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.

We continually monitor for new evidence relevant to the guideline topics. Any topics that have not been updated can be considered current.

On this page:

Draft recommendations for public consultation
New and updated recommendations
Versions published including minor changes
Suggest new topics or questions

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.

There are currently no draft recommendations for public consultation.

New and updated recommendations

Recommendations for the following topics have been updated based on new research evidence, in accordance with the 2016 NHMRC Standards for Guidelines.

Topic	Date	Change
Management of atrial fibrillation (Chapter 4)	8/12/2023	Updated weak recommendation based on a major new trial that specifies when to commence or recommence anticoagulation after ischaemic stroke.
Neurointervention (Chapter 3)	27/07/2023	Consolidated into one recommendation for endovascular clot retrieval in the internal carotid artery, middle cerebral artery, or basilar artery within 0–24 hours. Added a consensus-based recommendation for extending the time window for clot retrieval past 24 hours if imaging suggests there is salvageable brain tissue.
Oxygen therapy (Chapter 3)	27/07/2023	Oxygen therapy to be considered when the saturation (SpO₂) is less than 92% instead of less than 93%, and the target oxygen level changed to 92–96%, in line with the updated position statement from the Thoracic Society of Australia and New Zealand.
Central post-stroke pain (Chapter 6)	27/07/2023	New topic, with a consensus-based recommendation for cautious trials with planned follow-up of tricyclic antidepressant or antiepileptic medication to reduce pain, and non-pharmacological interventions only to be used within a research framework.
Driving (Chapter 8)	27/07/2023	Updated consensus recommendation, including non-driving periods following stroke or TIA and the process for fitness-to-drive assessments, to be consistent with the new edition of Assessing Fitness to Drive by Austroads (2022) and to include the Medical Aspects of Fitness to Drive by Waka Kotahi NZ Transport Agency.
Aphasia (Chapter 6)	6/12/2022	Communication partner training should be provided to health professionals or volunteers who interact with people with aphasia after stroke, and it may also be provided to their carers or family members.
Urinary incontinence (Chapter 6)	6/12/2022	Weak recommendation for structured continence management plans, for patients in hospital with confirmed continence difficulties, updated with new evidence.
Pre-hospital care (Chapter 1)	5/08/2022	New recommendation for pre-hospital treatment in a mobile stroke unit, for eligible patients in major cities.
Assessment for rehabilitation (Chapter 3)	5/08/2022	Updated wording in practice point to clarify that options include locally developed assessment tools (not subject to public consultation).
Aphasia (Chapter 5)	5/08/2022	Speech and language therapy now recommended to improve reading and auditory comprehension, and general expressive and written language, in addition to functional communication. Upgraded from weak to strong recommendation for early aphasia therapy starting in the first 4 weeks post stroke. New weak recommendation for intensive aphasia therapy for stroke survivors with chronic aphasia, plus changes to weak recommendation for intensity of aphasia therapy in the acute phase. Updated wording in weak recommendation against brain stimulation.
Dysarthria (Chapter 5)	5/08/2022	Tailored interventions that include speech production tasks targeting connected speech may be provided, e.g. reducing rate of speaking, emphasising articulatory placement or increasing loudness. Removed recommendation against non-speech oromotor exercises, which is addressed in the practical info of the main recommendation.
Prevention of depression (Chapter 6)	5/08/2022	Changed from weak recommendation against to weak recommendation for antidepressant medication.
Treatment for depression (Chapter 6)	5/08/2022	Recommendation for antidepressants changed from strong to weak, plus new recommendation that psychological therapy may be used, and updated recommendation for structured exercise programs to include resistance training. Non-invasive brain stimulation changed to weak recommendation for, from weak against.
Treatment for anxiety (Chapter 6)	5/08/2022	New consensus recommendation that psychological therapy and/or relaxation strategies may be trialled, with the addition of pharmacotherapy carefully considered.
Personality and behaviour (Chapter 6)	5/08/2022	New consensus recommendation that behavioural changes should be assessed and addressed through individually tailored interventions for survivors of stroke and their families/carers.
Pressure injury (Chapter 6)	5/08/2022	Reestablished practice point that staff and carers of patients at risk of pressure injuries should be trained to assess, provide care and treat pressure injuries consistent with existing guidelines.
Pre-hospital care (Chapter 1)	22/12/2021	New practice point for regular education to help clinicians identify stroke patients.
Acute stroke telehealth services (Chapter 3)	22/12/2021	New topic with recommendation for telestroke systems to help assess patients for thrombolysis and transfer for endovascular therapy, where 24/7 onsite specialists are unavailable.
Head position (Chapter 3)	22/12/2021	New topic with recommendation that any position may be used in the first 24 hours after hospital admission, while in bed and not receiving nasogastric feeding.
Management of atrial fibrillation (Chapter 4)	22/12/2021	Closing off the opening to the left atrial appendage may be reasonable when long-term anticoagulation is not possible.
Lifestyle modifications (Chapter 4)	22/12/2021	Everyone who has had a stroke or TIA may be given interventions addressing secondary stroke risk factors, with support and counselling, reviews by health care professionals, and exercise training. Also, a new consensus recommendation for a Mediterranean or similar style diet, and referral to a dietitian for individualised advice.
Arm activity (Chapter 5)	22/12/2021	Virtual reality and interactive games may now be used with any timing and duration, and independently of impairment severity.
Memory (Chapter 5)	22/12/2021	Cognitive rehabilitation, including both internal strategies and external aids, may be used to improve memory function in the short term.
Telehealth in rehabilitation (Chapter 5)	22/12/2021	New topic with recommendation that telehealth services may be used as an adjunct to in-person therapy, or an alternative for patients who cannot access specialist rehab in the community.
Swelling of the extremities (Chapter 6)	22/12/2021	Passive mobilisation is now recommended for prevention and management, along with elevation of the limb when resting.
Antiplatelet therapy (Chapter 4)	7/07/2021	Restarting antiplatelet therapy can be considered after the acute phase of an intracerebral haemorrhage if the person was previously on antithrombotic therapy.
Standing (Chapter 5)	7/07/2021	Recommendation for task-specific practice now split into a strong recommendation for activities that challenge balance, plus a weak recommendation for adding on virtual reality training, visual or auditory feedback or electromechanical assistance.
Activities of daily living (Chapter 5)	7/07/2021	Updated from strong recommendation against to a weak recommendation against routinely using acupuncture to improve activities of daily living. In addition, a new weak recommendation against using selective serotonin reuptake inhibitors to reduce disability.
Fatigue (Chapter 6)	7/07/2021	Minor wording changes and a mention of cognitive behavioural therapy as a possible intervention.
Sexuality (Chapter 8)	7/07/2021	New evidence added, but no change in recommendation apart from minor wording changes.
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.

Versions published including minor changes

In addition to public consultations and recommendation updates listed above, the guidelines are republished in MAGICapp whenever there is new evidence added, or changes to practical information or other text.

These various changes are listed below, with the version number of each chapter. Please note that some versions are not listed as they were either published for administrative reasons with no important changes, or multiple versions were published on the same day and only the last one is listed.

A full version history be found in the Clinical Guidelines for Stroke Management.

NOTE: Chapters and topics that have note been updated can be considered current, with new evidence being monitored but nothing identified.

Chapter	Version	Date	Comment
8 Community participation and long-term care	v7.0	11/01/2023	Public consultation opens for changes to driving recommendation.
5 Rehabilitation	v10.0	9/12/2022	New recommendations for the aphasia topic.
6 Managing complications	v10.0	9/12/2022	Update to the recommendation for the urinary incontinence topic.
5 Rehabilitation	v9.1	12/09/2022	Release of public consultation for communication partner training recommendations.
6 Managing complications	v9.1	12/09/2022	Public consultation opens for minor change to incontinence recommendation.
3 Acute medical and surgical management	v10.3	5/08/2022	Updated introduction following approved topics by NHMRC. Updated background references for several topics (reperfusion, acute blood pressure, ICH management).
1 Pre-hospital care	v8.2	9/05/2022	Republished post public consultation.
6 Managing complications	v8.1	1/04/2022	Added new draft recommendation for personality and behaviour.
1 Pre-hospital care	v8.0	16/03/2022	New (draft) recommendation for mobile stroke units for public consultation.
3 Acute medical and surgical management	v10.2	20/01/2022	Published post approval of multiple topics by NHMRC.
6 Managing complications	v7.10	20/01/2022	Published due to approval of several topics by NHMRC.
6 Managing complications	v7.9	5/11/2021	Added new evidence for urge incontinence, and decision aid for specialised professional input.
6 Managing complications	v7.6	11/08/2021	Updating heading after public consultation.
7 Discharge planning and transfer of care	v5.5	1/07/2021	Added practical info for carer training.
4 Secondary prevention	v8.6	15/06/2021	Update to lifestyle modification recommendations for public consultation.
5 Rehabilitation	v7.0	10/06/2021	Updated evidence for walking and added decision aids.
3 Acute medical and surgical management	v10.1	8/06/2021	Updated evidence for recommendations about decompressive hemicraniectomy surgery for ischaemic stroke.
4 Secondary prevention	v8.5	7/06/2021	Updated recommendation for management of atrial fibrillation.
6 Managing complications	v7.3	7/06/2021	Draft updates to swelling of the extremities.
1 Pre-hospital care	v6.8	3/06/2021	New (second) draft practice point for public consultation June 2021.
4 Secondary prevention	v8.4	25/05/2021	Added practical info to cerebral venous sinus thrombosis, with advice related to COVID-19 vaccines.
6 Managing complications	v7.2	13/05/2021	Oral hygiene: updated evidence and practical info. Subluxation: added new evidence and decision aids for consensus-based recommendation on use of supports and slings.
1 Pre-hospital care	v6.7	5/05/2021	Updated evidence for recommendation about ambulance services transferring suspected stroke patients and pre-notifying hospital.
5 Rehabilitation	v6.1	17/03/2021	Arm activity: updated evidence, moved information on trunk restraint during therapy to practical info of strong recommendation for constraint-induced movement therapy. Visual field loss: added practical info about screening of visual function and daily living with visual field loss post stroke. Standing balance: updated practical info for virtual reality recommendation, and added decision aids. Activities of daily living: added new evidence, updated and added practical info for several recommendations. Perception: added practical info about assessing perceptual difficulties. Attention and concentration: added and updated evidence. Executive function: added new evidence and updated practical info. Neglect: updated evidence and practical info.
4 Secondary prevention	v8.1	16/03/2021	Previous draft recommendation for cholesterol lowering now approved by NHMRC. New draft antiplatelet therapy recommendation for ICH, updated evidence, included new brand names in practical info, and added decision aids. Updated evidence for carotid surgery, added and updated practical info for all recommendations, to describe optimal medical management. Fixed typos for blood pressure recommendation.
6 Managing complications	v7.1	16/03/2021	Contracture: minor wording change and updated evidence, rationale and practical info for recommendation against routine use of splints and stretch. Subluxation: added new evidence to recommendation for electrical stimulation. Faecal incontinence: practical info added, including link to recommendations from Continence Foundation of Australia, and an assessment and treatment protocol flowchart. Prevention of depression: updated evidence, removed decision aid for psychotherapy. Deep venous thrombosis or pulmonary embolism: added evidence and decision aids to practice points.
1 Pre-hospital care	v6.6	12/02/2021	Added new reference to resources considerations under evidence to decision, and to practical info.
2 Early assessment and diagnosis	v6.5	12/02/2021	Minor changes to introduction based on new approved topics by NHMRC.
3 Acute medical and surgical management	v9.0	12/02/2021	Updated eligibility criteria under practical info for intravenous thrombolysis within 4.5 hours of stroke onset.
7 Discharge planning and transfer of care	v5.4	12/02/2021	Added new evidence to information and education, and added practical info to home assessment about assistive technology for safe discharge and OT home visits.
8 Community participation and long-term care	v6.1	12/02/2021	Added new evidence for self-management and return to work; replaced decision aid for leisure with practical info; added background evidence, practical info and decision aid for sexuality; and updated evidence and rationale for peer support and replaced decision aid with practical info.
3 Acute medical and surgical management	v8.3	16/09/2020	New draft recommendation added for Aspirin plus ticagrelor in minor stroke and TIA. Fixed minor spelling errors.
5 Rehabilitation	v6.0	11/09/2020	Changes to recommendations for weakness. Changes to the structure. Added new evidence to commencement of rehabilitation (formerly early mobilisation), new reference to resources considerations for goal setting, and practical info to practice point on screening for limb apraxia.
6 Managing complications	v6.0	11/09/2020	Changes to recommendations for shoulder pain. Updated background evidence in weak recommendation against use of stretch for spasticity, added new background evidence for strapping for shoulder pain, updated background evidence for treatment for emotionalism (formerly treatment for emotional distress), updated background evidence and added decision aids for treatment for depression, and updated background evidence and practical info for falls.
4 Secondary prevention	v7.0	8/09/2020	New recommendation for cholesterol lowering therapy; updated background evidence and practical info for anticoagulation therapy in management of atrial fibrillation; updated background text and references for patent foramen ovale management.
3 Acute medical and surgical management	v8.1	7/09/2020	Draft recommendation updates made to oxygen therapy; background changes made to stroke unit care, palliative care, surgery for ischaemic stroke, neuroprotection, pyrexia management. Updates made to glycaemic therapy.
7 Discharge planning and transfer of care	v5.3	3/09/2020	Updated practical info for information and education, added practical info to strong recommendation for comprehensive discharge care plans, and expanded practical info on consensus-based recommendation for discharge care planner coordination.
8 Community participation and long-term care	v5.3	3/09/2020	Added practical info for self-management; expanded practical info for driving, community mobility and outdoor travel, and return to work; added new evidence and decision aids for leisure therapy and peer support; and added decision aid for carer support and information.
1 Pre-hospital care	v6.5	1/09/2020	Updated practical info for interventions by paramedics.
4 Secondary prevention	v6.4	10/06/2020	Cholesterol lowering therapy: updated practical info for use of statins after ischaemic stroke or TIA. Cervical artery dissection: one additional sentence added to 'Benefits and harms' and 'Evidence summary' to include outcomes of previously included study; no change to recommendation. Hormone replacement therapy: added new reference to introduction, benefits and harms and evidence summary; no change to recommendation. Oral contraception: update to rationale and practical info only; no change to recommendation. Other minor terminology edits.
2 Early assessment and diagnosis	v6.4	21/11/2019	Modified order of PICOs under 'Imaging'.
5 Rehabilitation	v5.4	21/11/2019	Reordered PICO questions to correct numbering.
6 Managing complications	v5.4	21/11/2019	Correct PICO numbering to remove repetition.
1 Pre-hospital care	v6.4	7/11/2019	Updated wording for first recommendation and rationale. Also updated NHMRC approval to due to updated topics in chapter 3 and 4. Updated recommended citation.
2 Early assessment and diagnosis	v6.3	7/11/2019	Updated introduction.
3 Acute medical and surgical management	v7.0	7/11/2019	Updated recommendations for thrombolysis and acute antiplatelet therapy. Introduction updated also.
4 Secondary prevention	v6.0	7/11/2019	Updated recommendation for PFO closure and updated introduction.
5 Rehabilitation	v5.3	7/11/2019	Updated introduction.
6 Managing complications	v5.3	7/11/2019	Updated introduction.
3 Acute medical and surgical management	v6.0	30/07/2019	New (draft) recommendations for thrombolysis topic and draft change to the acute antiplatelet recommendation for minor stroke/TIA.
4 Secondary prevention	v5.7	30/07/2019	Changed recommendation for PFO for public consultation. Removed numbering of sections. Updated introduction, updated labels throughout and incorporated draft changes to antiplatelet section from chapter 3.
3 Acute medical and surgical management	v5.8	10/07/2018	Updated neurointervention with endovascular clot retrieval (ECR) approval from NHMRC, updated background text, and updated grade summary tags for extended window recommendation. Updated link to Assessment for Rehabilitation Tool.
3 Acute medical and surgical management	v5.2	29/03/2018	Updated recommendations for Section 8.2 Neurointervention.
4 Secondary prevention	v5.2	21/03/2018	Changed aspirin dose for antiplatelet therapy.
1 Pre-hospital care	v6.0	7/09/2017	Final version of 2017 Clinical Guidelines.
2 Early assessment and diagnosis	v6.0	7/09/2017	Final version of 2017 Clinical Guidelines.
3 Acute medical and surgical management	v5.0	7/09/2017	Final version of 2017 Clinical Guidelines.
4 Secondary prevention	v5.0	7/09/2017	Final version of 2017 Clinical Guidelines.
5 Rehabilitation	v5.0	7/09/2017	Final version of 2017 Clinical Guidelines.
6 Managing complications	v5.0	7/09/2017	Final version of 2017 Clinical Guidelines.
7 Discharge planning and transfer of care	v5.0	7/09/2017	Final version of 2017 Clinical Guidelines.
8 Community participation and long-term care	v5.0	7/09/2017	Final version of 2017 Clinical Guidelines.

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