Living guidelines keep Australian stroke management ahead of the world

Stroke

By Michael Woodhead

17 May 2022

Australia is leading the world with living guidelines for stroke that provide timely and sustainable recommendations in areas such as acute medical and surgical management, secondary prevention and rehabilitation, according to local experts.

Unlike traditional guidelines that may become outdated with a renewal cycle of five to seven years, living guidelines are continually updated to reflect the latest and best evidence, the developers of Australia’s guidelines write in the MJA this week.

Since they were launched in 2017, over 30 new and updated recommendations have been made including five new strong recommendations, according to authors Professor Coralie English of Newcastle University and Professor Bruce Campbell of the Melbourne Brain Centre at the Royal Melbourne Hospital.

But importantly, there have been no major downgrades  for any recommendation or cases of recommendation being changed multiple times.

“Important new recommendations have been made regarding lifesaving therapy such as extension of the time window for endovascular clot retrieval and the administration of alteplase for thrombolysis,” they note of the guidelines.

“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,” they said.

“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,” they concluded.

Developed by the Stroke Foundation and Cochrane Australia the 2018 recommendations became the first Australian living clinical guidelines and are the first and only living stroke guidelines worldwide.

According to the MJA article, the living guidelines have adopted five new strong recommendations in recent times:

  • 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 nine 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.

The latest updated guidelines are available in full at the Stroke Foundation.

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