World Stroke Organization The Paper of The Month – April
04 Apr 2023Title: Advancing the implementation of Stroke Recommendations
Title: Advancing the implementation of Stroke Recommendations
Author: Prof. Dr. Gustavo Saposnik – WSA Editor-in-Chief
This article is a commentary on the following: International Journal Of Stroke, A systematic review and synthesis of global stroke guidelines on behalf of the World Stroke Organization, https://journals.sagepub.com/doi/full/10.1177/17474930231156753
Commentary:
“Nothing liberates our greatness like the desire to help, the desire to serve.” – Marianne Williamson (Lecturer, politician, and bestseller writer)
“Strive not to be a success, but rather to be of value.” – Albert Einstein (Physicist, Mathematician and Nobel Prize Winner)
This month we are highlighting the results of a systematic review and synthesis of global stroke guidelines published in IJS.1
The WSO Guidelines Committee was commissioned to systematically review the literature to identify stroke guidelines since 1 January 2011, to evaluate quality, tabulate strong recommendations, and judge applicability according to stroke level of care (minimal, essential, advanced).
Overall, the authors identified 15,400 titles. 200 publications were scrutinized and classified in three areas: acute, secondary prevention, and rehabilitation. Strong recommendations were made for each of these areas. Of interest, the present manuscript offers specific criteria for stroke patients to be eligible for thrombectomy within 6 hours from last seen normal, including: age⩾18years; pre-stroke mRS score of 0–1; causative occlusion of the internal carotid artery or MCA (M1); (4) NIHSS score of⩾6; ASPECTS of⩾6; and treatment can be initiated (groin puncture) within 6 h of symptom onset or last known well.1
Other challenging therapeutic recommendations were provided for stroke subgroups (e.g., Patients with ESUS should not receive oral anticoagulants; antiplatelet therapy is recommended for patients with ischemic stroke or TIA and a carotid web in the ipsilateral vascular territory). Finally, the authors recommended a share decision making process for patients with massive strokes. The authors acknowledged there was no published methodology to synthetize the results of multiple guidelines. They also observed significant redundancy among published guidelines from different groups and scientific organizations. They called for a closer collaboration to improve efficiency, include more people with lived experience in the development process, consider comorbid conditions when provided recommendations, improving implementation.
In my personal view, the authors nicely summarized recommendations for the management of stroke based on the analysis of several guidelines. The authors are to be commended as this is not an easy task.
On the other hand, readers should be cautioned about the list of recommendations. For example, such difficult process of summarizing multiple guidelines carries a trade-off: availability of evidence vs. prevalence of some factors/conditions affecting how some strong recommendations were prioritized over others (e.g. the inclusion of ruling out infections – an uncommon etiology of cerebral venous thrombosis [CVT] in adults, whereas the assessment of the most common causes of CVT — underlying acquired/inherited prothrombotic conditions — did not make the list of strong recommendations).2-4
Please, refer to the article1 and the accompanied interview of the responsible authors for further details.
Disclosure: The opinions expressed in this commentary are those of the author. They do not purport to reflect the opinions or views of the WSO Executive/Board Members or the WSO.
References:
- Mead GE, Sposato LA, Sampaio Silva G, Yperzeele L, Wu S, Kutlubaev M, Cheyne J, Wahab K, Urrutia VC, Sharma VK, et al. A systematic review and synthesis of global stroke guidelines on behalf of the World Stroke Organization. Int J Stroke. 2023:17474930231156753. doi: 10.1177/17474930231156753
- Ulivi L, Squitieri M, Cohen H, Cowley P, Werring DJ. Cerebral venous thrombosis: a practical guide. Practical Neurology. 2020;20:356. doi: 10.1136/practneurol-2019-002415
- Alet M, Ciardi C, Alemán A, Bandeo L, Bonardo P, Cea C, Cirio J, Cossio J, Cuculic M, Esnaola MM, et al. Cerebral venous thrombosis in Argentina: clinical presentation, predisposing factors, outcomes and literature review. J Stroke Cerebrovasc Dis. 2020;29:105145. doi: 10.1016/j.jstrokecerebrovasdis.2020.105145
- Cumpston M, Li T, Page MJ, Chandler J, Welch VA, Higgins JP, Thomas J. Updated guidance for trusted systematic reviews: a new edition of the Cochrane Handbook for Systematic Reviews of Interventions. Cochrane Database Syst Rev. 2019;10:ED000142. doi: 10.1002/14651858.ED000142
Video Interview:
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