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December 2008 KEY to EVIDENCE STATEMENTS and GRADES of RECOMMENDATIONS

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December 2008 KEY to EVIDENCE STATEMENTS and GRADES of RECOMMENDATIONS SIGN Scottish Intercollegiate Guidelines Network Management of patients with stroke or TIA: assessment, investigation, immediate 108 management and secondary prevention A national clinical guideline December 2008 KEY TO EVIDENCE STATEMENTS AND GRADES OF RECOMMENDATIONS LEVELS OF EVIDENCE 1++ High quality meta-analyses, systematic reviews of 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, eg case reports, case series 4 Expert opinion GRADES OF RECOMMENDATION 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 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. NHS Quality Improvement Scotland (NHS QIS) is committed to equality and diversity. This guideline has been assessed for its likely impact on the six equality groups defined by age, disability, gender, race, religion/belief, and sexual orientation. For the full equality and diversity impact assessment report please see the “published guidelines” section of the SIGN website at www.sign.ac.uk/guidelines/published/numlist.html. The full report in paper form and/or alternative format is available on request from the NHS QIS Equality and Diversity Officer. Every care is taken to ensure that this publication is correct in every detail at the time of publication. However, in the event of errors or omissions corrections will be published in the web version of this document, which is the definitive version at all times. This version can be found on our web site www. sign.ac.uk. This document is produced from elemental chlorine-free material and is sourced from sustainable forests Scottish Intercollegiate Guidelines Network Management of patients with stroke or TIA: assessment, investigation, immediate management and secondary prevention A national clinical guideline December 2008 MANAGEMENT OF PATIENTS WITH STROKE OR TIA: ASSESSMENT, INVESTIGATION, IMMEDIATE MANAGEMENT AND SECONDARY PREVENTION ISBN 978 1 905813 40 7 Published December 2008 SIGN consents to the photocopying of this guideline for the purpose of implementation in NHSScotland Scottish Intercollegiate Guidelines Network Elliott House, 8 -10 Hillside Crescent Edinburgh EH7 5EA www.sign.ac.uk CONTENTS Contents 1 Introduction........................................................................................................................ 1 1.1 The need for a guideline ...................................................................................................... 1 1.2 Remit of the guideline ......................................................................................................... 1 1.3 Definitions .......................................................................................................................... 2 1.4 Statement of intent .............................................................................................................. 3 2 Key recommendations ........................................................................................................ 4 2.1 Management of suspected stroke or TIA .............................................................................. 4 2.2 In-hospital care .................................................................................................................... 4 2.3 Assessment, diagnosis and investigation .............................................................................. 4 2.4 Treatment of ischaemic stroke ............................................................................................. 4 2.5 Preventing recurrent stroke in patients with ischaemic stroke or TIA .................................... 5 2.6 Carotid intervention ............................................................................................................ 5 2.7 Provision of information ...................................................................................................... 5 3 Management of suspected stroke or TIA ............................................................................. 6 3.1 Systems of care .................................................................................................................... 6 3.2 Pre-hospital ......................................................................................................................... 7 3.3 In-hospital ........................................................................................................................... 7 4 Assessment, diagnosis and investigation ............................................................................. 10 4.1 Clinical assessment.............................................................................................................. 10 4.2 Brain imaging for suspected acute stroke or TIA .................................................................. 11 4.3 Carotid evaluation ............................................................................................................... 12 4.4 Cardiac imaging .................................................................................................................. 14 4.5 Diagnostic tests ................................................................................................................... 15 5 Treatment of ischaemic stroke ............................................................................................ 16 5.1 Thrombolysis....................................................................................................................... 16 5.2 Antiplatelet agents ............................................................................................................... 17 5.3 Anticoagulants..................................................................................................................... 18 5.4 Neuroprotectants ................................................................................................................. 20 5.5 Reducing raised intracranial pressure .................................................................................. 20 5.6 Decompressive surgery ....................................................................................................... 21 5.7 Mechanical reperfusion ....................................................................................................... 22 5.8 Prior statin therapy .............................................................................................................. 23 6 Treatment of primary intracerebral haemorrhage .............................................................. 24 6.1 Haematoma evacuation ....................................................................................................... 24 6.2 Thrombolysis....................................................................................................................... 24 6.3 Haemostatic therapies ......................................................................................................... 25 6.4 Reducing raised Intracranial pressure .................................................................................. 25 7 Other causes of stroke ........................................................................................................ 26 7.1 Cerebral venous thrombosis ................................................................................................ 26 7.2 Extracranial cervical arterial dissection ..................................................................................... 26 8 Physiological monitoring and intervention ......................................................................... 28 8.1 Physiological monitoring ..................................................................................................... 28 8.2 Physiological intervention ................................................................................................... 28 CMONANATGEROLMEN OFT OF P PAIATINEN INTS AWDULITH STTSROKE WIT ORH CTIA:ANCER ASSESSMENT, INVESTIGATION, IMMEDIATE
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