Stroke guidelines

Stroke guidelines

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. They identified areas of strong agreement across guidelines, and their global coverage.

To systematically review the literature to identify stroke guidelines (excluding primary stroke prevention and subarachnoid hemorrhage) since 1st January 2011, evaluate quality (AGREE II), tabulate strong recommendations, and judge applicability according to stroke care available (minimal, essential, advanced).

Searches identified 15400 titles, 911 texts were retrieved, 203 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 aetiological diagnosis, management of hypertensionweightdiabeteslipids, lifestyle modification; and for ischemic stroke: management of atrial fibrillationvalvular heart disease, left ventricular and atrial thrombi, patent foramen ovale, atherosclerotic extracranial large vessel disease, intracranial atherosclerotic disease, 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.

The review identified a number of areas of stroke care in there was strong consensus. However there was extensive repetition and redundancy in guideline recommendations. Future guidelines groups should consider closer collaboration to improve efficiency, include more people with lived experience in the development process, consider comorbidity, and advise on implementation 1).


1)

Mead GE, Sposato LA, Silva GS, Yperzeele L, Wu S, Kutlubaev MA, Cheyne J, Wahab K, Urrutia VC, Sharma VK, Sylaja PN, Hill K, Steiner T, Liebeskind DS, Rabinstein AA. Systematic review and synthesis of global stroke guidelines for the World Stroke Organization. Int J Stroke. 2023 Feb 1:17474930231156753. doi: 10.1177/17474930231156753. Epub ahead of print. PMID: 36725717.

Central nervous system tumor guidelines

Central nervous system tumor guidelines

The NCCN Guidelines for Central nervous system tumor focus on the management of the following adult CNS cancers: glioma (WHO grade 1, WHO grade 2-3 Oligodendroglioma IDH-mutant and 1p/19q-codeleted, WHO grade 2-4 Astrocytoma IDH-mutants, WHO grade 4 glioblastoma), intracranial and spinal ependymomas, medulloblastoma, limited and extensive brain metastasesleptomeningeal metastases, non-AIDS-related Primary central nervous system lymphomas, metastatic spine tumors, meningiomas, and primary spinal cord tumors. The information contained in the algorithms and principles of management sections in the NCCN Guidelines for CNS Cancers is designed to help clinicians navigate through the complex management of patients with CNS tumors. Several important principles guide surgical management and treatment with radiotherapy and systemic therapy for adults with brain tumors. The NCCN CNS Cancers Panel meets at least annually to review comments from reviewers within their institutions, examine relevant new data from publications and abstracts, and reevaluate and update their recommendations. These NCCN Guidelines Insights summarize the panel’s most recent recommendations regarding molecular profiling of glioma1)

Evidence-based, clinical practice guidelines in the management of central nervous system tumors (CNS) continue to be developed and updated through the work of the Joint Section on Tumors of the Congress of Neurological Surgeons (CNS) and the American Association of Neurological Surgeons (AANS).

The guidelines are created using the most current and clinically relevant evidence using systematic methodologies, which classify available data and provide recommendations for clinical practice.

This update summarizes the Tumor Section Guidelines developed over the last five years for non-functioning pituitary adenomas, low-grade gliomas, vestibular schwannomas, and metastatic brain tumors 2).


1)

Horbinski C, Nabors LB, Portnow J, Baehring J, Bhatia A, Bloch O, Brem S, Butowski N, Cannon DM, Chao S, Chheda MG, Fabiano AJ, Forsyth P, Gigilio P, Hattangadi-Gluth J, Holdhoff M, Junck L, Kaley T, Merrell R, Mrugala MM, Nagpal S, Nedzi LA, Nevel K, Nghiemphu PL, Parney I, Patel TR, Peters K, Puduvalli VK, Rockhill J, Rusthoven C, Shonka N, Swinnen LJ, Weiss S, Wen PY, Willmarth NE, Bergman MA, Darlow S. NCCN Guidelines® Insights: Central Nervous System Cancers, Version 2.2022. J Natl Compr Canc Netw. 2023 Jan;21(1):12-20. doi: 10.6004/jnccn.2023.0002. PMID: 36634606.
2)

Redjal N, Venteicher AS, Dang D, Sloan A, Kessler RA, Baron RR, Hadjipanayis CG, Chen CC, Ziu M, Olson JJ, Nahed BV. Guidelines in the management of CNS tumors. J Neurooncol. 2021 Feb;151(3):345-359. doi: 10.1007/s11060-020-03530-8. Epub 2021 Feb 21. PMID: 33611702.

Brain metastases treatment guidelines

Brain metastases treatment guidelines

Please see the full-text version of this guideline https://www.cns.org/guidelines/browse-guidelines-detail/guidelines-treatment-of-adults-with-metastatic-bra-2 for the target population of each recommendation listed below.

SURGERY FOR METASTATIC BRAIN TUMORS AT NEW DIAGNOSIS QUESTION: Should patients with newly diagnosed metastatic brain tumors undergo Brain metastases surgeryStereotactic radiosurgery for brain metastases (SRS), or whole brain radiotherapy (WBRT)?

RECOMMENDATIONS:

Level of Evidence 1: Surgery + WBRT is recommended as first-line treatment in patients with single brain metastases with favorable performance status and limited extracranial disease to extend overall survivalmedian survival, and local control.

Level of Evidence 3: Surgery plus SRS is recommended to provide survival benefit in patients with metastatic brain tumors

Level of Evidence 3: Multimodal treatments including either surgery + WBRT + SRS boost or surgery + WBRT are recommended as alternatives to WBRT + SRS in terms of providing overall survival and local control benefits.

SURGERY AND RADIATION FOR METASTATIC BRAIN TUMORS QUESTION: Should patients with newly diagnosed metastatic brain tumors undergo surgical resection followed by WBRT, SRS, or another combination of these modalities?

RECOMMENDATIONS:

Level 1: Surgery + WBRT is recommended as superior treatment to WBRT alone in patients with single brain metastases.

Level 3: Surgery + SRS is recommended as an alternative to treatment with SRS alone to benefit overall survival.

Level 3: It is recommended that SRS alone be considered equivalent to surgery + WBRT.

SURGERY FOR RECURRENT METASTATIC BRAIN TUMORS QUESTION: Should patients with recurrent metastatic brain tumors undergo surgical resection?

RECOMMENDATIONS:

Level 3: Craniotomy is recommended as a treatment for intracranial recurrence after initial surgery or SRS.   SURGICAL TECHNIQUE AND RECURRENCE QUESTION A: Does the surgical technique (en bloc resection or piecemeal resection) affect recurrence?

RECOMMENDATION:

Level 3: En bloc resection of the tumor, as opposed to piecemeal resection, is recommended to decrease the risk of postoperative leptomeningeal disease when resecting single brain metastases.

QUESTION B:

Does the extent of surgical resection (gross total resection or subtotal resection) affect recurrence?

RECOMMENDATION:

Level 3: Gross total resection is recommended over subtotal resection in Recursive partitioning analysis class 1 class I patients to improve overall survival and prolong time to recurrence1)


1)

Nahed BV, Alvarez-Breckenridge C, Brastianos PK, Shih H, Sloan A, Ammirati M, Kuo JS, Ryken TC, Kalkanis SN, Olson JJ. Congress of Neurological Surgeons Systematic Review and Evidence-Based Guidelines on the Role of Surgery in the Management of Adults With Metastatic Brain Tumors. Neurosurgery. 2019 Mar 1;84(3):E152-E155. doi: 10.1093/neuros/nyy542. PubMed PMID: 30629227.

Glioma Guidelines

Glioma Guidelines

The Korean Society for Neuro-Oncology (KSNO) published guidelines for managing adult glioma in 2019, and the National Comprehensive Cancer Network and European Association of Neuro-Oncology published guidelines in September 2021 and March 2021, respectively. However, these guidelines have several different recommendations in practice, including tissue management, adjuvant treatment after surgical resection, and salvage treatment for recurrent/progressive gliomas. Currently, the KSNO guideline working group is preparing an updated version of the guideline for managing adult gliomas 1).


EANO guidelines on the diagnosis and treatment of diffuse gliomas of adulthood2)


The National Comprehensive Cancer Network (NCCN) Guidelines for Patients Brain Cancer: Gliomas https://www.nccn.org/patients/guidelines/content/PDF/brain-gliomas-patient.pdf


Zhao et al. systematically searched PubMed, China National Knowledge Infrastructure (CNKI), and Wanfang databases to retrieve guidelines on glioma in China published from the establishment of the database to 24 January 2022. We performed a narrative review of current clinical studies related to the management of glioblastoma, especially in the surgical, targeted, and immunotherapy therapy and tumor-treating fields.

Key content and findings: In this review, 19 guidelines were included, including 8 subclassified as the guideline, 8 subclassified as the consensus, and 3 subclassified as the standard. Two guidelines reported the contents of the system search, 4 guidelines are updated, and 9 guidelines reported the source of funding. At present, most clinical trials on the immune and targeted therapy of glioblastoma are ongoing in China.

China’s guidelines still need to be improved in terms of preciseness, applicability, and editorial independence. In addition, the cooperation in clinical research of glioblastoma in multiple centers needs to be strengthened in China 3).


To follow the revision of the fourth edition of WHO classification and the recent progress on the management of diffuse gliomas, the joint guideline committee of Chinese Glioma Cooperative Group (CGCG), Society for Neuro-Oncology of China (SNO-China) and Chinese Brain Cancer Association (CBCA) updated the clinical practice guideline. It provides recommendations for diagnostic and management decisions, and for limiting unnecessary treatments and cost. The recommendations focus on molecular and pathological diagnostics, and the main treatment modalities of surgery, radiotherapy, and chemotherapy. In this guideline, we also integrated the results of some clinical trials of immune therapies and target therapies, which we think are ongoing future directions. The guideline should serve as an application for all professionals involved in the management of patients with adult diffuse glioma and also a source of knowledge for insurance companies and other institutions involved in the cost regulation of cancer care in China and other countries 4).


1)

Kim YZ, Kim CY, Lim DH. The Overview of Practical Guidelines for Gliomas by KSNO, NCCN, and EANO. Brain Tumor Res Treat. 2022 Apr;10(2):83-93. doi: 10.14791/btrt.2022.0001. PMID: 35545827; PMCID: PMC9098981.
2)

Weller M, van den Bent M, Preusser M, Le Rhun E, Tonn JC, Minniti G, Bendszus M, Balana C, Chinot O, Dirven L, French P, Hegi ME, Jakola AS, Platten M, Roth P, Rudà R, Short S, Smits M, Taphoorn MJB, von Deimling A, Westphal M, Soffietti R, Reifenberger G, Wick W. EANO guidelines on the diagnosis and treatment of diffuse gliomas of adulthood. Nat Rev Clin Oncol. 2021 Mar;18(3):170-186. doi: 10.1038/s41571-020-00447-z. Epub 2020 Dec 8. Erratum in: Nat Rev Clin Oncol. 2022 May;19(5):357-358. PMID: 33293629; PMCID: PMC7904519.
3)

Zhao MJ, Lu T, Ma C, Wang ZF, Li ZQ. A narrative review on the management of glioblastoma in China. Chin Clin Oncol. 2022 Aug;11(4):29. doi: 10.21037/cco-22-18. PMID: 36098100.
4)

Jiang T, Nam DH, Ram Z, Poon WS, Wang J, Boldbaatar D, Mao Y, Ma W, Mao Q, You Y, Jiang C, Yang X, Kang C, Qiu X, Li W, Li S, Chen L, Li X, Liu Z, Wang W, Bai H, Yao Y, Li S, Wu A, Sai K, Li G, Yao K, Wei X, Liu X, Zhang Z, Dai Y, Lv S, Wang L, Lin Z, Dong J, Xu G, Ma X, Zhang W, Zhang C, Chen B, You G, Wang Y, Wang Y, Bao Z, Yang P, Fan X, Liu X, Zhao Z, Wang Z, Li Y, Wang Z, Li G, Fang S, Li L, Liu Y, Liu S, Shan X, Liu Y, Chai R, Hu H, Chen J, Yan W, Cai J, Wang H, Chen L, Yang Y, Wang Y, Han L, Wang Q; Chinese Glioma Cooperative Group (CGCG); Society for Neuro‐Oncology of China (SNO-China); Chinese Brain Cancer Association (CBCA); Chinese Glioma Genome Atlas (CGGA); Asian Glioma Genome Atlas (AGGA) network. Clinical practice guidelines for the management of adult diffuse gliomas. Cancer Lett. 2021 Feb 28;499:60-72. doi: 10.1016/j.canlet.2020.10.050. Epub 2020 Nov 6. PMID: 33166616.

Parkinson’s Disease Treatment Guidelines

Parkinson’s Disease Treatment Guidelines

An update of the Parkinson’s Disease treatment Guidelines was commissioned by the European Academy of Neurology and the European section of the Movement Disorder Society. Although these treatments are initiated usually in specialized centers, the general neurologist should know the therapies and their place in the treatment pathway.

Grading of Recommendations Assessment, Development, and Evaluation (GRADEmethodology was used to assess the spectrum of approved interventions including deep brain stimulation (DBS) or brain lesioning with different techniques (radiofrequency thermocoagulationradiosurgery, magnetic resonance imaging-guided focused ultrasound surgery [MRgFUS] of the following targets: subthalamic nucleus [STN], ventrolateral thalamus, and pallidum internum [GPi]). Continuous delivery of medication subcutaneously (apomorphine pump) or through percutaneous ileostomy (Intrajejunal levodopa-carbidopa therapy) [LCIG]) was also included. Changes in motor features, health-related quality of life (QoL), adverse effects, and further outcome parameters were evaluated. Recommendations were based on high-class evidence and graded in three gradations. If only lower class evidence was available but the topic was felt to be of high importance, a clinical consensus of the guideline task force was gathered.

Two research questions have been answered with eight recommendations and five clinical consensus statements. Invasive therapies are reserved for specific patient groups and clinical situations mostly in the advanced stage of Parkinson’s disease (PD). Interventions may be considered only for special patient profiles, which are mentioned in the text. Therapy effects are reported as a change compared with current medical treatment. Subthalamic deep brain stimulation for Parkinson’s disease is the best-studied intervention for advanced disease with fluctuations not satisfactorily controlled with oral medications; it improves motor symptoms and QoL, and treatment should be offered to eligible patients. GPi-DBS can also be offered. For early PD with early fluctuations, STN-DBS is likely to improve motor symptoms, and QoL and can be offered. DBS should not be offered to people with early PD without fluctuations. LCIG and an apomorphine pump can be considered for advanced PD with fluctuations not sufficiently managed with oral treatments. Unilateral MRgFUS of the STN can be considered for distinctly unilateral PD within registries. The clinical consensus was reached on the following statements: Radiosurgery with gamma radiation cannot be recommended, unilateral radiofrequency thermocoagulation of the pallidum for advanced PD with treatment-resistant fluctuations, and unilateral radiofrequency thermocoagulation of the thalamus for resistant tremor can be recommended if other options are not available, unilateral MRgFUS of the thalamus for medication-resistant tremor of PD can be considered only within registries, and unilateral MRgFUS of the pallidum is not recommended.

Evidence for invasive therapies in PD is heterogeneous. Only some of these therapies have a strong scientific basis 1) 2).


European Academy of Neurology/Movement Disorder Society-European Section Guidelines on Pallidotomy for Parkinson’s Disease 3).



1)

Deuschl G, Antonini A, Costa J, Śmiłowska K, Berg D, Corvol JC, Fabbrini G, Ferreira J, Foltynie T, Mir P, Schrag A, Seppi K, Taba P, Ruzicka E, Selikhova M, Henschke N, Villanueva G, Moro E. European Academy of Neurology/Movement Disorder Society-European Section Guideline on the Treatment of Parkinson’s Disease: I. Invasive Therapies. Mov Disord. 2022 Jul;37(7):1360-1374. doi: 10.1002/mds.29066. Epub 2022 Jul 6. PMID: 35791767.
2)

Deuschl G, Antonini A, Costa J, Śmiłowska K, Berg D, Corvol JC, Fabbrini G, Ferreira J, Foltynie T, Mir P, Schrag A, Seppi K, Taba P, Ruzicka E, Selikhova M, Henschke N, Villanueva G, Moro E. European Academy of Neurology/Movement Disorder Society – European Section guideline on the treatment of Parkinson’s disease: I. Invasive therapies. Eur J Neurol. 2022 Sep;29(9):2580-2595. doi: 10.1111/ene.15386. Epub 2022 Jul 6. PMID: 35791766.
3)

Hariz M, Bronstein JM, Cosgrove GR, de Bie RMA, DeLong MR, Gross RE, Krack P, Krauss JK, Lang AE, Lees AJ, Lozano AM, Obeso JA, Schuurman PR, Vitek JL. European Academy of Neurology/Movement Disorder Society-European Section Guidelines on Pallidotomy for Parkinson’s Disease: Let’s Be Accurate. Mov Disord. 2022 Sep 1. doi: 10.1002/mds.29210. Epub ahead of print. PMID: 36047463.

Pediatric traumatic brain injury guidelines

Pediatric traumatic brain injury guidelines

see Guidelines for the Management of Pediatric Severe Traumatic Brain Injury, Third Edition

In a systematic review and guideline appraisal for pediatric clinical practice guidelines (CPGs) concerning the acute management of Pediatric Traumatic Brain Injury. Targeted guideline creation specific to the pediatric population has the potential to improve the quality of acute TBI clinical practice guidelines (CPGs).

Furthermore, it is crucial to address the applicability of a guideline to translate the CPG from a published manuscript into clinically relevant local practice tools and for resource limited practice settings 1).

Guidelines for Diagnosing and Managing Pediatric Concussion

Guidelines.


Thromboprophylaxis in Traumatic brain injury:

Low-molecular-weight heparin (LMWH) prophylaxis in pediatric traumatic brain injury appears to be more effective than unfractionated heparin (UH) in preventing venous thromboembolism (VTE). Large, multicenter prospective studies are warranted to confirm the superiority of LMWH over UH in pediatric patients with traumatic brain injury. Moreover, outcomes of VTE prophylaxis in the very young remain understudied; therefore, dedicated studies to evaluate this population are needed 2).


1)

Appenteng R, Nelp T, Abdelgadir J, Weledji N, Haglund M, Smith E, Obiga O, Sakita FM, Miguel EA, Vissoci CM, Rice H, Vissoci JRN, Staton C. A systematic review and quality analysis of pediatric traumatic brain injury clinical practice guidelines. PLoS One. 2018 Aug 2;13(8):e0201550. doi: 10.1371/journal.pone.0201550. eCollection 2018. PubMed PMID: 30071052; PubMed Central PMCID: PMC6072093.
2)

van Erp IA, Gaitanidis A, El Moheb M, Kaafarani HMA, Saillant N, Duhaime AC, Mendoza AE. Low-molecular-weight heparin versus unfractionated heparin in pediatric traumatic brain injury. J Neurosurg Pediatr. 2021 Feb 12:1-6. doi: 10.3171/2020.9.PEDS20615. Epub ahead of print. PMID: 33578391.

Aneurysmal Subarachnoid Hemorrhage Guidelines

Aneurysmal Subarachnoid Hemorrhage Guidelines

https://www.ahajournals.org/doi/full/10.1161/str.0b013e3182587839

Connolly ES Jr, Rabinstein AA, Carhuapoma JR, Derdeyn CP, Dion J, Higashida RT, Hoh BL, Kirkness CJ, Naidech AM, Ogilvy CS, Patel AB, Thompson BG, Vespa P; American Heart Association Stroke Council; Council on Cardiovascular Radiology and Intervention; Council on Cardiovascular Nursing; Council on Cardiovascular Surgery and Anesthesia; Council on Clinical Cardiology. Guidelines for the management of aneurysmal subarachnoid hemorrhage: a guideline for healthcare professionals from the American Heart Association/american Stroke Association. Stroke. 2012 Jun;43(6):1711-37. doi: 10.1161/STR.0b013e3182587839. Epub 2012 May 3. PubMed PMID: 22556195 1).

Hospital Characteristics and Systems of Care

According to current Aneurysmal Subarachnoid Hemorrhage Guidelines (aSAH) patients are mostly managed in intensive care units (ICU) regardless of baseline severity.

Low-volume hospitals (eg, <10 aSAH cases per year) should consider early transfer of patients with aSAH to high-volume centers (eg, >35 aSAH cases per year) with experienced cerebrovascular surgeons, endovascular specialists, and multidisciplinary neuro-intensive care services (Class I; Level of Evidence B). (Revised recommendation from previous guidelines)

Annual monitoring of complication rates for surgical and interventional procedures is reasonable (Class IIa; Level of Evidence C). (New recommendation)

A hospital credentialing process to ensure that proper training standards have been met by individual physicians treating brain aneurysms is reasonable (Class IIa; Level of Evidence C). (New recommendation) 2).


The adjusted odds of definitive repair were significantly higher in urban teaching hospitals than in urban nonteaching hospitals (odds ratio, 1.62) or rural hospitals (odds ratio, 3.08).7 In another study from 1993 to 2003, teaching status and larger hospital size were associated with higher charges and longer stay but also with better outcomes (P<0.05) and lower mortality rates (P<0.05), especially in patients who underwent aneurysm clipping (P<0.01). Endovascular treatment, which was more often used in the elderly, was also associated with significantly higher mortality rates in smaller hospitals (P<0.001) and steadily increasing morbidity rates (45%). Large academic centers were associated with better results, particularly for surgical clip placement 3).


Llull et al. from a Comprehensive Stroke Center in Barcelona assessed the prognostic and economic implications of initial admission of low-grade aSAH patients into a Stroke Unit (SU) compared to initial ICU admission.

They reviewed prospectively registered data from consecutive aSAH patients with a WFNS grade lower than 3 admitted at a Comprehensive Stroke Center between April-2013 and September-2018. Clinical and radiological baseline traits, in-hospital complications, length of hospital stay (LOS) and poor outcome at 90 days (modified Rankin Scale >2) were compared between the ICU and SU groups in the whole population and in a propensity score matched cohort.

From 131 patients, 74 (56%) were initially admitted in the ICU and 57 (44%) in the SU. In-hospital complication rates were similar in the ICU and SU groups and included rebleeding (10% vs 7%, p=0.757), angiographic vasospasm (61% vs 60%, p=0.893), delayed cerebral ischemia (12% vs 12%, p=0.984), pneumonia (6% vs 4%, p=0.697) and death (10% vs 5%, p=0.512). LOS did not differ across both groups [median (IQR) 22 (16-30) vs 19 (14-26) days, p=0.160]. In adjusted multivariate models, the location of initial admission was not associated with long-term poor outcome either in the whole population (OR=1.16, 95%CI=0.32-4.19, p=0.825) or in the matched cohort (OR=0.98, 95%CI=0.24-4.06, p=0.974).

A dedicated SU cared by a multidisciplinary team might be an optimal alternative to ICU to initially admit patients with low-risk aSAH 4).


Bederson JB, Connolly ES Jr, Batjer HH, Dacey RG, Dion JE, Diringer MN, Duldner JE Jr, Harbaugh RE, Patel AB, Rosenwasser RH; American Heart Association. Guidelines for the management of aneurysmal subarachnoid hemorrhage: a statement for healthcare professionals from a special writing group of the Stroke Council, American Heart Association. Stroke. 2009 Mar;40(3):994-1025. doi: 10.1161/STROKEAHA.108.191395. Epub 2009 Jan 22. Review. Erratum in: Stroke. 2009 Jul;40(7):e518. PubMed PMID: 19164800. 5).

References

1) , 2)

Connolly ES Jr, Rabinstein AA, Carhuapoma JR, Derdeyn CP, Dion J, Higashida RT, Hoh BL, Kirkness CJ, Naidech AM, Ogilvy CS, Patel AB, Thompson BG, Vespa P; American Heart Association Stroke Council; Council on Cardiovascular Radiology and Intervention; Council on Cardiovascular Nursing; Council on Cardiovascular Surgery and Anesthesia; Council on Clinical Cardiology. Guidelines for the management of aneurysmal subarachnoid hemorrhage: a guideline for healthcare professionals from the American Heart Association/american Stroke Association. Stroke. 2012 Jun;43(6):1711-37. doi: 10.1161/STR.0b013e3182587839. Epub 2012 May 3. PubMed PMID: 22556195.
3)

Andaluz N, Zuccarello M. Recent trends in the treatment of cerebral aneurysms: analysis of a nationwide inpatient database. J Neurosurg. 2008 Jun;108(6):1163-9. doi: 10.3171/JNS/2008/108/6/1163. PMID: 18518722.
4)

Llull L, Mayà G, Torné R, Mellado R, Renú A, López-Rueda A, Laredo C, Culebras D, Ferrando C, Blasco J, Amaro S, Chamorro Á. Stroke Units could be a valid alternative to Intensive Care Units for low-grade aneurysmal subarachnoid haemorrhage patients. Eur J Neurol. 2020 Sep 22. doi: 10.1111/ene.14548. Epub ahead of print. PMID: 32961609.
5)

Bederson JB, Connolly ES Jr, Batjer HH, Dacey RG, Dion JE, Diringer MN, Duldner JE Jr, Harbaugh RE, Patel AB, Rosenwasser RH; American Heart Association. Guidelines for the management of aneurysmal subarachnoid hemorrhage: a statement for healthcare professionals from a special writing group of the Stroke Council, American Heart Association. Stroke. 2009 Mar;40(3):994-1025. doi: 10.1161/STROKEAHA.108.191395. Epub 2009 Jan 22. Review. Erratum in: Stroke. 2009 Jul;40(7):e518. PubMed PMID: 19164800.

COVID-19 Clinical Practice Guidelines

COVID-19 Clinical Practice Guidelines
Stay current on new guidelines and recommendations.
View Guidelines
New COVID-19 Clinical Guidelines, including the following:
CDC Guidelines for Evaluating and Testing Persons Under Investigation ›
CDC Guidelines for Collecting, Handling, and Testing Clinical Specimens from Persons ›
FDA Guidance on Face Masks ›
CMS Guidance for Infection Control and Prevention in Nursing Homes ›
ACC Guidance on Cardiac Implications ›
ISUOG Guidance on COVID-19 During Pregnancy and Puerperium ›
AAO Guidance on COVID-19 for Ophthalmologists ›
CMS Guidance on Containing Hospital Spread of COVID-19 ›
CPAM Rapid Advice Guidelines ›

Scandinavian guidelines for initial management of minimal, mild, and moderate head injuries

Scandinavian guidelines for initial management of minimal, mild, and moderate head injuries

The Scandinavian Neurotrauma Committee (SNC) published practical, evidence based guidelines for children with Glasgow Coma Scale (GCS) scores of 9-15.

The Scandinavian Guidelines for Initial Management of Minimal, Mild, and Moderate Head Injuries in Adults (Scandinavian guidelines) are the first to incorporate serum measurement of the S100 astroglial calcium-binding protein B (S100B) to emergency department (ED) triage of patients with head injury (HI).

1).


A prospective validation study was conducted in the ED of the Tampere University Hospital, Finland, between November 2015 to November 2016. All consecutive adult patients with HI presenting to the ED within 24 hours from injury were eligible for inclusion. Venous blood for S100B sampling was drawn from all patients and the result was available at the ED. Head CTs were performed according to the on-call physician’s evaluation. Only the samples collected within 6 hours after injury were used. A one-week follow-up was conducted to identify possible HI-related complications. A total of 295 patients (median age=67.0 years, range=18-100; women=48.8%) were enrolled. Of those, 196 (66.4%) were scanned. Acute traumatic lesions were detected on 31 (15.8%) of the scans. Two of the CT-positive patients were scanned without a guidelines-based indication. These lesions did not require any specific treatment or repeated imaging. The guidelines-based sensitivity was 0.94 (95% CI=0.77-0.99) and specificity 0.19 (95% CI=0.13-0.26) for predicting traumatic intracranial CT abnormalities. The positive and negative predictive value for positive head CT was 0.18 (95% CI=0.12-0.25) and 0.94 (95% CI=0.78-0.99), respectively. In the mild-low risk group, no false negative S100B values were recorded. Thirteen patients (4.4%) were re-admitted to the ED and 2 patients (0.7%) died one week after the primary HI. The deaths were unrelated to the injury. None of these adverse events were directly caused by a primarily undiagnosed intracranial injury. The Scandinavian guidelines incorporated with S100B are a valid means of screening clinically significant acute traumatic lesions following HI and have the potential to reduce unnecessary CT scanning 2).


In a large prospective cohort of children (< 18 years) with TBI of all severities, from ten Australian and New Zealand hospitals, was used to assess the SNC guidelines. Firstly, a validation study was performed according to the inclusion and exclusion criteria of the SNC guideline. Secondly, they compared the accuracy of SNC, CATCH, CHALICE and PECARN CDRs in patients with GCS 13-15 only. Diagnostic accuracy was calculated for outcome measures of need for neurosurgery, clinically important TBI (ciTBI) and brain injury on CT.

The SNC guideline could be applied to 19,007/20,137 of patients (94.4%) in the validation process. The frequency of ciTBI decreased significantly with stratification by decreasing risk according to the SNC guideline. Sensitivities for the detection of neurosurgery, ciTBI and brain injury on CT were 100.0% (95% CI 89.1-100.0; 32/32), 97.8% (94.5-99.4; 179/183) and 95% (95% CI 91.6-97.2; 262/276), respectively, with a CT/admission rate of 42% (mandatory CT rate of 5%, 18% CT or admission and 19% only admission). Four patients with ciTBI were missed; none needed specific intervention. In the homogenous comparison cohort of 18,913 children, the SNC guideline performed similar to the PECARN CDR, when compared with the other CDRs.

The SNC guideline showed a high accuracy in a large external validation cohort and compares well with published CDRs for the management of paediatric TBI 3).

References

1)

Ingebrigtsen T, Romner B, Kock-Jensen C. Scandinavian guidelines for initial management of minimal, mild, and moderate head injuries. The Scandinavian Neurotrauma Committee. J Trauma. 2000 Apr;48(4):760-6. PubMed PMID: 10780615.
2)

Minkkinen M, Iverson GL, Kotilainen AK, Pauniaho SL, Mattila V, Lehtimäki T, Berghem K, Posti JP, Luoto TM. Prospective Validation of the Scandinavian Guidelines for Initial Management of Minimal, Mild, and Moderate Head Injuries in Adults. J Neurotrauma. 2019 May 21. doi: 10.1089/neu.2018.6351. [Epub ahead of print] PubMed PMID: 31111795.
3)

Undén J, Dalziel SR, Borland ML, Phillips N, Kochar A, Lyttle MD, Bressan S, Cheek JA, Neutze J, Donath S, Hearps S, Oakley E, Dalton S, Gilhotra Y, Babl FE; Paediatric Research in Emergency Departments International Collaborative (PREDICT). External validation of the Scandinavian guidelines for management of minimal, mild and moderate head injuries in children. BMC Med. 2018 Oct 12;16(1):176. doi: 10.1186/s12916-018-1166-8. PubMed PMID: 30309392; PubMed Central PMCID: PMC6182797.

Guidelines for the Management of Severe Traumatic Brain Injury, Fourth Edition

The scope and purpose of the Guidelines for the Management of Severe Traumatic Brain Injury, Fourth Edition. is 2-fold: to synthesize the available evidence and to translate it into recommendations. This document provides recommendations only when there is evidence to support them. As such, they do not constitute a complete protocol for clinical use.
The intention is that these recommendations be used by others to develop treatment protocols, which necessarily need to incorporate consensus and clinical judgment in areas where current evidence is lacking or insufficient.
Carney et al. think it is important to have evidence-based recommendations to clarify what aspects of practice currently can and cannot be supported by evidence, to encourage use of evidence-based treatments that exist, and to encourage creativity in treatment and research in areas where evidence does not exist. The communities of neurosurgery and neurointensive care have been early pioneers and supporters of evidence based medicine and plan to continue in this endeavor. The complete guideline document, which summarizes and evaluates the literature for each topic, and supplemental appendices (A-I) are available online at https://www.braintrauma.org/coma/guidelines 1).
4th edition
Free article of Neurosurgery

1) Carney N, Totten AM, OʼReilly C, Ullman JS, Hawryluk GW, Bell MJ, Bratton SL, Chesnut R, Harris OA, Kissoon N, Rubiano AM, Shutter L, Tasker RC, Vavilala MS, Wilberger J, Wright DW, Ghajar J. Guidelines for the Management of Severe Traumatic Brain Injury, Fourth Edition. Neurosurgery. 2016 Sep 20. [Epub ahead of print] PubMed PMID: 27654000.