Guideline:
EFNS guideline on neuroimaging in acute stroke
Bibliographic Source(s)
- Masdeu JC Irimia P Asenbaum S Bogousslavsky J Brainin M Chabriat H Herholz K Markus HS Martinez-Vila E Niederkorn K Schellinger PD Seitz RJ EFNS. EFNS guideline on neuroimaging in acute stroke. Report of an EFNS task force. Eur J Neurol 2006 Dec;13(12):1271-83. [161 references] PubMed
Guideline Status
This is the current release of the guideline.
This guideline should be reviewed and if necessary revised not later than 2008.
Guideline Category
Diagnosis
Evaluation
Risk Assessment
Technology Assessment
Intended Users
Emergency Medical Technicians/Paramedics
Health Care Providers
Physicians
Guideline Objective(s)
- To develop and publish a European Federation of Neurological Societies (EFNS) Guideline on the use of neuroimaging for the management of acute stroke
- To provide updated and evidence-based recommendations regarding the use of diagnostic neuroimaging techniques including cerebrovascular ultrasonography (US) in patients with stroke and thus guide neurologists other healthcare professionals and healthcare providers in clinical decision making and in the elaboration of clinical protocols
Target Population
Patients with acute stroke
Interventions and Practices Considered
- Computed tomography (CT) perfusion CT (PCT)
- Magnetic resonance imaging (MRI) diffusion-weighted (DWI) and perfusion-weighted (PWI) MRI
- Magnetic resonance angiography (MRA)
- Single photon emission computed tomography (SPECT)
- Positron emission tomography (PET) (considered but not recommended)
- Ultrasonography (US)
- CT angiography (CTA)
- Digital subtraction angiography (DSA)
- Transcranial Doppler (TCD)
- CT venography
Major Outcomes Considered
Sensitivity specificity and usefulness of diagnostic tests
Methods Used to Collect/Select Evidence
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases
Description of Methods used to Collect/Select the Evidence
The Cochrane Library was consulted and no studies were found regarding the use of neuroimaging techniques in stroke. A comprehensive literature review using the MEDLINE database has been conducted by searching for the period 1965–2005. Relevant literature in English including existing guidelines meta-analyses systematic reviews randomized controlled trials and observational studies has been critically assessed.
Number of Source Documents
Not stated
Methods Used to Assess the Quality and Strength of the Evidence
Weighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence
Evidence Classification Scheme for a Diagnostic Measure
Class I: A prospective study in a broad spectrum of persons with the suspected condition using a "gold standard" for case definition where the test is applied in a blinded evaluation and enabling the assessment of appropriate tests of diagnostic accuracy
Class II: A prospective study of a narrow spectrum of persons with the suspected condition or a well-designed retrospective study of a broad spectrum of persons with an established condition (by "gold standard") compared to a broad spectrum of controls where test is applied in a blinded evaluation and enabling the assessment of appropriate tests of diagnostic accuracy
Class III: Evidence provided by a retrospective study where either persons with the established condition or controls are of a narrow spectrum and where test is applied in a blinded evaluation
Class IV: Any design where test is not applied in blinded evaluation OR evidence provided by expert opinion alone or in descriptive case series (without controls)
Methods Used to Analyze the Evidence
Review of Published Meta-Analyses
Systematic Review
Description of the Methods Used to Analyze the Evidence
Selected articles have been rated based on the quality of study design and clinical practice recommendations have been developed and stratified to reflect the quality and the content of the evidence according to European Federation of Neurological Societies (EFNS) criteria (see the "Availability of Companion Documents" field in this summary).
Methods Used to Formulate the Recommendations
Expert Consensus (Delphi)
Description of Methods Used to Formulate the Recommendations
The author panel critically assessed the topic through analysis of the medical literature. A proposed guideline with specific recommendations was drafted for circulation to all panel members. Each panelist studied and commented in writing on each successive guideline draft revised to progressively accommodate the panel consensus. After the approval of the panelists two independent experts gave their opinion on the final version.
Rating Scheme for the Strength of the Recommendations
Rating of Recommendations
Level A rating (established as useful/predictive or not useful/predictive) requires at least one convincing class I study or at least two consistent convincing class II studies.
Level B rating (established as probably useful/predictive or not useful/predictive) requires at least one convincing class II study or overwhelming class III evidence.
Level C rating (established as possibly useful/predictive or not useful/predictive) requires at least two convincing class III studies.
Good clinical practice point (GCPP) supported primarily by expert opinion
Cost Analysis
A formal cost analysis was not performed and published cost analyses were not reviewed.
Method of Guideline Validation
Peer Review
Description of Method of Guideline Validation
The guidelines were validated according to the European Federation of Neurological Societies (EFNS) criteria (see "Availability of Companion Documents" field).
Major Recommendations
The levels of evidence (class I-IV) supporting the recommendations and ratings of recommendations (A-C good clinical practice point [GCPP]) are defined at the end of the "Major Recommendations" field.
Imaging of the Brain
Non-contrast computed tomography (CT) scan is the established imaging procedure for the initial evaluation of patients with stroke to document or exclude intracerebral hemorrhage (ICH) and subarachnoid hemorrhage (SAH) (class II level C). However CT use has been consecrated more by availability than by randomized studies comparing its effectiveness with magnetic resonance imaging (MRI). Either CT or MRI should be used for the definition of stroke type and treatment of stroke (class I level A).
Given the controversial nature of data on early CT infarct signs involving more than one-third of the territory of the middle cerebral artery (MCA) as predictors of the outcome of intravenous (IV) recombinant tissue plasminogen activator (rtPA) treatment the presence of such signs cannot be construed as an absolute contraindication to thrombolysis in the first 3 hours after stroke (class IV level GCPP). Perfusion CT is helpful when MRI is not available and for the study of stroke patients for whom MRI is contraindicated (class IV level GCPP). MRI has a higher sensitivity than conventional CT for the documentation of infarction within the first hours of stroke onset lesions in the posterior fossa identification of small lesions and documentation of vessel occlusion and brain edema (class I level A). In conjunction with MRI and magnetic resonance angiography (MRA) perfusion and diffusion MR are very helpful for the evaluation of patients with acute ischemic stroke (class I level A). Perfusion and diffusion MR are helpful to select patients for intravenous thrombolysis beyond 3 h (class II level B). MRI with MRA is the method recommended for the diagnosis and follow-up of arterial dissection (class II level B).
Single photon emission computed tomography (SPECT) is helpful to predict the malignant course of brain swelling with large hemispheric infarctions (class III level C). SPECT is also helpful in the evaluation of cerebral perfusion in non-acute cerebrovascular disease for instance in the days after a SAH (class III level C).
Detection of Hemorrhagic Stroke
In stroke MRI can detect acute and chronic ICH (class I level A). Although the detection of SAH is possible with MRI currently CT scan is the diagnostic procedure of choice (class I level A).
Imaging of Extracranial Vessels
Ultrasonography (US) is the non-invasive screening technique indicated for the study of vessels involved in causing symptoms of carotid stenosis (class IV GCPP). MR angiography has slightly higher sensitivity and specificity than US to determine carotid stenosis and occlusion but other factors such as availability may render one procedure more useful than the other (class II level B). CT angiography (CTA) has a sensitivity and specificity similar to MR for carotid occlusion and similar to US for the detection of severe stenosis (class II level B). Digital subtraction angiography (DSA) is generally recommended for grading carotid stenosis prior to endarterectomy (class I level A) but when there is concordance of non-invasive methods cerebral arteriography may not be necessary (class IV level GCPP).
Imaging of Intracranial Vessels
Transcranial Doppler (TCD) is very useful for assessing stroke risk of children aged 2 to 16 years with sickle cell disease (class I level A) detection and monitoring of vasospasm after SAH (class I level A) diagnosis of intracranial steno-occlusive disease (class II level B) diagnosis of right-to-left shunts (class II level A) and for monitoring arterial reperfusion after thrombolysis of acute MCA occlusions (class II level B). TCD can detect cerebral emboli and impaired cerebral hemodynamics. The presence of embolic signals with carotid stenosis predicts early recurrent stroke risk (class II level A). The detection of impaired cerebral hemodynamics in carotid occlusion may identify a group at high risk of recurrent stroke (class III level B).
MRA and CTA are very useful for the diagnosis of intracranial stenosis and cerebral aneurysms >5 mm (class II level B). MRA is the recommended technique for screening cerebral aneurysms in individuals with a history of aneurysms or SAH in a first-degree relative (class II level B). DSA is the recommended technique for the diagnosis of cerebral aneurysm as the cause of SAH (class I level A). MRI with MRA is recommended for the diagnosis and follow-up of cerebral venous thrombosis (CVT) (class II level B). Alternatively CT venography is accurate and can be used for the same purpose (class III level C).
Definitions:
Evidence Classification Scheme for a Diagnostic Measure
Class I: A prospective study in a broad spectrum of persons with the suspected condition using a "gold standard" for case definition where the test is applied in a blinded evaluation and enabling the assessment of appropriate tests of diagnostic accuracy
Class II: A prospective study of a narrow spectrum of persons with the suspected condition or a well-designed retrospective study of a broad spectrum of persons with an established condition (by "gold standard") compared to a broad spectrum of controls where test is applied in a blinded evaluation and enabling the assessment of appropriate tests of diagnostic accuracy
Class III: Evidence provided by a retrospective study where either persons with the established condition or controls are of a narrow spectrum and where test is applied in a blinded evaluation
Class IV: Any design where test is not applied in blinded evaluation OR evidence provided by expert opinion alone or in descriptive case series (without controls)
Rating of Recommendations
Level A rating (established as useful/predictive or not useful/predictive) requires at least one convincing class I study or at least two consistent convincing class II studies.
Level B rating (established as probably useful/predictive or not useful/predictive) requires at least one convincing class II study or overwhelming class III evidence.
Level C rating (established as possibly useful/predictive or not useful/predictive) requires at least two convincing class III studies.
Good clinical practice point (GCPP) supported primarily by expert opinion
Clinical Algorithm(s)
None provided
Type of Evidence supporting the Recommendations
The type of supporting evidence is identified and graded for selected recommendations (see "Major Recommendations").
Potential Benefits
Appropriate use of neuroimaging for the diagnosis and management of acute stroke
Potential Harms
Angiography carries the risk of stroke and death and many centers are not using digital subtraction angiography (DSA) prior to carotid endarterectomy
Contraindications
- Pregnancy diabetes renal failure and allergy to contrast material are relative contraindications to perform a perfusion brain computed tomography (CT).
- Limitations and contraindications for the use of magnetic resonance imaging (MRI) are: claustrophobia agitation morbid obesity the presence of intracranial ferromagnetic elements an aneurysm recently clipped or coiled otic or cochlear implants some old prosthetic heart valves pacemakers and some not all neurostimulators.
Qualifying Statements
- This guideline provides the view of an expert task force appointed by the Scientific Committee of the European Federation of Neurological Societies (EFNS). It represents a peer-reviewed statement of minimum desirable standards for the guidance of practice based on the best available evidence. It is not intended to have legally binding implications in individual cases.
- The resulting report is intended to provide updated and evidence-based recommendations regarding the use of diagnostic neuroimaging techniques including cerebrovascular ultrasonography (US) in patients with stroke and thus guide neurologists other healthcare professionals and healthcare providers in clinical decision making and in the elaboration of clinical protocols. It is not intended to have legally binding implications in individual situations.
Description of Implementation Strategy
The European Federation of Neurological Societies has a mailing list and all guideline papers go to national societies national ministries of health World Health Organisation European Union and a number of other destinations. Corporate support is recruited to buy large numbers of reprints of the guideline papers and permission is given to sponsoring companies to distribute the guideline papers from their commercial channels provided there is no advertising attached.
Implementation Tools
Staff Training/Competency Material
For information about availability see the "Availability of Companion Documents" and "Patient Resources" fields below.
IOM Care Need
Getting Better
IOM Domain
Effectiveness
Bibliographic Source(s)
- Masdeu JC Irimia P Asenbaum S Bogousslavsky J Brainin M Chabriat H Herholz K Markus HS Martinez-Vila E Niederkorn K Schellinger PD Seitz RJ EFNS. EFNS guideline on neuroimaging in acute stroke. Report of an EFNS task force. Eur J Neurol 2006 Dec;13(12):1271-83. [161 references] PubMed
Adaptation
Not applicable: The guideline was not adapted from another source.
Source(s) of Funding
European Federation of Neurological Societies
Guideline Committee
European Federation of Neurological Societies Task Force on Neuroimaging in Acute Stroke
Composition of Group that Authored the Guideline
Task Force Members: J. C. Masdeu Department of Neurology and Neurosurgery University of Navarra Pamplona Spain; P. Irimia Department of Neurology and Neurosurgery University of Navarra Pamplona Spain; S. Asenbaum Department of Neurology Medical University of Vienna Vienna Austria; J. Bogousslavsky Department of Neurology Centre Hospitalier Universitaire Vaudois Lausanne Switzerland; M. Brainin Department of Neurology Donauklinikum and Donau-Universität Maria Gugging Austria; H. Chabriat Department of Neurology Lariboisiere Hospital University of Paris Paris France; K. Herholz Wolfson Molecular Imaging Centre University of Manchester Manchester; H. S. Markus Department of Neurology and Clinical Neuroscience St George's Hospital Medical School London UK; E. Martinez-Vila Department of Neurology and Neurosurgery University of Navarra Pamplona Spain; K. Niederkorn Department of Neurology Karl Franzens University Graz Austria; P. D. Schellinger Department of Neurology University Clinic at Heidelberg Germany; R. J. Seitz Department of Neurology University Hospital Düsseldorf Düsseldorf Germany
Financial Disclosures/Conflicts of Interest
None of the authors has a conflict of interest with regard to the contents of this manuscript.
Guideline Status
This is the current release of the guideline.
This guideline should be reviewed and if necessary revised not later than 2008.
Guideline Availability
Electronic copies: Available to registered users from the European Federation of Neurological Societies Web site.
Print copies: Available from Dr Jose Masdeu Neurological Sciences University of Navarra Medical School C.U.N. Avda. Pio XII 36 31008 Pamplona Spain; Phone: +34 948 255 400; Fax: +34 948 29 65 00; E-mail: masdeu@unav.es
Availability of Companion Documents
The following are available:
- Brainin M Barnes M Baron JC Gilhus NE Hughes R Selmaj K Waldemar G; Guideline Standards Subcommittee of the EFNS Scientific Committee. Guidance for the preparation of neurological management guidelines by EFNS scientific task forces – revised recommendations 2004. Eur J Neurol. 2004 Sep;11(9):577-81. Electronic copies: Available in Portable Document Format (PDF) from the European Federation of Neurological Societies Web site.
- Guideline papers. European Federation of Neurological Societies. Electronic copies: Available from the European Federation of Neurological Societies Web site.
- Continuing Medical Education questions available from the European Journal of Neurology Web site.
Patient Resources
None available
NGC STATUS
This NGC summary was completed by ECRI on April 13 2007. The information was verified by the guideline developer on May 15 2007.
COPYRIGHT STATEMENT
This NGC summary is based on the original guideline which is subject to the Blackwell-Synergy copyright restrictions.
NGC Disclaimer
The National Guideline Clearinghouse™ (NGC) does not develop produce approve or endorse the guidelines represented on this site.
All guidelines summarized by NGC and hosted on our site are produced under the auspices of medical specialty societies relevant professional associations public or private organizations other government agencies health care organizations or plans and similar entities.
Guidelines represented on the NGC Web site are submitted by guideline developers and are screened solely to determine that they meet the NGC Inclusion Criteria which may be found at http://www.guideline.gov/about/inclusion.aspx .
NGC AHRQ and its contractor ECRI Institute make no warranties concerning the content or clinical efficacy or effectiveness of the clinical practice guidelines and related materials represented on this site. Moreover the views and opinions of developers or authors of guidelines represented on this site do not necessarily state or reflect those of NGC AHRQ or its contractor ECRI Institute and inclusion or hosting of guidelines in NGC may not be used for advertising or commercial endorsement purposes.
Readers with questions regarding guideline content are directed to contact the guideline developer.