Canadian Stroke Best Practice Recommendations for Acute Stroke Management: Prehospital, Emergency Department, and Acute Inpatient Stroke Care, 6th Edition, Update 2018

The 2018 update of the Canadian Stroke Best Practice Recommendations for Acute Stroke Management, 6th edition, is a comprehensive summary of current evidence-based recommendations, appropriate for use by healthcare providers and system planners caring for persons with very recent symptoms of acute stroke or transient ischemic attack. The recommendations are intended for use by a interdisciplinary team of clinicians across a wide range of settings and highlight key elements involved in prehospital and Emergency Department care, acute treatments for ischemic stroke, and acute inpatient care. The most notable changes included in this 6th edition are the renaming of the module and its integration of the formerly separate modules on prehospital and emergency care and acute inpatient stroke care. The new module, Acute Stroke Management: Prehospital, Emergency Department, and Acute Inpatient Stroke Care is now a single, comprehensive module addressing the most important aspects of acute stroke care delivery. Other notable changes include the removal of two sections related to the emergency management of intracerebral hemorrhage and subarachnoid hemorrhage. These topics are covered in a new, dedicated module, to be released later this year. The most significant recommendation updates are for neuroimaging; the extension of the time window for endovascular thrombectomy treatment out to 24 h; considerations for treating a highly selected group of people with stroke of unknown time of onset; and recommendations for dual antiplatelet therapy for a limited duration after acute minor ischemic stroke and transient ischemic attack. This module also emphasizes the need for increased public and healthcare provider’s recognition of the signs of stroke and immediate actions to take; the important expanding role of paramedics and all emergency medical services personnel; arriving at a stroke-enabled Emergency Department without delay; and launching local healthcare institution code stroke protocols. Revisions have also been made to the recommendations for the triage and assessment of risk of recurrent stroke after transient ischemic attack/minor stroke and suggested urgency levels for investigations and initiation of management strategies. The goal of this updated guideline is to optimize stroke care across Canada, by reducing practice variations and reducing the gap between current knowledge and clinical practice.

Download Full-text

Automated Continuous Electrocardiogram Monitoring Accelerates the Detection of Atrial Fibrillation after Ischemic Stroke or Transient Ischemic Attack on a Hyper Acute Stroke Unit

Journal of Stroke and Cerebrovascular Diseases ◽

10.1016/j.jstrokecerebrovasdis.2020.104669 ◽

2020 ◽

Vol 29 (4) ◽

pp. 104669

Author(s):

Lucio D'Anna ◽

Arindam Kar ◽

Zoe Brown ◽

Kirsten Harvey ◽

Soma Banerjee ◽

...

Keyword(s):

Atrial Fibrillation ◽

Ischemic Stroke ◽

Acute Stroke ◽

Transient Ischemic Attack ◽

Stroke Unit ◽

Acute Stroke Unit ◽

Ischemic Attack ◽

Electrocardiogram Monitoring

Download Full-text

Presenting symptoms for the identification of acute stroke and transient ischemic attack in the emergency department

Journal of the Neurological Sciences ◽

10.1016/j.jns.2013.07.986 ◽

2013 ◽

Vol 333 ◽

pp. e256

Author(s):

K.-H. Cho ◽

S.-H. Baek

Keyword(s):

Emergency Department ◽

Acute Stroke ◽

Transient Ischemic Attack ◽

Presenting Symptoms ◽

Ischemic Attack

Download Full-text

A prospective study on patients with transient ischemic attack and minor ischemic stroke presenting to a tertiary care emergency department

Current Medical Issues ◽

10.4103/cmi.cmi_2_20 ◽

2020 ◽

Vol 18 (2) ◽

pp. 130

Author(s):

Aparna Lohanathan ◽

JubinMerin Jacob ◽

Sanjith Aaron

Keyword(s):

Emergency Department ◽

Ischemic Stroke ◽

Prospective Study ◽

Transient Ischemic Attack ◽

Tertiary Care ◽

Minor Ischemic Stroke ◽

Ischemic Attack ◽

A Prospective Study

Download Full-text

Clinical, Laboratory, and Imaging Characteristics of Transient Ischemic Attack Caused by Large Artery Lesions: A Comparison between Carotid and Intracranial Arteries

Cerebrovascular Diseases Extra ◽

10.1159/000440731 ◽

2015 ◽

Vol 5 (3) ◽

pp. 115-123 ◽

Cited By ~ 3

Author(s):

Toshiyuki Uehara ◽

Tomoyuki Ohara ◽

Kazunori Toyoda ◽

Kazuyuki Nagatsuka ◽

Kazuo Minematsu

Keyword(s):

Ischemic Stroke ◽

Carotid Artery ◽

Transient Ischemic Attack ◽

Clinical Laboratory ◽

Stroke Care ◽

Large Artery ◽

Intracranial Artery ◽

Imaging Characteristics ◽

Artery Disease ◽

Ischemic Attack

Background/Aims: The aims of this study were to determine the differences in clinical characteristics and the risk of ischemic stroke between patients with transient ischemic attack (TIA) attributable to extracranial carotid and intracranial artery occlusive lesions. Methods: Among 445 patients admitted to our stroke care unit within 48 h of TIA onset between April 2008 and December 2013, 85 patients (63 men, mean age 69.4 years) with large artery occlusive lesions relevant to symptoms were included in this study. The primary endpoints were ischemic stroke at 2 and 90 days after TIA onset. Results: Twenty-eight patients had carotid artery occlusive lesions (extracranial group), and 57 patients had intracranial artery occlusive lesions (intracranial group). Patients in the intracranial group were significantly younger, had lower levels of fibrinogen, and were less likely to have occlusion when compared with those in the extracranial group. Eleven patients in the extracranial group and none in the intracranial group underwent revascularization procedures within 90 days of TIA onset. The 2-day risk (14.2 vs. 0%, p = 0.044) and the 90-day risk (17.1 vs. 0%, p = 0.020) of ischemic stroke after TIA onset were significantly higher in the intracranial group than in the extracranial group. Conclusions: Among our patients with TIA caused by large artery disease, patients with intracranial artery occlusive lesions were more frequent and were at higher risk of early ischemic stroke than those with extracranial carotid artery occlusive lesions. These data highlight the importance of prompt assessment of intracranial artery lesions in patients with TIA.

Download Full-text

Predictors of Hospitalization in Patients With Transient Ischemic Attack or Minor Ischemic Stroke

Canadian Journal of Neurological Sciences / Journal Canadien des Sciences Neurologiques ◽

10.1017/cjn.2016.12 ◽

2016 ◽

Vol 43 (4) ◽

pp. 523-528 ◽

Cited By ~ 4

Author(s):

Moira K. Kapral ◽

Ruth Hall ◽

Jiming Fang ◽

Peter C. Austin ◽

Frank L. Silver ◽

...

Keyword(s):

Emergency Department ◽

Ischemic Stroke ◽

Transient Ischemic Attack ◽

Population Based ◽

Minor Stroke ◽

Local Health ◽

Stroke Registry ◽

Persistent Symptoms ◽

Minor Ischemic Stroke ◽

Ischemic Attack

AbstractBackground: Transient ischemic attack (TIA) and minor stroke are associated with a substantial risk of subsequent stroke; however, there is uncertainty about whether such patients require admission to hospital for their initial management. We used data from a clinical stroke registry to determine the frequency and predictors of hospitalization for TIA or minor stroke across the province of Ontario, Canada. Methods: The Ontario Stroke Registry collects information on a population-based sample of all patients seen in the emergency department with acute stroke or TIA in Ontario. We identified patients with minor ischemic stroke or TIA included in the registry between April 1, 2008, and March 31, 2011, and used multivariable analyses to evaluate predictors of hospitalization. Results: Our study sample included 8540 patients with minor ischemic stroke or TIA, 47.2% of whom were admitted to hospital, with a range of 37.6% to 70.3% across Ontario’s 14 local health integration network regions. Key predictors of admission were preadmission disability, vascular risk factors, presentation with weakness, speech disturbance or prolonged/persistent symptoms, arrival by ambulance, and presentation on a weekend or during periods of emergency department overcrowding. Conclusions: More than one-half of patients with minor stroke or TIA were not admitted to the hospital, and there were wide regional variations in admission patterns. Additional work is needed to provide guidance to health care workers around when to admit such patients and to determine whether discharged patients are receiving appropriate follow-up care.

Download Full-text

181: Risk of an Ischemic Stroke Following a Transient Ischemic Attack in Patients Managed in an Emergency Department Observation Unit

Annals of Emergency Medicine ◽

10.1016/j.annemergmed.2008.06.198 ◽

2008 ◽

Vol 52 (4) ◽

pp. S98

Author(s):

L. Vaidyanathan ◽

W.W. Decker ◽

M. Bellolio ◽

S. Suravaram ◽

A. Bhagra ◽

...

Keyword(s):

Emergency Department ◽

Ischemic Stroke ◽

Transient Ischemic Attack ◽

Observation Unit ◽

Ischemic Attack

Download Full-text

Why Stroke Patients Don’t Receive T-PA? An Analysis of Patient Eligibility: Implications for Improving Clinical Impact by Increasing Future Treatment Numbers

Stroke ◽

10.1161/str.32.suppl_1.372-d ◽

2001 ◽

Vol 32 (suppl_1) ◽

pp. 372-372

Author(s):

Philip A Barber ◽

Jinijin Zhang ◽

Andrew M Demchuk ◽

Michael D Hill ◽

Andrea Cole-Haskayne ◽

...

Keyword(s):

Emergency Department ◽

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Stroke Care ◽

Stroke Patients ◽

Acute Stroke Care ◽

Stroke Registry ◽

Specific Protocol ◽

Stroke Type ◽

Ischemic Attack

P183 Background T-PA is an effective treatment of acute ischemic stroke within 3 hours. However, the success of t-PA on reducing disability is dependent on it being accessible to more patients. We identified the reasons why patients with ischemic stroke did not receive intravenous t-PA and assessed the community impact of the therapy in a large North American city. Methods Consecutive patients with acute ischemic stroke were identified in a prospective stroke registry at a teaching hospital between October 1996 and December 1999. Additional patients with ischemic stroke admitted to one of three other hospitals during the study period were identified. The Oxford Community Stroke Program Classification was used to record stroke type. Results Of 2165 stroke patients presenting to the emergency department 1179 (54.5%) were diagnosed with ischemic stroke, 31.7% with intracranial hemorrhage, and 13.8 % with transient ischemic attack. 84/339 (29%) patients were admitted within 3 hours of stroke received intravenous t-PA. The major reasons for exclusion for stroke patients presenting within 3 hours were mild stroke (20%), clinical improvement (18.6%), and specific protocol exclusions (11.5%). Delay in presentation to emergency department excluded 840/1179 (71%). 1817 ischemic stroke patients were admitted to Calgary hospitals during the study period of which 4.6% received intravenous t-PA. Generalization of the Calgary experience to other Canadian communities suggests the benefit from t-PA for ischemic stroke may be substantial with an additional 460 independent survivors per annum. Conclusion The effectiveness of t-PA can be improved by understanding why patients are excluded from its use. The eligibility of patients for t-PA must increase by promoting health education programs and by developing organized acute stroke care infrastructure within the community.

Download Full-text

Association Between Immigration Status and Acute Stroke Care

Stroke ◽

10.1161/strokeaha.119.027791 ◽

2020 ◽

Vol 51 (5) ◽

pp. 1555-1562

Author(s):

Manav V. Vyas ◽

Andreas Laupacis ◽

Peter C. Austin ◽

Jiming Fang ◽

Frank L. Silver ◽

...

Keyword(s):

Ischemic Stroke ◽

Transient Ischemic Attack ◽

Care Delivery ◽

Stroke Care ◽

Future Research ◽

Immigration Status ◽

Acute Stroke Care ◽

Adjusted Risk ◽

Ischemic Attack

Background and Purpose— Immigrants to high-income countries have a lower incidence of stroke compared with long-term residents; however, little is known about the care and outcomes of stroke in immigrants. Methods— We used linked clinical and administrative data to conduct a retrospective cohort study of adults seen in the emergency department or hospitalized with ischemic stroke or transient ischemic attack between July 1, 2003, and April 1, 2013, and included in the provincial stroke registry. We ascertained immigration status using immigration records and compared processes of stroke care delivery between immigrants (defined as those immigrating after 1985) and long-term residents. In the subgroup with ischemic stroke, we calculated inverse probability treatment weight (IPTW)–adjusted risk ratios for disability on discharge (modified Rankin Scale score of 3 to 5), accounting for demographic characteristics and comorbid conditions to compare outcomes between immigrants and long-term residents. Results— We included 34 987 patients with ischemic stroke or transient ischemic attack, of whom 2649 (7.6%) were immigrants. Immigrants were younger than long-term residents at the time of stroke/transient ischemic attack (median age 67 years versus 76 years; P <0.001). In the subgroup with ischemic stroke, there were no differences in stroke care delivery, except that a higher proportion of immigrants received thrombolysis than long-term residents (21.2% versus 15.5%; P <0.001). Immigrants with ischemic stroke had a higher adjusted risk of being disabled on discharge (adjusted risk ratio, 1.18; 95% CI, 1.13–1.22) compared to long-term residents. Conclusions— Stroke care is similar in Canadian immigrants and long-term residents. Future research is needed to confirm the observed association between immigration status and disability after stroke and to identify factors underlying the association.

Download Full-text

Abstract WP136: Clinical, Laboratory, and Imaging Characteristics Oof Transient Ischemic Attack Caused by Large Artery Lesion: A Comparison Between Carotid and Intracranial Artery

Stroke ◽

10.1161/str.47.suppl_1.wp136 ◽

2016 ◽

Vol 47 (suppl_1) ◽

Author(s):

Toshiyuki Uehara ◽

Tomoyuki Ohara ◽

Kazuyuki Nagatsuka ◽

Kazunori Toyoda ◽

Kazuo Minematsu

Keyword(s):

Ischemic Stroke ◽

Carotid Artery ◽

Transient Ischemic Attack ◽

Clinical Laboratory ◽

Stroke Care ◽

Large Artery ◽

Intracranial Artery ◽

Imaging Characteristics ◽

Artery Disease ◽

Ischemic Attack

Background: The purpose of this study was to determine the differences in clinical characteristics and the risk of ischemic stroke between patients with transient ischemic attack (TIA) attributable to extracranial carotid and intracranial artery occlusive lesions. Methods: Among 445 patients admitted to our stroke care unit within 48 hours of TIA onset between April 2008 and December 2013, 85 patients (63 men, 69.4 years) with large artery occlusive lesions relevant to symptoms were included in this study. The primary endpoints were ischemic stroke at 2 days and 90 days after TIA onset. Results: Twenty-eight patients had carotid artery occlusive lesions (extracranial group), and 57 patients had intracranial artery occlusive lesions (intracranial group). Patients in the intracranial group were significantly younger, had lower levels of fibrinogen, and were less likely to have occlusion when compared to those in the extracranial group. Eleven patients in the extracranial group and no patient in the intracranial group underwent revascularization procedures within 90 days of TIA onset. The 2-day risk (14.2% vs. 0%, p = 0.044) and 90-day risk (17.1% vs. 0%, p = 0.020) of ischemic stroke after TIA onset were significantly higher in the intracranial group than in the extracranial group. Conclusions: Patients with intracranial artery occlusive lesions were more frequent and were at higher risk of early ischemic stroke than those with extracranial carotid artery occlusive lesions among our patients with TIA caused by large artery disease. These data highlight the importance of prompt assessment of intracranial artery lesions in patients with TIA.

Download Full-text