Comparison of Some Management Principles of Three Major Guidelines for Stroke
Supplementary Table 1
Comparison of some management principles of three major guidelines for stroke
European Stroke Organisation [4] / American Stroke Association [5] / National Institute for Health and Clinical Excellence (UK) [6]Oxygenation and ventilation / Administer oxygen if oxygen saturations fall below 95%
Ventilation may be necessary in patients with severely compromised respiratory function / Supplemental oxygen should be used to maintain oxygen saturations >94%. Not recommended in non-hypoxic patients
Airway support and ventilator assistance recommended in AIS patients with decreased consciousness or bulbar dysfunction that compromises airway / Administer supplemental oxygen only if oxygen saturations <95%. Routine use not recommended in the non-hypoxic
No specific recommendations regarding intubation and MV
Temperature / If pyrexic (temperature >37.5° C) search for infection and treat with paracetamol and fanning
Antibiotic prophylaxis not recommended in immunocompetent / Identify and treat sources of hyperthermia (>38° C) with antipyretics / Maintain temperature <37.2° C
Fluid resuscitation / Normal saline recommended for fluid replacement in the first 24 hours / Hypovolemia: correct with intravenous normal saline / No specific recommendations
Glucose levels / Hypoglycemia: Treat if <50 mg/dL with intravenous dextrose or infusion of 10-20% glucose
Hyperglycemia: Treatment of serum glucose levels >180 mg/dL with insulin titration recommended / Hypoglycemia (blood glucose <60 mg/dL): treat to aim for normoglycemia
Hyperglycemia: treat to aim for blood glucose levels 140 – 180 mg/dL / Treat to maintain blood glucose 4 – 11 mmol/L (approx. 72 – 198 mg/dL)
Blood pressure (BP) / Routine BP lowering is not recommended
Cautious BP lowering in patients with BP > 220/120 mmHg, or with severe cardiac failure, aortic dissection, or hypertensive encephalopathy
Lower BP of ≥185/110 mmHg before thrombolysis and maintain <185/110 mmHg for 24 hours post-thrombolysis
Avoid abrupt BP lowering
Treat low BP with volume expanders / Eligible for thrombolysis or any other acute intervention for recanalizing occluded vessels, and hypertensive: BP should be lowered to <185/110 mmHg before commencing treatment and maintained <180/105 mmHg for at least the first 24 hours after
Not receiving fibrinolytic therapy and hypertensive: lower blood pressure by 15% in the first 24 hours. Withhold medications in this period unless the systolic BP >220 mmHg or diastolic BP >120 mmHg / Anti-hypertensive treatment only advised if hypertensive emergency AND suffering from hypertensive encephalopathy, hypertensive nephropathy, hypertensive cardiac failure/myocardial infarction, aortic dissection, (pre-)eclampsia, and/or intracerebral hemorrhage with systolic BP >200 mmHg
Consider BP reduction to ≤185/110 mmHg if eligible for thrombolysis
Anticoagulation and antiplatelet therapy / Aspirin (160-325 mg) loading dose should be given within 48 hours of AIS, but not within 24 hours of thrombolysis
Use of other antiplatelets (single or combined), glycoprotein IIb-IIIa inhibitors, and early administration of unfractionated heparin or LMWH are not recommended treatments for AIS
Low-dose subcutaneous heparin/LMWH should be considered for those at high risk of DVT or PE / Oral high-dose aspirin is recommended within 48 hours of AIS onset in those not undergoing thrombolysis where it should be withheld for at least 24 hours
Aspirin should not replace other acute interventions such as IV rt-PA
Role of clopidogrel and IV antiplatelets remains to be established
Utility of thrombin inhibitors not well-established, and should be used in clinical trials
Utility of urgent anticoagulation in patients with severe ipsilateral ICA stenosis is not well-established
Urgent anticoagulation is not recommended, and should not commence within 24 hours of IV rt-PA
Recommends subcutaneous anticoagulation administration in immobile patients to prevent DVT / High-dose aspirin recommended within 24 hours of AIS onset in those where primary ICH has been excluded through imaging
Proton pump inhibitors should be co-prescribed in those with a history of dyspepsia
In those allergic or “genuinely intolerant” of aspirin, an alternative antiplatelet should be given
Anticoagulant treatment should not be used routinely for AIS
Intracranial pressure (ICP) / No specific recommendations for ICP monitoring made
Surgical decompression within 48 h of symptom onset recommended if age ≤60 years with evolving MCA infarct
Osmotherapy can be used to treated raised ICP prior to surgery
Ventriculostomy or surgical decompression for large cerebellar infarcts compressing the brainstem / No specific recommendations for ICP monitoring made
Decompressive surgery for malignant edema of the cerebral hemisphere effective and potentially life saving
The usefulness of aggressive medical measures for deteriorating patients with malignant brain edema after large cerebral infarction is not well established
Decompressive surgical evacuation of space-occupying cerebellar infarction effective in preventing and treating herniation and brainstem compression
Placement of a ventricular drain useful in patients with acute hydrocephalus secondary to AIS / No specific recommendations for ICP monitoring made
Consider decompressive hemicraniectomy if MCA infarct referred within 24 h of symptom onset and treated within 48 h, and: age ≤60 years, clinical deficits suggestive of MCA territory infarction, NIHSS score >15, decrease in consciousness to give score of ≥1 on item 1a of NIHSS, and CT signs of infarct ≥50% MCA territory, +/- infarction to ipsilateral ACA/PCA territory, or infarct volume >145cm3 on diffusion-weighted MRI
ACA, anterior cerebral artery; AF, atrial fibrillation; AIS, acute ischemic stroke; BP, blood pressure; CT, computed tomography; DVT, deep vein thrombosis; ICA, internal carotid artery; ICH, intracerebral hemorrhage; INR, international normalized ratio; IV, intravenous; LMWH, low molecular weight heparin; MCA, middle cerebral artery; MRI, magnetic resonance imaging; MV, mechanical ventilation; NIHSS, National Institutes for Health Stroke Score; PCA, posterior cerebral artery; PE, pulmonary embolus; PFO, patent foramen ovale; rt-PA, recombinant tissue-Plasminogen Activator.