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Living guidelines updates

The Stroke Foundation’s Clinical Guidelines for Stroke Management have evolved into the world's first living stroke guidelines as the next generation of health evidence translation.

This three-year pilot project is building and evaluating a dynamically updating summary of stroke evidence to guide clinical practice and policy development.

Draft recommendations are posted here during public consultation.

On this page:
New and updated recommendations
Draft recommendations for public consultation
Changes to background evidence or text including practical information
How living guidelines work
Suggest new topics or questions

New and updated recommendations

Recommendations for the following topics have been updated based on new research evidence, in accordance with the 2011 NHMRC Standard for clinical practice guidelines.

Topic Date Change
Acute antiplatelet therapy (Chapter 3) 11/02/2021 A new drug, ticagrelor, in combination with aspirin soon after a minor ischaemic stroke or high-risk transient ischaemic attack, may be considered to prevent another stroke.
Oxygen therapy (Chapter 3)
11/02/2021 More specific targets and thresholds set for blood oxygen levels, above which supplemental oxygen should not be given.
Cholesterol lowering therapy (Chapter 4) 11/02/2021 A new target set for lowering LDL cholesterol to prevent further strokes and cardiovascular disease.
Weakness (Chapter 5) 11/02/2021 Added new evidence for recovery of muscle strength with progressive resistance training. Also a new recommendation for certain types of repetitive practice.
Shoulder pain (Chapter 6) 11/02/2021 Electrical stimulation may now be used for pain management, when previously it was recommended against. Acupuncture may also be used to reduce pain.
Thrombolysis (Chapter 3) 7/11/2019 Time window for intravenous thrombolysis extended up to 9 hours after a person has had their stroke, if brain scans show they will benefit. The 9 hours can be counted from the mid-point of sleep if the person woke up with stroke symptoms. Tenecteplase may also be used in thrombolysis as an alternative to alteplase, especially for people with a blockage in large brain arteries.
Acute antithrombotic therapy (Chapter 3) 7/11/2019 Upgrade to strong recommendation for taking the antiplatelet medications aspirin and clopidogrel together in the first three weeks after a minor stroke or transient ischaemic attack (TIA).
Patent foramen ovale (PFO) management (Chapter 4) 7/11/2019 Closing a PFO (patent foramen ovale) is recommended when people under 60 years old have had a stroke, and other possible causes of their stroke have been ruled out.

See all current recommendations in the Clinical Guidelines for Stroke Management.


Draft recommendations for public consultation

When new research evidence leads to a change in recommendations, our Guidelines Working Group prepares drafts to be submitted to the NHMRC for approval under section 14A of the National Health and Medical Research Council Act 1992.

As part of the approval process, we are seeking public submissions on the following draft recommendations. Submissions must be received by 5pm, Friday 30 April 2021.

You can make a submission by following the links below to the MAGICapp platform, and leaving a comment under the Feedback tab below each recommendation. Please note you need to sign in to MAGICapp to leave a comment. Create an account for free at MAGICapp.org.

Topic Change
Antiplatelet therapy (Chapter 4) New weak recommendation for resuming antiplatelet therapy for secondary prevention in patients who have had an intracerebral haemorrhage, based on the RESTART trial.
Standing balance (Chapter 5)
Split into strong recommendation for functional standing activities that challenge balance, and weak recommendation for additional interventions that may be used.
Activities of daily living (Chapter 5)
Recommendation against routinely using acupuncture to improve activities of daily living (ADL) updated from strong to weak. Also now a weak recommendation against using selective serotonin reuptake inhibitors to reduce disability.
Fatigue (Chapter 6) Minor wording change to consensus-based recommendation, including a reference to cognitive behavioural therapy.
Sexuality (Chapter 8) Minor wording change to clarify consensus-based recommendation.


Changes to background evidence or text including practical information

Minor changes have been made to a number of topics. These are summarised below and can be found in the Clinical Guidelines for Stroke Management.

Topic Date Comment
Contracture (Chapter 6) 16/03/2021 Minor wording change and updated evidence, rationale and practical info for recommendation against routine use of splints and stretch.
Thrombolysis (Chapter 3) 12/02/2021 Updated eligibility criteria under practical info for intravenous thrombolysis within 4.5 hours of stroke onset.
Home assessment (Chapter 7) 12/02/2021 Added practical info about assistive technology for safe discharge and OT home visits.
Sexuality (Chapter 8) 12/02/2021 Added background evidence and practical info.
Peer support (Chapter 8) 12/02/2021 Updated evidence and rationale, and added practical info.
Management of atrial fibrillation (Chapter 4) (formerly Anticoagulant therapy) 8/09/2020 Updated background evidence and practical info for use of oral anticoagulation. 
Pre-hospital care (Chapter 1)
Updated practical info for interventions by paramedics.
Cholesterol lowering therapy (Chapter 4) 10/06/2020 Updated practical info for use of statins after ischaemic stroke or TIA.
Cervical artery dissection (Chapter 4) 10/06/2020
Added outcomes of new reference to evidence summary, and benefits and harms under evidence to decision.
Hormone replacement therapy (Chapter 4) 10/06/2020
Added new reference to benefits and harms under evidence to decision.
Oral contraception (Chapter 4) 10/06/2020
Updated rationale and practical info for weak recommendation about oral contraception after stroke.


How living guidelines work

The living guidelines use ‘evidence surveillance’ systems that continually scan for relevant new research, incorporate it into evidence summaries and rapidly update guideline recommendations whenever there is a substantial change in the evidence.

The ultimate goal is to create a near real-time, closed-loop evidence system in which global evidence and local data are integrated for insight and health decision making.

This work will be supported by new evidence systems from Cochrane Australia, including artificial intelligence, the Cochrane Crowd citizen science community, and the Covidence online systematic review platform.

Guideline recommendations will continue to be developed and published using the MAGICapp platform.

Diagram of how the evidence summaries turn newly published research and clinical practice data into updated recommendations, which then feed into clinical practice and policy

For more information on the methodology and processes, see Guidelines supporting information.

Suggest a new topic or question

To keep our living guidelines relevant, we annually review the topics the guidelines cover and the questions about practice that they answer. The current topics make up the table of contents of the Clinical Guidelines.

We welcome your suggestions for new topics that you believe are critical to include. New topics will be considered during our project steering committee's annual review.

Please email your suggestions to guidelines@strokefoundation.org.au


For more information or to consider volunteering in the expert working group, please contact guidelines@strokefoundation.org.au

This project is a partnership between the Stroke Foundation and Cochrane Australia, and is supported by the Australian government’s Medical Research Future Fund.

Cochrane Australia