[CBO guideline 'Stroke' (revision) Dutch Institute for Healthcare Improvement]

Abstract

The stroke consensus dating from 1991 had to be revised, because of the introduction of new developments in the treatment of patients with stroke. More than 50 representatives from 25 professions and institutions participated. Under methodological assistance of the Dutch Institute for Healthcare Improvement CBO separate working groups (diagnosis, treatment, organization of care, rehabilitation/education, implementation and cost-effectiveness) studied the literature and translated the results into recommendations with explanatory text. The strength of scientific evidence was classified. During a national public meeting the results were discussed. In the field of guideline development cost-effectiveness analyses and specific attention for implementation are new. Care on a stroke unit decreases the risk of mortality, life-long disabilities, and dependence on permanent care with about 20%. Regional stroke services should be instituted, in which continuity and efficient care can be guaranteed. Very early thrombolysis with recombinant tissue plasminogen activator strongly decreases the number of patients dying, or remaining care-dependent in a selected group of appropriate patients. Secondary prevention (lifestyle measures, acetylsalicyclic acid, treatment of hypertension and hypercholesterolaemia, and surgery of the carotids) may decrease the number of residual strokes and myocardial infarctions. In the occurrence of cerebral ischaemia and atrial fibrillation oral anticoagulants are indicated. Early intensive rehabilitation increases the chance of recovery. Silent cognitive defects may hinder rehabilitation. The extensive guideline summarises the scientific literature about treatment of patients with stroke and should serve as a basis for local protocols and appointments.