The 2022 update of the Canadian Stroke Best Practice Recommendations (CSBPR) for Acute Stroke Management, 7th edition, is a comprehensive summary of current evidence-based recommendations, appropriate for use by an interdisciplinary team of healthcare providers and system planners caring for persons with an acute stroke or transient ischemic attack. These recommendations are a timely opportunity to reassess current processes to ensure efficient access to acute stroke diagnostics, treatments, and management strategies, proven to reduce mortality and morbidity. The topics covered include prehospital care, emergency department care, intravenous thrombolysis and endovascular thrombectomy (EVT), prevention and management of inhospital complications, vascular risk factor reduction, early rehabilitation, and end-of-life care. These recommendations pertain primarily to an acute ischemic vascular event. Notable changes in the 7th edition include recommendations pertaining the use of tenecteplase, thrombolysis as a bridging therapy prior to mechanical thrombectomy, dual antiplatelet therapy for stroke prevention,1 the management of symptomatic intracerebral hemorrhage following thrombolysis, acute stroke imaging, care of patients undergoing EVT, medical assistance in dying, and virtual stroke care. An explicit effort was made to address sex and gender differences wherever possible. The theme of the 7th edition of the CSBPR is building connections to optimize individual outcomes, recognizing that many people who present with acute stroke often also have multiple comorbid conditions, are medically more complex, and require a coordinated interdisciplinary approach for optimal recovery. Additional materials to support timely implementation and quality monitoring of these recommendations are available at www.strokebestpractices.ca.

Wake-up stroke (WUS) or ischemic stroke occurring during sleep accounts for 14%–29.6% of all ischemic strokes. Management of WUS is complicated by its narrow therapeutic time window and attributable risk factors, which can affect the safety and efficacy of administering intravenous (IV) tissue plasminogen activator (t-PA). This manuscript will review risk factors of WUS, with a focus on obstructive sleep apnea, potential mechanisms of WUS, and evaluate studies assessing safety and efficacy of IV t-PA treatment in WUS patients guided by neuroimaging to estimate time of symptom onset. The authors used PubMed (1966 to March 2018) to search for the term “Wake-Up Stroke” cross-referenced with “pathophysiology,” ‘‘pathogenesis,” “pathology,” “magnetic resonance imaging,” “obstructive sleep apnea,” or “treatment.” English language Papers were reviewed. Also reviewed were pertinent papers from the reference list of the above-matched manuscripts. Studies that focused only on acute Strokes with known-onset of symptoms were not reviewed. Literature showed several potential risk factors associated with increased risk of WUS. Although the onset of WUS is unknown, a few studies investigated the potential benefit of magnetic resonance imaging (MRI) in estimating the age of onset which encouraged conducting clinical trials assessing the efficacy of MRI-guided thrombolytic therapy in WUS.

Acute ischaemic stroke is common in older people and is associated with a higher morbidity and mortality compared with younger patients. Intravenous thrombolysis with recombinant tissue plasminogen activator (r-tPA) has become the mainstay of treatment and is the only evidence-based specific treatment for acute ischaemic stroke. However, little data are available on the safety of thrombolysis in the over-80 years age group due to under-representation of this group in trials and the upper age limit for licensing of the drug. In this review, we look at the pathophysiology of stroke and recent advances in neuroimaging techniques. We also look at the evidence base for use of thrombolysis in stroke and in particular analyse the trials that include the very elderly as subjects. Finally, issues around ongoing trials and future research are discussed.

Objectives: To investigate the factors that influenced the adoption and diffusion of thrombolysis in acute myocardial infarction in England and to verify usage data from 1981 to 2001.

Methods: Survey of cardiologists in England using a pre-prepared time line of historical events and a plot of thrombolysis diffusion since 1981. The cardiologists were divided into three groups that were provided with (i) the time line only, (ii) the diffusion curve only, and (iii) the time line and the diffusion curve.

Results: The GISSI and ISIS-2 clinical trials were perceived to have had a significant influence upon the initial diffusion of thrombolysis in England occurring over the 3 years after launch. Other positive influences included the initial listing in the national formulary, the change to administration in emergency departments, the rise in evidence-based medicine, and production of national guidance.

Conclusions: Although it is apparent that the overall influences on adoption and diffusion of thrombolysis were multiple; clinical trials, service developments, and national guidelines all were judged to have played a part. The GISSI and ISIS-2 clinical trials were confirmed as the major influence on initial adoption.

Objectives: To describe the adoption and take up of thrombolytic agents for acute myocardial infarction since 1980 in England and compare use with the estimated ceiling of need.

Methods: Data on national sales and use of thrombolysis since 1980 (supplied by IMS Health) was used to draw an adoption and diffusion curve. The epidemiological ceiling of acute myocardial infarction, from hospital activity statistics, was modified to an estimated clinical need by accounting for diagnostic difficulty and contraindications using information from published surveys of thrombolysis use in the United Kingdom.

Results: There was a rapid uptake of thrombolytic agents in the first 2 years after availability in 1987, then a plateau, followed by a rise to a peak use in 1995. The shortfall in doses resulting from the difference between estimated ceiling of clinical need and doses purchased and provided in the 14 years since availability is estimated as 167,800 (95 percent confidence range 94,000 to 241,700).

Conclusions: Although there was a rapid initial uptake of thrombolysis in England, usage took 8 years to reach the ceiling of clinical need of 65 percent of patients with acute myocardial infarction, with many patients missing the opportunity to benefit. Monitoring of uptake of innovations known to be cost-effective is required to identify those developments that need additional stimulus for change to ensure that patients do not miss out on the opportunity to benefit.

Objectives: The objective of the study was to estimate the costs and health benefits of a public awareness campaign aimed at shortening the delay for thrombolytic therapy in patients with acute myocardial infarction (AMI) and to estimate the incremental costs and benefits of an additional telemedicine program.

Methods and Results: By using trial data on the impact of a Swedish campaign, a model was developed to simulate the current distribution of thrombolytic delay in Denmark and the delay after a campaign. The reduction in delay was translated into reduced fatality assuming reductions from the campaign and additional effects of a telemedicine program. The costs of the campaign were based on trial data and Danish unit costs while telemedicine costs were taken from a Danish demonstration program. The analyses indicate that the awareness campaign will translate into five fewer fatal AMIs (sixty-two life years gained) and a cost per life year of DKK283,300, with both costs and benefits discounted at 5 percent. When combining the public campaign with prehospital telemedicine diagnostics, the incremental cost per life year gained was DKK854.700.

Conclusions: Programs aimed at reducing delay of thrombolysis in patients with AMI are likely to have a limited impact on AMI fatality. Information campaigns may have acceptable cost-effectiveness ratios, while telemedicine programs lead to threefold greater ratios. Whether such programs can be considered cost-effective will depend on how life year gains are valued by society.

Objective: We studied the influence of the methodologic quality of individual trials on the outcome of a landmark meta-analysis on thrombolytic therapy in acute myocardial infarction. From each study we extracted the number of patients in both groups who died in hospital or during follow-up. Methodologic quality was assessed using the Delphi list. We first recalculated pooled odds ratios (ORs) and 95% confidence intervals (CIs), on the studies found and compared them with the original results of Yusuf et al. Next we incorporated the results of quality assessment in five different ways in the calculation of the pooled ORs: a) component analysis; b) visual plot; c) quality score as a threshold score; d) quality score as a weighting factor; and e) cumulative pooling.

Results and Conclusion: No correlation between quality scores and ORs was found. Studies with a proper description of the different quality components provided an estimate close to the true treatment effect. No major differences were found between the results of the five different methods of incorporating the quality scores into the final conclusion.

Prehospital 12-lead electrocardiographic (ECG) diagnostic strategies have been proven feasible and effective, provided they are designed and implemented properly. The authors of this communication have expended considerable time and effort in determining appropriate planning, implementation, and process monitoring necessary for successful implementation of a variety of prehospital diagnostic strategies. Many of these issues may not be obvious to an emergency medical services (EMS) director initiating a 12-lead ECG program. This level of attention to protocol development, education, training, inservice education, coordination of the health-care community, objective program assessment, monitoring and continuos quality improvement can serve as a model for other diagnostic EMS programs that may develop as an expanded role for EMS.