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Chinese Stroke Association Guidelines for Clinical Management

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Chinese Stroke Association Guidelines for Clinical Management Open access Guidelines Chinese Stroke Association guidelines Stroke Vasc Neurol: first published as 10.1136/svn-2020-000355 on 8 July 2020. Downloaded from for clinical management of cerebrovascular disorders: executive summary and 2019 update on organizational stroke management Min Lou ,1 Jing Ding,2 Bo Hu ,3 Yusheng Zhang,4 Hao Li ,5 ZeFeng Tan,4 Yan Wan,3 An- Ding Xu ,4 Chinese Stroke Association Stroke Council Guideline Writing Committee To cite: Lou M, Ding J, ABSTRACT China to elaborate the clinical comprehen- Hu B, et al. Chinese Stroke Aim Stroke is characterised by high morbidity, mortality sive management of the diagnosis, treatment, Association guidelines for and disability, which seriously affects the health and clinical management of prevention and rehabilitation of a series of safety of the people. Stroke has become a serious cerebrovascular disorders: stroke-related diseases, so as to help medical executive summary and 2019 public health problem in China. Organisational stroke service providers make better clinical deci- update on organizational stroke management can significantly reduce the mortality sions, improve the quality of medical services and disability rates of patients with stroke. We provide management. Stroke & Vascular and maximise the benefits of patients. Neurology 2020;0. doi:10.1136/ this evidence- based guideline to present current and svn-2020-000355 comprehensive recommendations for organisational Evidence- based medical evidence confirms stroke management. that the organisational stroke management Received 20 February 2020 Methods A formal literature search of MEDLINE model can benefit all patients with stroke, Revised 26 April 2020 and significantly improve the survival rate Accepted 3 May 2020 (1 January 1997 through 30 September 2019) was performed. Data were synthesised with the use of evidence and independent living ability of patients tables. Writing group members met by teleconference with stroke.1 Stroke organisational manage- to discuss data-derived recommendations. The Chinese ment covers prehospital first aid system of Stroke Association’s Levels of Evidence grading algorithm stroke, rapid diagnosis and treatment of was used to grade each recommendation. emergency in stroke centre, organisational http://svn.bmj.com/ Results Evidence-based guidelines are presented for the management of stroke unit and stroke © Author(s) (or their organisational management of patients presenting with clinic, construction of regional collaborative stroke. The focus of the guideline was subdivided into employer(s)) 2020. Re- use network among stroke centres at all levels permitted under CC BY- NC. No prehospital first aid system of stroke, rapid diagnosis and and evaluation and continuous improve- commercial re- use. See rights treatment of emergency in stroke centre, organisational and permissions. Published by management of stroke unit and stroke clinic, construction ment of stroke medical quality related to BMJ. the above- mentioned links. This chapter will 1 of regional collaborative network among stroke centres and on October 2, 2021 by guest. Protected copyright. Department of Neurology, The evaluation and continuous improvement of stroke medical elaborate on the above- mentioned content. Second Affilliated Hospital of quality. Zhejiang University, School of Medicine, Hangzhou, China Conclusions The guidelines offer an organisational stroke 2Department of Neurology, management model for patients with stroke which might Zhongshan Hospital Fudan help dramatically. RECOMMENDED CLASSIFIcatION AND EVIDENCE University, Shanghai, China LEVEL OF THE GUIDELINE 3 Department of Neurology, Stroke has become a serious global public This guideline adopts the recommended clas- Union Hospital, Tongji Medical College, Huazhong University of health problem. To further reduce incidence sification and evidence level specified in the Science and Technology, Wuhan, rate, disability rate, mortality rate and recur- guidelines for the development of Stroke Society of China rence rate of stroke and improve China's China. This recommended classification and 4 Department of Neurology and standardised prevention and treatment of evidence level are consistent with the system Stroke Center, The First Affiliated cerebrovascular diseases, the Chinese Stroke Hospital, Jinan University, adopted in the latest American Heart Associa- Guangzhou, China Association organised a domestic expert to tion and American Stroke Association (AHA/ 5Beijing Tiantan Hospital, Capital write the Chinese Stroke Association Guide- ASA) guidelines. Medical University, Beijing, lines for Clinical Management of Cere- 1. Recommended classification China brovascular Disorders. The guideline fully – Class I: there is evidence to prove or Correspondence to combines the research of Chinese scholars unanimously agree that the operation Dr An- Ding Xu; tlil@ jnu. edu. cn and the widely used clinical interventions in or treatment given is effective. Lou M, et al. Stroke & Vascular Neurology 2020;0. doi:10.1136/svn-2020-000355 1 Open access – Class II: there are controversial evidences or opin- RECOMMENDATIONS Stroke Vasc Neurol: first published as 10.1136/svn-2020-000355 on 8 July 2020. Downloaded from ions on the effectiveness of operation or treatment. Organisational management of prehospital emergency system – IIa: some evidences or opinions support the va- Rapid identification of stroke before hospital lidity. ► Emergency personnel use standardised tools such as – IIb: there is no good evidence for its effective- stroke 120, Cincinnati Prehospital Stroke Scale, Los ness. Angeles Prehospital Stroke Scale or face arm speech – Class III: operation and treatment are ineffective test (FAST) scale to screen patients with stroke before and harmful in some cases. hospital, so that patients with stroke can be quickly 2. Level of evidence identified. (Class I, level of evidence B) – Level of evidence A: evidence comes from multi- ► Emergency personnel used Rapid Arterial Occlusion ple randomised controlled trials (RCTs) or meta- Evaluation, Los Angeles Motor Scale, Field Assessment analysis. References must be provided and quoted Stroke Triage for Emergency Destination (FAST-ED) in the recommendations. or Prehospital Acute Stroke Severity Scale to screen – Level of evidence B: evidence comes from a single patients with stroke for large vessel occlusion before RCT or non- randomised trial. References must be hospital. (Class II, level of evidence B) provided and quoted in the recommendations. Dispatch of emergency medical service personnel and onsite – Level of evidence C: evidence only comes from ex- diagnosis and treatment perts’ opinions, case studies, etc. ► Emergency medical service (EMS) dispatchers should use prehospital identification and screening tools to CHAPTER 1: ORGANISatIONAL MANAGEMENT OF PREHOSPItaL quickly identify suspected patients with stroke, and EMERGENCY SYSTEM priority should be given to ambulances and EMS personnel. (Class I, level of evidence B) ‘Time is brain’. The effect of stroke treatment is strongly ► EMS personnel should make brief assessment and time dependent. Prehospital emergency management is necessary emergency treatment as soon as possible one of the key links in the life chain of stroke first aid, for suspected patients with stroke, including deter- which plays a decisive role in the treatment and prog- mining the onset time, dealing with respiratory and nosis of patients with stroke. Intravenous thrombolytic circulatory problems, conducting ECG examination therapy with recombinant tissue-type plasminogen acti- and vital signs monitoring, establishing intravenous vator (rt- PA) is one of the most effective treatments channels and avoiding delays in transportation due for acute ischaemic stroke (AIS). It is recommended to prehospital intervention. (Class I, level of evidence by domestic and foreign guidelines,2 3 but restricted B) by strict time window (within 4.5 hours from onset).4 According to China National Stroke Registry, only 2514 Rapid transportation to hospitals with stroke treatment capacity http://svn.bmj.com/ (21.5%) of 11 675 patients with AIS arrived in the emer- ► In order to achieve the purpose of rapid and efficient gency room within 3 hours from onset, and only 284 transportation, EMS personnel should formulate a 5 (2.4%) received intravenous thrombolysis. In addition, reasonable transportation plan based on the patient's the China Quality Evaluation of Stroke Care and Treat- condition and the ability of referral hospital to treat ment (China QUEST) study showed that onset-to- door stroke, while following the principle of proximity. time of 6102 patients with stroke averaged 15 hours (Class I, level of evidence A) on October 2, 2021 by guest. Protected copyright. (ranging from 2.8 to 51.0 hours), of which 1546 cases ► For suspected patients with AIS who may need intra- (25.3%) and 2244 cases (36.8%) were within 3 hours and venous thrombolysis within the onset time window, 6 hours, respectively, and exceeding 24 hours as high as EMS personnel should transfer them to the nearest 41.3%. In the end, only 1.9% of patients received intra- qualified primary stroke centres (PSC)/comprehen- 6 venous thrombolysis. As showed, prehospital delays are sive stroke centres (CSC) in the shortest time. (Class common in patients with stroke in China, which is an I, level of evidence A) important reason for the low thrombolytic therapy rate ► Patients suspected of large vessel occlusion (LVO)- and poor clinical prognosis
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