A systematic review and synthesis of global stroke guidelines on behalf of the World Stroke Organization

Gillian E Mead¹, Luciano A Sposato^{2

3

4

5}, Gisele Sampaio Silva^{6

7}, Laetitia Yperzeele^{8

9}, Simiao Wu¹⁰, Mansur Kutlubaev¹¹, Joshua Cheyne¹², Kolawole Wahab¹³, Victor C Urrutia¹⁴, Vijay K Sharma^{15

16}, P N Sylaja¹⁷, Kelvin Hill¹⁸, Thorsten Steiner¹⁹, David S Liebeskind²⁰, Alejandro A Rabinstein²¹

Affiliations

¹ Usher Institute, University of Edinburgh and Royal Infirmary of Edinburgh, Little France Crescent, Edinburgh, UK.
² Department of Clinical Neurological Sciences, London Health Sciences Centre, Western University, London, ON, Canada.
³ Heart & Brain Lab, Western University, London, ON, Canada.
⁴ Robarts Research Institute, London, ON, Canada.
⁵ Lawson Health Research Institute, London, ON, Canada.
⁶ Department of Neurology and Neurosurgery, Federal University of São Paulo (UNIFESP), São Paulo, Brazil.
⁷ Hospital Israelita Albert Einstein, São Paulo, Brazil.
⁸ Antwerp NeuroVascular Center and Stroke Unit, Antwerp University Hospital, Antwerp, Belgium.
⁹ Research Group on Translational Neurosciences, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium.
¹⁰ Department of Neurology, West China Hospital, Sichuan University, Chengdu, China.
¹¹ Department of Neurology, Bashkir State Medical University, Ufa, Russia.
¹² Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK.
¹³ Department of Medicine, University of Ilorin, Ilorin, Nigeria.
¹⁴ Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
¹⁵ Yong Loo Lin School of Medicine, National University of Singapore, Singapore.
¹⁶ Division of Neurology, University Medicine Cluster, National University Health System, Singapore.
¹⁷ Neurology and Comprehensive Stroke Care Program, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, India.
¹⁸ Stroke Treatment, Stroke Foundation, Melbourne, VIC, Australia.
¹⁹ Departments of Neurology, Klinikum Frankfurt Höchst and Heidelberg University Hospital, Frankfurt, Germany.
²⁰ UCLA Department of Neurology, Neurovascular Imaging Research Core, UCLA Comprehensive Stroke Center, Los Angeles, CA, USA.
²¹ Neurology, Mayo Clinic, Rochester, MN, USA.

PMID: 36725717
PMCID: PMC10196933
DOI: 10.1177/17474930231156753

A systematic review and synthesis of global stroke guidelines on behalf of the World Stroke Organization

Gillian E Mead et al. Int J Stroke. 2023 Jun.

. 2023 Jun;18(5):499-531.

doi: 10.1177/17474930231156753. Epub 2023 Mar 1.

Authors

Affiliations

¹ Usher Institute, University of Edinburgh and Royal Infirmary of Edinburgh, Little France Crescent, Edinburgh, UK.
² Department of Clinical Neurological Sciences, London Health Sciences Centre, Western University, London, ON, Canada.
³ Heart & Brain Lab, Western University, London, ON, Canada.
⁴ Robarts Research Institute, London, ON, Canada.
⁵ Lawson Health Research Institute, London, ON, Canada.
⁶ Department of Neurology and Neurosurgery, Federal University of São Paulo (UNIFESP), São Paulo, Brazil.
⁷ Hospital Israelita Albert Einstein, São Paulo, Brazil.
⁸ Antwerp NeuroVascular Center and Stroke Unit, Antwerp University Hospital, Antwerp, Belgium.
⁹ Research Group on Translational Neurosciences, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium.
¹⁰ Department of Neurology, West China Hospital, Sichuan University, Chengdu, China.
¹¹ Department of Neurology, Bashkir State Medical University, Ufa, Russia.
¹² Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK.
¹³ Department of Medicine, University of Ilorin, Ilorin, Nigeria.
¹⁴ Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
¹⁵ Yong Loo Lin School of Medicine, National University of Singapore, Singapore.
¹⁶ Division of Neurology, University Medicine Cluster, National University Health System, Singapore.
¹⁷ Neurology and Comprehensive Stroke Care Program, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, India.
¹⁸ Stroke Treatment, Stroke Foundation, Melbourne, VIC, Australia.
¹⁹ Departments of Neurology, Klinikum Frankfurt Höchst and Heidelberg University Hospital, Frankfurt, Germany.
²⁰ UCLA Department of Neurology, Neurovascular Imaging Research Core, UCLA Comprehensive Stroke Center, Los Angeles, CA, USA.
²¹ Neurology, Mayo Clinic, Rochester, MN, USA.

PMID: 36725717
PMCID: PMC10196933
DOI: 10.1177/17474930231156753

Abstract

Background: There are multiple stroke guidelines globally. To synthesize these and summarize what existing stroke guidelines recommend about the management of people with stroke, the World Stroke Organization (WSO) Guideline committee, under the auspices of the WSO, reviewed available guidelines.

Aims: To systematically review the literature to identify stroke guidelines (excluding primary stroke prevention and subarachnoid hemorrhage) since 1 January 2011, evaluate quality (The international Appraisal of Guidelines, Research and Evaluation (AGREE II)), tabulate strong recommendations, and judge applicability according to stroke care available (minimal, essential, advanced).

Summary of review: Searches identified 15,400 titles; 911 texts were retrieved, 200 publications scrutinized by the three subgroups (acute, secondary prevention, rehabilitation), and recommendations extracted from most recent version of relevant guidelines. For acute treatment, there were more guidelines about ischemic stroke than intracerebral hemorrhage; recommendations addressed pre-hospital, emergency, and acute hospital care. Strong recommendations were made for reperfusion therapies for acute ischemic stroke. For secondary prevention, strong recommendations included establishing etiological diagnosis; management of hypertension, weight, diabetes, lipids, and lifestyle modification; and for ischemic stroke, management of atrial fibrillation, valvular heart disease, left ventricular and atrial thrombi, patent foramen ovale, atherosclerotic extracranial large vessel disease, intracranial atherosclerotic disease, and antithrombotics in non-cardioembolic stroke. For rehabilitation, there were strong recommendations for organized stroke unit care, multidisciplinary rehabilitation, task-specific training, fitness training, and specific interventions for post-stroke impairments. Most recommendations were from high-income countries, and most did not consider comorbidity, resource implications, and implementation. Patient and public involvement was limited.

Conclusion: The review identified a number of areas of stroke care where there was strong consensus. However, there was extensive repetition and redundancy in guideline recommendations. Future guideline groups should consider closer collaboration to improve efficiency, include more people with lived experience in the development process, consider comorbidity, and advise on implementation.

Keywords: Stroke rehabilitation; acute stroke care; guidelines; secondary stroke prevention; stroke care.

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Conflict of interest statement

The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Mansur Kutlubaev, Honoraria for lectures from Pfizer, Abbot Laboratories, Merz. Supported by the Bashkir State Medical University Strategic Academic Leadership Program (PRIORITY-2030). Thorsten Steiner, honoraria for lectures from Bayer, Boehringer, Pfizer, Daiichy, Astra; participation in data monitoring committee or advisory board: Boehringer; leadership role in ESO and WSO. Alejandro Rabinstein, grant for investigator initiated project from Chiesi; CEC committee for Boston Scientific, Advisory boards for Astra Zeneca, Novo Nordisk, Shionogi, Brainomix; leadership role for Life Source (unpaid). Luciano A Sposato, Kathleen and Dr. Henry Barnett Chair in Stroke Research (Western University) Saraydar Neurosciences Fund (Western University); Honoraria from Pfizer Boehringer Ingelheim Gore. Victor C Urrutia, Research grant from Genentech, Inc. Gillian E Mead, honoraria from Imperative Care, Royalties from Elsevier for a book on exercise training after stroke, co-leads Cochrane Stroke which hosts DORIS, President of British and Irish Association of Stroke Physicians. Gisele Sampaio Silva, Medication donation for the Resilient Extend IV trial - to her Institution from Boehringer Ingelheim; personal payment for consulting from Boehringer Ingelheim; honoraria/lectures-personal payment from Boehringer Ingelheim Astra Zeneca and Pfizer; Advisory Board: personal payment from Astra Zeneca. Kolawale Wahab, funding for the Development of Algorithm for management of hypertension in Nigeria and Development of a Training Manual for the treatment of hypertension in Nigeria from Sanofi Pharmaceuticals; Secretary-General, Nigerian Hypertension Society. Laetitia Yperzeele, World Stroke Organisation: Future Stroke Leaders Program funded project on the needs of Young People with Stroke 20.000 USD; Vives Hogeschool and UCLL Genk: Payment for lectures in the course for stroke nurses (payment to her organization, not personal account; World Stroke Organisation: Attendance of WSC 2022 Singapore. Member of the Scientific Board of the Belgian Stroke Council-no funding received. The other authors do not have conflicts of interest.

Figures

**Figure 1.**
PRISMA flow diagram showing selection of guidelines.

See this image and copyright information in PMC

References

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1. Alteplase for treating acute ischemic stroke, 2012, https://www.nice.org.uk/guidance/ta264/resources/alteplase-for-treating-...

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A systematic review and synthesis of global stroke guidelines on behalf of the World Stroke Organization

Affiliations

A systematic review and synthesis of global stroke guidelines on behalf of the World Stroke Organization

Authors

Affiliations

Abstract

Conflict of interest statement

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References

Publication types

MeSH terms

LinkOut - more resources

Full Text Sources

Medical

Research Materials