Swedish National Board of Health and Welfare has released draft version of new national guidelines for acute stroke

Although the number of strokes decreases in Sweden, between 25000-30000 people per year have stroke. The sooner a stroke is detected and can be treated the better the chances that the damage of brain tissue can be minimized. National Board of Health and Welfare (Socialstyrelsen) has published referral version of the National guidelines for the treatment of stroke. It will be open to comment before the final version will be published in spring 2018.

The national guidelines for stroke care contain about 110 recommendations, including primary prevention, acute care, diagnostics, emergency treatment and care, early and late rehabilitation, follow-up and secondary prevention.

All recommendations are divided into three categories:

• Measures that health care provider should, may or may, in exceptional cases, offer, which are reported according to priority scale from 1 to 10, where priority 1 has the highest rating and 10 – the lowest rating
• Measures that health care provider should not perform routinely, but only within the framework of research and development
• Measures that health care provider should not perform at all

Recommendations in relation to mechanical thrombectomy

The evidence that thrombectomy, as relatively new treatment method, has very good effect has recently been greatly strengthened. The method involves a significant step for stroke care and National Board of Health wants it to be used more frequently than is has been already used. Increased use of thrombectomy will mean higher health care costs. The economic consequences of new recommendations are that health care costs for stroke care will rise and set high standards for improving skills, not least regarding the opportunities to offer more patients thrombectomy, which requires increased training of neuro-interventionists.

In this context, National Board of Health released the following draft recommendations with the highest level of priority for application of thrombectomy in patients with stroke:

• Direct admission and treatment in stroke units should be provided;
• Health care provider should use CT angiography directly in conjunction with computer tomography survey in order to identify occlusion of the brain's major large vessels in persons with suspected acute ischemic stroke where thrombectomy may be relevant;
• Health care provider should offer thrombectomy with stent-retriever to people with acute ischemic stroke with occlusion of the major cerebral vessels, except basilar artery thrombosis in the emergency phase, when thrombectomy with stent-retriever should be used only within research and development.

Recommendations in relation to diagnosis of stroke

Diagnosis of stroke plays important role in the management and outcomes of treatment. National Board of Health provides the following recommendations for selection of appropriate imaging diagnostics:

• Health care provider should use computer tomography to diagnose subarachnoid bleeding in people with sudden headache where less than 6 hours have passed after symptom depletion (priority level of recommendation – 1)
• Prehospital computer tomography in ambulance should not be routinely performed in people with suspected stroke or TIA (only within research and development)
• Health care provider should use telemedicine for specialist emergency consultation in order to provide adequate treatment of suspected stroke (priority level of recommendation – 2)
• Magnetic resonance imaging (MR) including diffusion should be performed in patients with suspected ischemic stroke or TIA with differential diagnostic difficulties (priority level of recommendation – 2)

Recommendations in relation to detection of underlying cause of stroke

There are the following recommendations for exclusion or detection of possible underlying heart disease in suspected cryptogenic ischemic stroke:

• Health care provider can use transesophageal echocardiography (TEE) as a complementary diagnostic method to exclude or detect possible underlying heart disease in suspected cryptogenic ischemic stroke (priority level of recommendation – 5)
• Health care provider can perform long-term registration of cardiac arrhythmias with Holter ECG or telemetry, to detect atrial fibrillation in persons with ischemic stroke or TIA (priority level of recommendation – 2). As for long-term registration of cardiac arrhythmia with hand-held ECG registration or implantable loop recorder, it should be used only in the context of research and development

Recommendations in relation to cases with relevance of carotid intervention

There are specific recommendations for patients with TIA or ischemic stroke where carotid intervention (surgery / stent) may be relevant:

• Health care provider should perform ultrasound in people with TIA or ischemic stroke where carotid intervention (surgery / stent) may be relevant (priority level of recommendation – 1).
• Health care provider should perform CT angiography in people with TIA or ischemic stroke where carotid intervention (surgery / stent) may be relevant (priority level of recommendation – 2)
• Health care provider should perform MRI angiography in people with TIA or ischemic stroke where carotid intervention (surgery / stent) may be relevant (priority level of recommendation – 3)
• Ultrasound of neck vessels, carotid endarterectomy and insertion of stent into carotid artery can be offered to people with suspected atherosclerosis and very high risk of stroke or myocardial infarction only within research and development

Full document is available in Sweden here.

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