Article: Sharon - What Treatment Should You Expect After A Stroke? Best Practice Guidelines.

Worldwide, to ensure that patients get appropriate treatment, stroke professionals have sifted through the research evidence and designed guidelines for the most effective treatments.

In the United States, the American Stroke Association best practice guidelines are “Get with the Guidelines, 2009.”  In Canada,  the Canadian Stroke Network has developed comprehensive recommendations for best practices – the “Canadian Stroke Strategy Stroke Best Practice Recommendations Update 2010.”

There are many way that stroke survivors and care-partners can use the best practice guidelines:

• If you are new to stroke, you can see what treatment you should expect.
• If you are newly discharged home from the hospital or from rehabilitation 
• If you had a stroke many years ago you can compare the treatment you received with best practices. 

Let’s see how someone with a mild stroke might use the Best Practice Guidelines.

In Alberta, about 40% of people diagnosed with stroke or TIA go either to their family doctor or to an emergency facility. They are experiencing mild symptoms like slight numbness in their arm, tingling in their fingers, or they might have some trouble finding words or speaking.

The Canadian Stroke Network Best Practice Guidelines refer to this as “non-disabling stroke.”  Mike (not his real name) had this experience:

Mike drove himself to emergency because he had some numbness in his right arm.  When he arrived he had some trouble explaining to the triage nurse what was wrong, but he was able to give her his health care card and answer the simple questions she asked.  While he waited for the doctor, he noticed that the numbness was getting better. The doctor said it was likely a TIA (transient ischemic attack) and sent him for a brain scan.  Indeed, after the doctor saw the scan, he told Mike that it was a TIA. The doctor checked to see if Mike was taking daily aspirin to prevent another stroke and complemented Mike on coming to emergency so quickly, “Many people would not have even come to emergency with your symptoms. ”  He recommended that Mike make an appointment with his family doctor as early as possible.   He explained that with Alberta’s electronic health record, his doctor would have a record of this emergency visit.  

So according to the Best Practice Guidelines (Page 55) what should Mike expect when he calls his family doctor? The guidelines for TIA or non-disabling stroke recommend:

“All patients with suspected transient ischemic attack or non-disabling ischemic stroke should   undergo an assessment that includes an electrocardiogram, brain imaging, and non-invasive vascular imaging (for carotid territory transient ischemic attacks or non-disabling strokes) within seven days of symptom onset, and have a consultation with a stroke specialist [Evidence Level B].”

Why is this important?

• Stroke recurs in 20% of patients, most commonly within the first year after TIA or minor stroke, most within the first 90 days.  
• The risk of stroke after TIA or minor stroke is 8-12% at 7 days and 11-15% at one month. 
• Patients suffering a second stroke are likely to have increased impairment and spend more time in hospital and rehabilitation (Malewezi, 2011). 

So one would expect that the earlier that Mike sees the doctor, has these assessments done, and follows the treatment recommendations that he will be at much lower risk of having a larger stroke.  The Best Practice Guidelines recognize this:

“Patients presenting with transient ischemic attack or non-disabling ischemic stroke and motor or speech symptoms should optimally have the assessment on the day of symptom onset. ”

What happened to Mike?

When Mike was driving home after the doctor discharged him from emergency, he noticed that he was having some trouble reading the road signs. It was 3 AM so there wasn’t much traffic. Still, he was anxious about the small changes he was noticing and worried about another stroke, so when he arrived home he asked his son to check on him.  The following day he called his family doctor. He noticed that he had trouble remembering the doctor’s phone number.  He made an appointment to see the doctor later in the week and then went off to work.  He couldn’t believe how tired he was at work.  He assumed he was fatigued because he hadn’t slept much.

Many people with mild stroke experience problems like Mike’s.  They may have trouble remembering things, feel fatigued, or have difficulty balancing a check book or reading.   The Canadian Stroke Network Best Practice Guidelines recommend a Comprehensive outpatient assessment for impairments:

Patients with non-disabling ischemic stroke who are not admitted to hospital should be considered for referred for a comprehensive outpatient assessment of functional impairment, which should include a cognitive evaluation, screening for depression, screening of fitness to drive, and functional assessments for potential rehabilitation treatment [Evidence Level B]. 

See the guidelines for Supporting patients and families through transitions and Patient and Family education Link:

Consult the Canadian Stroke Network Best Practice Guidelines.

References: Malewizi, E. (2012). Stroke policy and secondary prevention: how well are we adhering to these guidelines. British Journal of Neuroscience Nursing. 7(6), 684-690.