Key Updates to “Living” Stroke Guidelines



The first major update since 2018 contains several strong new recommendations for stroke management.

The updated guidelines include five strong new recommendations and three updated recommendations.

Australia and New Zealand Clinical guidelines for stroke management are the world’s first and only living stroke guidelines, updated as new evidence emerges.

This week, the guidelines underwent the first refresh since 2018 to include new and updated “strong” recommendations.

The new strong recommendations are:


  • For patients with potentially disabling ischemic stroke who meet criteria for infusion inadequacy in addition to standard clinical criteria, the recommended time window for safe administration of alteplase has been extended to nine hours after stroke.
  • For patients with potentially disabling ischemic stroke due to large vessel occlusion who meet specific eligibility criteria, intravenous tenecteplase (0.25 mg/kg, maximum 25 mg) or alteplase (0.9 mg/kg, maximum 90 mg) should be administered up to 4.5 hours after the patient was last known to be healthy
  • For patients with ischemic stroke caused by large vessel occlusion in the internal carotid artery, proximal middle cerebral artery (M1 segment), or with tandem occlusion of the cervical carotid and large intracranial arteries, a Endovascular thrombectomy should be undertaken when the procedure can be started between six and 24 hours after they were last known to be well, if clinical perfusion or MRI and CT scan features indicate the presence of brain tissue recoverable
  • In hospitals that do not have medical specialists on site 24/7, telestroke systems should be used to aid in patient assessment and decision making regarding acute thrombolytic therapy and possible transfer for endovascular treatment
  • In patients with ischemic stroke, cholesterol-lowering therapy should target low-density lipoprotein cholesterol

To support healthcare professionals providing stroke management, the Australian Medical Journal (MJA) published a summary of updated clinical guidelines, outlining the new and updated recommendations, and associated challenges and benefits.

The authors of the MJA abstract say that the primary benefit of having living guidelines is the ability to quickly update recommendations in response to new evidence.

“Rapid updates to guidelines within a living model have almost certainly played a significant role in accelerating local and statewide system changes,” they wrote.

“It is important to note that living guidelines provide guidance. The AVC experience as well as other guidelines demonstrate that the rigor of the methods need not be compromised when lifestyles are adopted.

Dr. Gary Deed, member of the RACGP – Quality Care expert committee, said newsGP the summary guideline updates should help GPs, but they should also recognize all the details, especially of the five new recommendations.

“The guidelines serve the purpose, whereby the [MJA] experts or peers have distilled a whole range of information into a succinct reference, so you personally don’t have to strain to read multiple articles or reviews,” he said.

“A quick review of recommendations and high-level summaries can help update knowledge when you’re pressed for time, but remember there’s so much more detail, so a practical way to use it. is to keep them handy – especially in electronic form in clinical practice, so that you can refer to the content regularly.

In 2017, the stroke guidelines moved from being published in a static format to being posted online as “living guidelines”.

A total of 35 new or updated recommendations have since been made, with 16 new recommendations (five strong, 10 weak and one practice point) and updates to 19 recommendations.

There were no instances in which a recommendation for intervention was downgraded from a ‘strong’ recommendation to a ‘weak’ recommendation, and no recommendation was changed multiple times. In addition, important new recommendations have been made regarding life-saving treatment, such as the administration of alteplase for thrombolysis.

Three updates categorized as “strong” recommendations are also included in the new guidelines:

  • Aspirin plus clopidogrel should be started within 24 hours and used short-term (first three weeks) in patients with minor ischemic stroke or high-risk transient ischemic attack to prevent stroke recurrence
  • In patients with ischemic stroke less than 60 years of age in whom a patent foramen ovale is considered the probable cause of the stroke after complete exclusion of other etiologies, percutaneous closure of the patent foramen ovale is recommended.
  • For stroke survivors with reduced arm or leg strength, progressive resistance training should be offered to improve strength.

According to MJA authors, the living guideline template, along with the summary, not only ensures up-to-date clinical advice, but an easily accessible reference that should be considered the way forward.

“Our model of continued monitoring of evidence and timely updates of recommendations is feasible, but sustainability remains a challenge,” they wrote.

“Now that we’ve started down this path, the message from guideline end users is that a return to the old model of static updates is no longer acceptable, and continued long-term investment in living guidelines must be a priority.”

The full version of the updated life Clinical guidelines for stroke management is available on the Stroke Foundation website.

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