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Optimized Management of Endovascular Treatment for Acute Ischemic Stroke
Published on: January 18, 2018
National Stroke Association guidelines for the management of transient ischemic attacks
S Claiborne Johnston1, Mai N Nguyen-Huynh, Miriam E Schwarz
1Department of Neurology, University of California, San Francisco, CA 94143-0114, USA. clay.johnston@ucsfmedctr.org
Insights
This study presents updated, evidence-based guidelines for managing transient ischemic attacks (TIAs). The new recommendations stress the critical need for prompt evaluation and treatment to prevent stroke.
Area of Science:
- Neurology
- Clinical Guidelines
- Evidence-Based Medicine
Background:
- Transient ischemic attacks (TIAs) are significant predictors of future stroke.
- Current TIA management guidelines are outdated, leading to varied clinical practices.
Purpose of the Study:
- To develop comprehensive, unbiased, and evidence-based guidelines for TIA patient management.
- To address the need for updated recommendations in TIA care.
Main Methods:
- Systematic review of existing guidelines and recent clinical studies.
- Modified Delphi approach involving 15 expert panelists over six questionnaire iterations.
- Independent quality rating of recommendations by experts, with conflict of interest avoidance.
Main Results:
- Identified 13 relevant guideline documents from 257 reviewed.
- Developed 53 consensus-based recommendations covering TIA management.
- Recommendations addressed initial care, evaluation, medical/surgical treatments, and risk factors.
Conclusions:
- The developed guidelines underscore the urgency of TIA evaluation and treatment.
- The novel guideline development methodology is feasible, adaptable, and reduces bias.
Objective:
Transient ischemic attacks are common and important harbingers of subsequent stroke. Management varies widely, and most published guidelines have not been updated in several years. We sought to create comprehensive, unbiased, evidence-based guidelines for the management of patients with transient ischemic attacks.
Methods:
Fifteen expert panelists were selected based on objective criteria, using publication metrics that predicted nomination by practitioners in the field. Prior published guidelines were identified through systematic review, and recommendations derived from them were rated independently for quality by the experts. Highest quality recommendations were selected and subsequently edited by the panelists using a modified Delphi approach with multiple iterations of questionnaires to reach consensus on new changes. Experts were provided systematic reviews of recent clinical studies and were asked to justify wording changes based on new evidence and to rate the final recommendations based on level of evidence and quality. No expert was allowed to contribute to recommendations on a topic for which there could be any perception of a conflict of interest.
Results:
Of 257 guidelines documents identified by systematic review, 13 documents containing 137 recommendations met all entry criteria. Six iterations of questionnaires were required to reach consensus on wording of 53 final recommendations. Final recommendations covered initial management, evaluation, medical treatment, surgical treatment, and risk factor management.
Interpretation:
The final recommendations on the care of patients with transient ischemic attacks emphasize the importance of urgent evaluation and treatment. The novel approach used to develop these guidelines is feasible, allows for rapid updating, and may reduce bias.
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