scholarly journals Etiologic Workup in Cases of Cryptogenic Stroke

Stroke ◽  
2020 ◽  
Vol 51 (5) ◽  
pp. 1419-1427 ◽  
Author(s):  
Naoimh E. McMahon ◽  
Munirah Bangee ◽  
Valerio Benedetto ◽  
Emma P. Bray ◽  
Rachel F. Georgiou ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Clinical Practice ◽  
Secondary Prevention ◽  
Acute Ischemic Stroke ◽  
Clinical Practice Guidelines ◽  
Practice Guidelines ◽  
Cryptogenic Stroke ◽  
Unique Identifier ◽  
Missed Opportunities ◽  
Consensus Statements

Background and Purpose— Identifying the etiology of acute ischemic stroke is essential for effective secondary prevention. However, in at least one third of ischemic strokes, existing investigative protocols fail to determine the underlying cause. Establishing etiology is complicated by variation in clinical practice, often reflecting preferences of treating clinicians and variable availability of investigative techniques. In this review, we systematically assess the extent to which there exists consensus, disagreement, and gaps in clinical practice recommendations on etiologic workup in acute ischemic stroke. Methods— We identified clinical practice guidelines/consensus statements through searches of 4 electronic databases and hand-searching of websites/reference lists. Two reviewers independently assessed reports for eligibility. We extracted data on report characteristics and recommendations relating to etiologic workup in acute ischemic stroke and in cases of cryptogenic stroke. Quality was assessed using the AGREE II tool (Appraisal of Guidelines for Research & Evaluation). Recommendations were synthesized according to a published algorithm for diagnostic evaluation in cryptogenic stroke. Results— We retrieved 16 clinical practice guidelines and 7 consensus statements addressing acute stroke management (n=12), atrial fibrillation (n=5), imaging (n=5), and secondary prevention (n=1). Five reports were of overall high quality. For all patients, guidelines recommended routine brain imaging, noninvasive vascular imaging, a 12-lead ECG, and routine blood tests/laboratory investigations. Additionally, ECG monitoring (>24 hours) was recommended for patients with suspected embolic stroke and echocardiography for patients with suspected cardiac source. Three reports recommended investigations for rarer causes of stroke. None of the reports provided guidance on the extent of investigation needed before classifying a stroke as cryptogenic. Conclusions— While consensus exists surrounding standard etiologic workup, there is little agreement on more advanced investigations for rarer causes of acute ischemic stroke. This gap in guidance, and in the underpinning evidence, demonstrates missed opportunities to better understand and protect against ongoing stroke risk. Registration— URL: https://www.crd.york.ac.uk/PROSPERO/ ; Unique identifier: CRD42019127822.

scholarly journals Update of the Korean Clinical Practice Guidelines for Endovascular Recanalization Therapy in Patients with Acute Ischemic Stroke

2016 ◽  
Vol 18 (1) ◽  
pp. 102-113 ◽  
Author(s):  
Keun-Sik Hong ◽  
Sang-Bae Ko ◽  
Kyung-Ho Yu ◽  
Cheolkyu Jung ◽  
Sukh Que Park ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Clinical Practice ◽  
Acute Ischemic Stroke ◽  
Clinical Practice Guidelines ◽  
Practice Guidelines ◽  
Endovascular Recanalization

scholarly journals 2019 Update of the Korean Clinical Practice Guidelines of Stroke for Endovascular Recanalization Therapy in Patients with Acute Ischemic Stroke

2020 ◽  
Vol 38 (2) ◽  
pp. 77-87 ◽  
Author(s):  
Sang-Bae Ko ◽  
Hong-Kyun Park ◽  
Byung Moon Kim ◽  
Ji Hoe Heo ◽  
Joung-Ho Rha ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Clinical Practice ◽  
Acute Ischemic Stroke ◽  
Clinical Practice Guidelines ◽  
Practice Guidelines ◽  
Randomized Clinical Trials ◽  
Time Window ◽  
Late Time ◽  
Large Artery ◽  
Endovascular Recanalization

Endovascular recanalization therapy (ERT) has been a standard of care for patients with acute ischemic stroke due to large artery occlusion (LAO) within 6 hours after onset since the five landmark ERT trials up to 2015 demonstrated its clinical benefit. Recently, two randomized clinical trials demonstrated that ERT, even in the late time window up to 16 hours or 24 hours after last known normal time, improved the outcome of patients who had a target mismatch defined as either clinical-core mismatch or perfusion-core mismatch, which prompted the update of national guidelines in several countries. Accordingly, to provide evidence-based and up-to-date recommendations for ERT in patients with acute LAO in Korea, the Clinical Practice Guidelines Committee of the Korean Stroke Society decided to revise the previous Korean Clinical Practice Guidelines of Stroke for ERT. For this update, the members of the writing group were appointed by the Korean Stroke Society and the Korean Society of Interventional Neuroradiology. After thorough reviewing the updated evidence from two recent trials and relevant literature, the writing members revised recommendations, for which formal consensus was achieved by convening an expert panel composed of 45 experts from the participating academic societies. The current guidelines are intended to help healthcare providers, patients, and their caregivers make their well-informed decisions and to improve the quality of care regarding ERT. The ultimate decision for ERT in a particular patient must be made in light of circumstances specific to that patient.

scholarly journals Management of Hepatocellular Carcinoma in Japan: JSH Consensus Statements and Recommendations 2021 Update

Liver Cancer ◽  
2021 ◽  
pp. 1-43
Author(s):  
Masatoshi Kudo ◽  
Yusuke Kawamura ◽  
Kiyoshi Hasegawa ◽  
Ryosuke Tateishi ◽  
Kazuya Kariyama ◽  
...  
Keyword(s):  
Hepatocellular Carcinoma ◽  
Clinical Practice ◽  
Public Relations ◽  
Clinical Practice Guidelines ◽  
Practice Guidelines ◽  
Expert Panel ◽  
Clinical Practices ◽  
Fourth Edition ◽  
Level Of Evidence ◽  
Consensus Statements

The Clinical Practice Manual for Hepatocellular Carcinoma was published based on evidence confirmed by the Evidence-based Clinical Practice Guidelines for Hepatocellular Carcinoma along with consensus opinion among a Japan Society of Hepatology (JSH) expert panel on hepatocellular carcinoma (HCC). Since the JSH Clinical Practice Guidelines are based on original articles with extremely high levels of evidence, expert opinions on HCC management in clinical practice or consensus on newly developed treatments are not included. However, the practice manual incorporates the literature based on clinical data, expert opinion, and real-world clinical practice currently conducted in Japan to facilitate its use by clinicians. Alongside each revision of the JSH Guidelines, we issued an update to the manual, with the first edition of the manual published in 2007, the second edition in 2010, the third edition in 2015, and the fourth edition in 2020, which includes the 2017 edition of the JSH Guideline. This article is an excerpt from the fourth edition of the HCC Clinical Practice Manual focusing on pathology, diagnosis, and treatment of HCC. It is designed as a practical manual different from the latest version of the JSH Clinical Practice Guidelines. This practice manual was written by an expert panel from the JSH, with emphasis on the consensus statements and recommendations for the management of HCC proposed by the JSH expert panel. In this article, we included newly developed clinical practices that are relatively common among Japanese experts in this field, although all of their statements are not associated with a high level of evidence, but these practices are likely to be incorporated into guidelines in the future. To write this article, coauthors from different institutions drafted the content and then critically reviewed each other’s work. The revised content was then critically reviewed by the Board of Directors and the Planning and Public Relations Committee of JSH before publication to confirm the consensus statements and recommendations. The consensus statements and recommendations presented in this report represent measures actually being conducted at the highest-level HCC treatment centers in Japan. We hope this article provides insight into the actual situation of HCC practice in Japan, thereby affecting the global practice pattern in the management of HCC.

scholarly journals Clinical Practice Guidelines and Consensus Statements in Oncology – An Assessment of Their Methodological Quality

PLoS ONE ◽  
2014 ◽  
Vol 9 (10) ◽  
pp. e110469 ◽  
Author(s):  
Carmel Jacobs ◽  
Ian D. Graham ◽  
Julie Makarski ◽  
Michaël Chassé ◽  
Dean Fergusson ◽  
...  
Keyword(s):  
Clinical Practice ◽  
Clinical Practice Guidelines ◽  
Practice Guidelines ◽  
Methodological Quality ◽  
Consensus Statements

Abstract TP372: Outcomes of the Extended Ischemic Stroke Treatment Window

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Michele J Patterson ◽  
Tracy Moore ◽  
Paula Cline ◽  
Lee Birnbaum
Keyword(s):  
Ischemic Stroke ◽  
Clinical Practice ◽  
Clinical Practice Guidelines ◽  
Practice Guidelines ◽  
Community Education ◽  
Stroke Severity ◽  
Complication Rates ◽  
Stroke Treatment ◽  
Stroke Disability ◽  
Treatment Window

Background: After clinical practice guidelines extended the mechanical endovascular reperfusion [MER] window, our Comprehensive Stroke Program expanded its stroke alert [SA] to include last known well [LKW] 6-24 hours [h]. Expansion included implementation of a standardized large vessel screen, RAPID brain imaging software, revised algorithm, EMS and community education, and regional transfer guidelines. Purpose: Evaluate outcomes of the extended window [EW] for ischemic stroke treatment. Method: We reviewed ischemic strokes over a 2 year period and categorized them into two groups: 2017 pre-guideline [PG] and 2018 EW post-guideline [PostG]. Each group was divided into all-MERs and MERs 6-24h. Groups were compared by LKW, NIHSS, TICI scores, complications, discharge [DC] disposition and Modified Rankin Score [mRS] at DC and 90 days [90d]. Outcomes were evaluated to identify the EW impact. Results: Of 744 strokes reviewed, 365 were PG and 379 were EW PostG. LKW 6-24h was greater PostG [22%=PG versus [v] 30%=EW], in all-MERs [19%=PG v 31%=EW] and MERs 6-24h [69%=PG v 83%=EW]. Stroke severity [NIHSS>7] was higher PostG [41%=PG v 45%=EW], in all-MERs [88%=PG v 91%=EW] and MERs 6-24h [85%=PG v 96%=EW]. MER treatment rates increased PostG [13%=PG v 17%=EW]. Post-MER TICI 2b/3 reperfusion rates were higher PostG in all-MERs [63%=PG v 77%=EW] and MERs 6-24h [38%=PG v 71%=EW]. Any complication was lower PostG [27%=PG v 22%=EW] with higher complication rates in MERs 6-24h [15%=PG v 17%=EW]. More patients were DC home PostG [42%=PG v 46%=EW], in all-MERs [25%=PG v 30%=EW], and MERs 6-24h [8%=PG v 29%=EW]. mRS 0-2 at DC was increased PostG [20%=PG v 29%=EW], in all-MERs [12%=PG v 27%=EW], and MERs 6-24h [8%=PG v 34%=EW]. mRS at 90d was increased PostG for all-MERs [25%=PG v 34%=EW] with decreased deaths [15%=PG v 10%=EW]. Conclusion: The EW has increased patients treated and improved overall outcomes. Patients arriving with LKW 6-24h has increased along with stroke severity. Reperfusion rates improved and overall complications were lower, however higher rates were seen in MERs 6-24h. Patients treated in the EW had reductions in post stroke disability, increases in DC to home, and improvements in mRS at DC and 90d.

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