Guidelines for Management of Ischaemic Stroke 2008 MISSION OF ESO To reduce the incidence and burden of stroke by changing the way stroke is viewed and treated in Europe ESO Guidelines 2008 Content: Education, Referral and Emergency room Stroke Unit Imaging and Diagnostics Prevention General Treatment Acute Treatment Management of Complications Rehabilitation ESO Writing Committee Chair: Werner Hacke, Heidelberg, Germany Co-Chairs: Marie-Germaine Bousser, Paris, France Gary Ford, Newcastle, UK ESO Writing Committee Education, Referral and Emergency room Co-Chairs: Michael Brainin, Krems, Austria; Jos Ferro, Lisbon, Portugal Members: Charlotte Cordonnier, Lille, France; Heinrich P. Mattle, Bern, Switzerland; Keith Muir, Glasgow, UK; Peter D. Schellinger, Erlangen, Germany Stroke Units Co-Chairs: Hans-Christoph Diener, Essen, Germany; Peter Langhorne, Glasgow, UK Members: Antony Davalos, Barcelona, Spain; Gary Ford, Newcastle, UK; Veronika Skvortsova, Moscow, Russia ESO Writing Committee Imaging and Diagnostics Co-Chairs: Michael Hennerici, Mannheim, Germany; Markku Kaste, Helsinki, Finland Members: Hugh S. Markus, London, UK; E. Bernd Ringelstein, Mnster, Germany; Rdiger von Kummer, Dresden, Germany; Joanna Wardlaw, Edinburgh, UK Prevention Co-Chairs: Phil Bath, Nottingham, UK; Didier Leys, Lille, France Members: lvaro Cervera, Barcelona, Spain; Lszl Csiba, Debrecen, Hungary; Jan Lodder, Maastricht, The Netherlands; Nils Gunnar Wahlgren, Stockholm ESO Writing Committee General Treatment Co-Chairs: Christoph Diener, Essen, Germany; Peter Langhorne, Glasgow, UK Members: Antony Davalos, Barcelona, Spain; Gary Ford, Newcastle, UK; Veronika Skvortsova, Moscow, Russia Acute Treatment and Treatment of Complications Co-Chairs: Angel Chamorro, Barcelona, Spain; Bo Norrving, Lund, Sweden Members: Valerica Caso, Perugia, Italy; Jean-Louis Mas, Paris, France; Victor Obach, Barcelona, Spain; Peter A. Ringleb, Heidelberg, Germany; Lars Thomassen, Bergen, Norway ESO Writing Committee Rehabilitation Co-Chairs: Kennedy Lees, Glasgow, UK; Danilo Toni, Rome, Italy Members: Stefano Paolucci, Rome, Italy; Juhani Sivenius, Kuopio, Finland; Katharina Stibrant Sunnerhagen, Gteborg, Sweden; Marion F. Walker, Nottingham, UK; Substantial assistance: Yvonne Teuschl, Isabel Henriques, Terence Quinn Definitions of Levels of Evidence Level AEstablished as useful/predictive or not useful/predictive for a diagnostic measure or established as effective, ineffective or harmful for a therapeutic intervention; requires at least one convincing Class I study or at least two consistent, convincing Class II studies. Level BEstablished as useful/predictive or not useful/predictive for a diagnostic measure or established as effective, ineffective or harmful for a therapeutic intervention; requires at least one convincing Class II study or overwhelming Class III evidence. Level CEstablished as useful/predictive or not useful/predictive for a diagnostic measure or established as effective, ineffective or harmful for a therapeutic intervention; requires at least two Class III studies. Good Clinical Practice (GCP) Recommended best practice based on the experience of the guideline development group. Usually based on Class IV evidence indicating large clinical uncertainty, such GCP points can be useful for health workers. Classification of Evidence Evidence classification scheme for a therapeutic intervention Class IAn adequately powered, prospective, randomized, controlled clinical trial with masked outcome assessment in a representative population or an adequately powered systematic review of prospective randomized controlled clinical trials with masked outcome assessment in representative populations. Class IIProspective matched-group cohort study in a representative population with masked outcome assessment or a randomized, controlled trial in a representative population that lacks one criterion for class I evidence. Class IIIAll other controlled trials (including well-defined natural history controls or patients serving as own controls) in a representative population, where outcome assessment is independent of patient treatment. Class IVEvidence from uncontrolled studies, case series, case reports, or expert opinion. Classification of Evidence Evidence classification scheme for a diagnostic measure Class IA prospective study in a broad spectrum of persons with the suspected condition, using a gold standard for case definition, where the test is applied in a blinded evaluation, and enabling the assessment of appropriate tests of diagnostic accuracy. Class IIA prospective study of a narrow spectrum of persons with the suspected condition, or a well-designed retrospective study of a broad spectrum of persons with an established condition (by gold standard) compared to a broad spectrum of controls, where test is applied in a blinded evaluation, and enabling the assessment of appropriate tests of diagnostic accuracy. Class IIIEvidence provided by a retrospective study where either persons with the established condition or controls are of a narrow spectrum, and where test is applied in a blinded evaluation. Class IVEvidence from uncontrolled studies, case series, case reports, or expert opinion. ESO Guidelines 2008 Content: Education, Referral and Emergency room Stroke Unit Imaging and Diagnostics Prevention General Treatment Acute Treatment Management of Complications Rehabilitation Education, Referral, Emergency management Stroke as an Emergency Background Stroke is the most important cause of morbidity and long term disability in Europe1 Demographic changes are likely to result in an increase in both incidence and prevalence Stroke is also the second most common cause of dementia, the most frequent cause of epilepsy in the elderly, and a frequent cause of depression2,3 1: Lopez AD et al. Lancet (2006) 367:1747-1757 2: Rothwell PM et al. Lancet (2005) 366:1773-1783 3: OBrien JT et al. Lancet Neurol (2003) 2:89-98 Education, Referral, Emergency management Stroke as an Emergency Background Stroke is a medical and occasionally a surgical emergency The majority of ischaemic stroke patients do not reach the hospital quickly enough The delay between stroke onset and hospital admission is; reduced if the Emergency Medical Systems (EMS) are used increased if doctors outside the hospital are consulted first Education, Referral, Emergency management Stroke as an Emergency Emergency care in acute stroke depends on a four-step chain: Rapid recognition of, and reaction to, stroke signs and symptoms Immediate EMS contact and priority EMS dispatch Priority transport with notification of the receiving hospital Immediate emergency room triage, clinical, laboratory and imaging evaluation, accurate diagnosis, and administration of appropriate treatments at the receiving hospital. Education, Referral, Emergency management Stroke as an Emergency Delays during acute stroke management have been identified at three different levels1 at the population level, due to failure to recognize the symptoms of stroke and contact emergency services at the level of the emergency services and emergency physicians, due to a failure to prioritize transport of stroke patients at the hospital level, due to delays in neuroimaging and inefficient in-hospital care 1:Kwan J et al. Age Ageing (2004) 33:116-121 Education, Referral, Emergency management Education Recommendations Educational programmes to increase awareness of stroke at the population level are recommended (Class II, Level B) Educational programmes to increase stroke awareness among professionals (paramedics, emergency physicians) are recommended (Class II, Level B) Education, Referral, Emergency management Referral Recommendations (1/2) Immediate EMS contact and priority EMS dispatch are recommended (Class II, Level B) Priority transport with advance notification of the receiving hospital is recommended (Class III, Level B) Suspected stroke victims should be transported without delay to the nearest medical centre with a stroke unit that can provide ultra-early treatment (Class III, Level B) Patients with suspected TIA should be referred without delay to a TIA clinic or a stroke unit (Class III, Level B) Education, Referral, Emergency management Referral Recommendations (2/2) Dispatchers and ambulance personnel should be trained to recognise stroke using simple instruments such as the Face-Arm-Speech-Test (Class IV, GCP) Immediate emergency room triage, clinical, laboratory and imaging evaluation, accurate diagnosis, therapeutic decision and administration of appropriate treatments are recommended (Class III, Level B) In remote or rural areas helicopter transfer and telemedicine should be considered to improve access to treatment (Class III, Level C) Education, Referral, Emergency management Emergency Management The time window for treatment of patients with acute stroke is narrow Acute emergency management of stroke requires parallel processes operating at different levels of patient management Acute assessment of neurological and vital functions parallels the treatment of acutely life-threatening conditions Time is the most important factor Education, Referral, Emergency management Emergency Management The initial examination should include Observation of breathing and pulmonary function and concomitant heart disease Assessment of blood pressure and heart rate Determination of arterial oxygen saturation Blood samples for clinical chemistry, coagulation and haematology studies Observation of early signs of dysphagia Targeted neurological examination Careful medical history focussing on risk factors for arteriosclerosis and cardiac disease Diagnostics Ancillary Diagnostic Tests In all patients Brain Imaging: CT or MRI ECG Laboratory Tests Complete blood count and platelet count, prothrombin time or INR, PTT Serum electrolytes, blood glucose CRP or sedimentation rate Hepatic and renal chemical analysis Diagnostics Ancillary Diagnostic Tests In selected patients Duplex / Doppler ultrasound MRA or CTA Diffusion and perfusion MR or perfusion CT Echocardiography, Chest X-ray Pulse oximetry and arterial blood gas analysis Lumbar puncture EEG Toxicology screen Education, Referral, Emergency management Emergency Management Recommendations Organization of pre-hospital and in-hospital pathways and systems for acute stroke patients is recommended (Class III, Level C) All patients should receive brain imaging, ECG, and laboratory tests. Additional diagnostic examinations are necessary in selected patients (Class IV, GCP) ESO Guidelines 2008 Content: Education, Referral and Emergency room Stroke Unit Imaging and Diagnostics Prevention General Treatment Acute Treatment Management of Complications Rehabilitation Education, Referral, Emergency management Stroke Unit A stroke unit Is a dedicated and geographically defined part of a hospital that takes care of stroke patients Has specialised staff with coordinated multidisciplinary expert approach to treatment and care Comprises core disciplines: medical, nursing, physiotherapy, occupational therapy, speech and language therapy, social work 1 1:Langhorne P et al. Age Ageing (2002) 31:365-371 Education, Referral, Emergency management Stroke Unit Typical components of stroke units include Assessment Medical assessment and diagnosis, early assessment of nursing and therapy needs Early management policies Early mobilisation, prevention of complications, treatment of hypoxia, hyperglycaemia, pyrexia and dehydration Ongoing rehabilitation policies Coordinated multidisciplinary team care Early assessments of needs after discharge Education, Referral, Emergency management Stroke Unit Treatment at a stroke unit compared to treatment in a general ward1 reduces mortality (absolute risk reduction of 3%) reduces dependency (5%) reduces need for institutional care (2%) All types of patients, irrespective of gender, age, stroke subtype and stroke severity, appear to benefit from treatment in stroke units1 1:Stroke Unit Trialists Collaboration Cochrane Rev (2007) Education, Referral, Emergency management Stroke Services and Stroke Units Recommendations All stroke patients should be treated in a stroke unit (Class I, Level A) Healthcare systems must ensure that acute stroke patients can access high technology medical and surgical stroke care when required (Class III, Level B) The development of clinical networks, including telemedicine, is recommended to expand the access to high technology specialist stroke care (Class II, Level B) ESO Guidelines 2008 Content: Education, Referral and Emergency room Stroke Unit Imaging and Diagnostics Prevention General Treatment Acute Treatment Management of Complications Rehabilitation Diagnostics Emergency Diagnostic Tests Differentiate between different types of stroke Assess the underlying cause of brain ischaemia Assess prognosis Provide a basis for physiological monitoring of the stroke patient Identify concurrent diseases or complications associated with stroke Rule out other brain diseases Diagnostics Emergency Diagnostic Tests Cranial Computed Tomography (CT) Immediate plain CT scanning distinguishes reliably between haemorrhagic and ischaemic stroke Detects signs of ischaemia as early as 2 h after stroke onset1 Helps to identify other neurological diseases (e.g. neoplasms) Most cost-effective strategy for imaging acute stroke patients2 1: von Kummer R et al. Radiology (2001) 219:95-100 2: Wardlaw J et al. Stroke (2004) 35:2477-2483 Diagnostics Emergency Diagnostic Tests Magnetic Resonance Imaging (MRI) Diffusion-weighted MRI (DWI) is more sensitive for detection of early ischaemic changes than CT DWI can be negative in patients with definite stroke1 Identifies ischaemic lesions in the posterior fossa reliably Detects even small intracerebral haemorrhages reliably on T2* sequences MRI is particularly important in acute stroke patients with unusual presentations 1: Ay H et al. Cerebrovasc Dis (2002) 14:177-186 Diagnostics Emergency Diagnostic Tests Mismatch Concept Mismatch between tissue abnormal on DWI and tissue with reduced perfusion may reflect tissue at risk of further ischaemic damage1 There is disagreement on how to best identify irreversible ischaemic brain injury and to define critically impaired blood flow2 There is no clear evidence that patients with particular perfusion patterns are more or less likely to benefit from thrombolysis3 1: Jansen O et al. Lancet (1999) 353:2036-2037 2: Kane I et al. Stroke (2007) 38:3158-3164 3: Albers GW et al. Ann Neurol (2006) 60:508-517 Diagnostics Emergency Diagnostic Tests Ultrasound studies Cerebrovascular ultrasound is fast and non-invasive and can be administered using portable machines. It is therefore applicable to patients unable to co- operate with MRA or CTA1 Combinations of ultrasound imaging techniques and MRA can produce excellent results that are equal to Digital subtraction angiography (DSA)2 1: Allendrfer J et al. Lancet Neurology (2005) 5:835-840 2: Nederkoorn P et al. Stroke (2003) 34:1324-1332 Diagnostics Emergency Diagnostic Tests Imaging in TIA-patients Up to 10% recurrence risk in the first 48 hours1 Simple clinical scoring systems can be used to identify patients at particularly high risk1 Up to 50% of patients with TIAs have acute ischaemic lesions on DWI. These patients are at increased risk of early recurrent disabling stroke2 There is currently no evidence that DWI provides better stroke prediction than clinical risk scores3 1: Rothwell P et al. Lancet Neurol (2005) 5:323-331 2: Coutts S et al. Ann Neurol (2005) 57:848-854 3: Redgrave J et al. Stroke (2007) 38:1482-1488 Diagnostics Emergency Diagnostic Tests Electrocardiogram (ECG) Cardiac abnormalities are common in acute stroke patients1 Arrhythmias may induce stroke, stroke may cause arrhythmias Holter monitoring is superior to routine ECG for the detection of atrial fibrillation (AF)2 It is unclear whether continuous ECG recording at the bedside is equivalent to Holter monitoring for the detection of AF 1: Christensen H et al. Neurol Sci (2005) 234:99 103 2: Gunalp M et al. Adv Ther (2006) 23:854-60 Diagnostics Emergency Diagnostic Tests Echocardiography (TTE / TOE) Echocardiography can detect many potential causes of stroke1 It is particularly required in patients with history of cardiac disease, ECG pathologies, suspected source of embolism, suspected aortic disease, suspected paradoxical embolism Transoesophageal echocardiography (TOE) might be superior to transthoracic echocardiography (TTE) for the detection of potential cardiac sources of embolism2 1: Lerakis S et al. Am J Med Sci (2005) 329:310-6 2: de Bruijn SF et al. Stroke (2006) 37:2531-4 Diagnostics Emergency Diagnostic Tests Laboratory tests Haematology (RBC, WBC, platelet count) Basic clotting parameters Electrolytes Renal and hepatic chemistry Blood Glucose CRP, sedimentation rate Education, Referral, Emergency management Diagnostic Imaging Recommendations In patients with suspected TIA or stroke, urgent cranial CT (Class I), or alternatively MRI (Class II), is recommended (Level A) If MRI is used, the inclusion of diffusion weighted imaging (DWI) and T2*-weighted gradient echo sequences is recommended (Class II, Level A) In patients with TIA, minor stroke, or early spontaneous recovery immediate diagnostic work-up, including urgent vascular imaging (ultrasound, CT-angiography, or MR angiography) is recommended (Class I, Level A) Diagnostics Other Diagno