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Stroke (Acute Management)

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General Information

Description

Also Called

  • cerebrovascular accident (CVA)
  • CVA
  • cerebral infarct
  • "brain attack"

Definitions

  • American Heart Association/American Stroke Association definitions related to stroke
    • the term 'stroke' includes all of the following
      • central nervous system (CNS) infarction - brain, spinal cord, or retinal cell death due to ischemia based on either
        • pathological, imaging, or other objective evidence of focal ischemic injury in vascular distribution
        • clinical evidence of focal ischemic injury based on symptoms lasting ≥ 24 hours or until death as long as other etiologies are excluded
      • ischemic stroke - episode of neurological dysfunction caused by CNS infarction
      • silent CNS infarction - pathological or imaging evidence of CNS infarction without history of neurologic dysfunction attributable to lesion
      • intracerebral hemorrhage
        • intracerebral hemorrhage - focal collection of blood within brain parenchyma or ventricular system not caused by trauma
        • stroke caused by intracerebral hemorrhage - rapidly developing neurologic dysfunction attributable to intracerebral hemorrhage
        • silent cerebral hemorrhage - pathological or imaging evidence of intracerebral hemorrhage without a history of acute neurological dysfunction
      • subarachnoid hemorrhage
        • subarachnoid hemorrhage - bleeding into subarachnoid space between the arachnoid membrane and the pia mater of the brain or spinal cord
        • stroke caused by subarachnoid hemorrhage - rapidly developing neurologic dysfunction attributable to subarachnoid hemorrhage which is not caused by trauma
      • stroke caused by cerebral venous thrombosis - infarction or hemorrhage in CNS due to thrombosis of cerebral venous structure; symptoms or signs caused by reversible edema without infarction or hemorrhage do not qualify as stroke
      • stroke not otherwise specified - episode of acute neurologic dysfunction presumed to be caused by ischemia or hemorrhage persisting ≥ 24 hours or until death but not able to be classified in another category
    • Reference - 23652265Stroke 2013 Jul;44(7):2064OpenInNew
  • cryptogenic stroke
    • Trial of Org 10172 in Acute Stroke Treatment (TOAST) criteria for cryptogenic stroke
      • cerebral infarct not attributed to definite source of large-vessel atherosclerosis, cardioembolism, or small-vessel disease despite extensive vascular, cardiac, hematologic, and serological evaluation
      • evidence of > 1 competing cause
      • incomplete diagnostic evaluation
    • Causative Classification System criteria for cryptogenic stroke
      • cryptogenic embolism
        • stroke with angiographic evidence of abrupt cutoff consistent with blood clot appearing within otherwise angiographically normal-looking intracranial arteries
        • imaging evidence of complete recanalization of previously occluded artery
        • presence of multiple acute infarctions occurring close together in time with no detectable abnormality in related vessels
      • other cryptogenic stroke defined as stroke not fulfilling criteria of cryptogenic embolism
    • Reference - 28154102Circ Res 2017 Feb 3;120(3):527OpenInNew
  • transient ischemic attack (TIA)
  • reversible ischemic neurologic deficit (event > 24 hours but < 7 days) considered obsolete term (19423857Stroke 2009 Jun;40(6):2276OpenInNewfull-textOpenInNew)

Types

References

General references used

  1. Powers WJ, Rabinstein AA, Ackerson T, et al; American Heart Association Stroke Council. 2018 Guidelines for the Early Management of Patients With Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke. 2018 Mar;49(3):e46-e110OpenInNew, corrections can be found in Stroke 2018 Mar;49(3):e138OpenInNew and Stroke 2018 Jun;49(6):e233OpenInNew
  2. Yew KS, Cheng EM. Diagnosis of acute stroke. Am Fam Physician. 2015 Apr 15;91(8):528-36OpenInNewfull-textOpenInNew
  3. Casaubon LK, Boulanger JM, Blacquiere D, et al; Heart and Stroke Foundation of Canada Canadian Stroke Best Practices Advisory Committee. Canadian Stroke Best Practice Recommendations (CSBPR): Hyperacute stroke care guidelines, update 2015. Int J Stroke 2015 Aug;10(6):924-40OpenInNew
  4. Casaubon LK, Boulanger JM, Glasser E, et al; Heart and Stroke Foundation of Canada Canadian Stroke Best Practices Advisory Committee. Canadian Stroke Best Practice Recommendations: Acute inpatient stroke care guidelines, update 2015. Int J Stroke 2016 Feb;11(2):239-52OpenInNew
  5. Jauch EC, Saver JL, Adams HP Jr, et al; American Heart Association Stroke Council, Council on Cardiovascular Nursing, Council on Peripheral Vascular Disease, and Council on Clinical Cardiology. Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2013 Mar;44(3):870-947OpenInNewfull-textOpenInNew

Recommendation grading systems used

  • American Academy of Neurology/American Heart Association (AAN/AHA) grades of recommendation
    • grades of recommendation
      • Grade A - ≥ 1 convincing Class I study or ≥ 2 convincing Class II studies
      • Grade B - ≥ 1 convincing Class II studies or ≥ 2 convincing Class III studies
      • Grade C - ≥ 2 convincing and consistent Class III studies
      • Grade U - uncertain, data insufficient
    • levels of evidence
      • Class I - evidence provided by prospective, randomized, controlled clinical trial with blinded outcome assessment in representative population
        • requirements include
          • primary outcome clearly stated
          • exclusion/inclusion criteria defined
          • accounting for dropouts/crossovers without potential for bias
          • lack of differences between baseline groups
      • Class II - evidence provided by one of the following
        • prospective, matched cohort study in representative population with blinded outcome assessment meeting criteria for Class I rigor
        • randomized controlled trial in representative population lacking requirements for Class I
      • Class III - evidence provided by all other controlled trials (including well defined natural history controls or patients serving as own controls) in representative population, in which outcome assessment is independent of patient treatment
      • Class IV - evidence from uncontrolled studies, case series, case reports, or expert opinion
    • Reference - AAN/AHA guidelines on anticoagulants and antiplatelet agents in acute ischemic stroke (12105302Neurology 2002 Jul 9;59(1):13OpenInNew)
  • American College of Chest Physicians (ACCP) grades
    • Grade 1 - strong recommendation based on clear risk/benefit balance
    • Grade 2 - weak recommendation based on unclear or close risk/benefit balance
    • Grade A - high-quality evidence based on consistent evidence from randomized trials without important limitations or exceptionally strong evidence from observational studies
    • Grade B - moderate-quality evidence based on randomized trials with important limitations (inconsistent results, methodologic flaws, indirect or imprecise results) or very strong evidence from observational studies
    • Grade C - low- or very low-quality evidence based on evidence for ≥ 1 critical outcome from observational studies, case series, or randomized trials with serious flaws or indirect evidence
    • Reference - ACCP evidence-based clinical practice guideline on methodology for development of antithrombotic therapy and prevention of thrombosis (22315256Chest 2012 Feb;141(2 Suppl):53SOpenInNewfull-textOpenInNew), commentary can be found in 23546508Chest 2013 Apr;143(4):1190OpenInNew
  • American College of Physicians (ACP) guideline grading system
    • strength of recommendation
      • Strong - benefits clearly outweigh risks and burden, or risks and burden clearly outweigh benefits
      • Weak - benefits closely balanced with risks and burden or uncertainty in estimates of benefits, risks, and burdens
      • Insufficient - balance of benefits and risks cannot be determined
    • quality of evidence
      • High - randomized trials without important limitations, or overwhelming evidence from observational studies
      • Moderate - randomized trials with important limitations (inconsistent results, methodologic flaws, indirect, or imprecise), or exceptionally strong evidence from observational studies
      • Low - observational studies or case series
      • Insufficient - evidence is conflicting, poor quality, or lacking
    • Reference - ACP methods for development of clinical practice guidelines and guidance statements (20679562Ann Intern Med 2010 Aug 3;153(3):194OpenInNew)
  • American Heart Association/American Stroke Society (AHA/ASA) 2018 grading system for recommendations
    • classifications of recommendations
      • Class I - procedure or treatment should be performed or administered
      • Class IIa - reasonable to perform procedure or administer treatment, but additional studies with focused objectives needed
      • Class IIb - procedure or treatment may be considered; additional studies with broad objectives needed, additional registry data would be useful
      • Class III - procedure or treatment should not be performed or administered because it is not helpful or may be harmful
        • Class III ratings may be subclassified as Class III No Benefit or Class III Harm
    • levels of evidence
      • Level A - high-quality evidence from > 1 randomized controlled trial or meta-analysis of high-quality randomized controlled trials
      • Level B-R - moderate-quality evidence from ≥ 1 randomized controlled trial or meta-analysis of moderate-quality randomized controlled trials
      • Level B-NR - moderate-quality evidence from ≥ 1 well-designed nonrandomized trial, observational studies, or registry studies, or meta-analysis of such studies
      • Level C-LD - randomized or nonrandomized studies with methodological limitations or meta-analyses of such studies
      • Level C-EO - consensus of expert opinion based on clinical experience
  • American Heart Association/American Stroke Association (AHA/ASA) 2011-2015 grading system for recommendations
    • classifications of recommendations
      • Class I - procedure or treatment should be performed or administered
      • Class IIa - reasonable to perform procedure or administer treatment, but additional studies with focused objectives needed
      • Class IIb - procedure or treatment may be considered; additional studies with broad objectives needed, additional registry data would be useful
      • Class III - procedure or treatment should not be performed or administered because it is not helpful or may be harmful
        • Class III ratings may be subclassified as Class III No Benefit or Class III Harm
    • levels of evidence
      • Level A - data derived from multiple randomized clinical trials or meta-analyses
      • Level B - data derived from single randomized trial or nonrandomized studies
      • Level C - only expert opinion, case studies, or standard of care
  • Canadian Cardiovascular Society (CCS) grading system for recommendations
    • strength of recommendation
      • Strong
      • Conditional (weak)
    • quality of evidence
      • High - future research unlikely to change confidence in estimate of effect; multiple well-designed, well-conducted clinical trials
      • Moderate - further research likely to have important impact on confidence in estimate of effect and may change estimate; limited clinical trials, inconsistency of results, or study limitations
      • Low - further research very likely to have significant impact on estimate of effect and is likely to change estimate; small number of clinical studies or cohort observations
      • Very Low - estimate of effect is very uncertain; case studies or consensus opinion
    • References
  • Canadian Stroke Best Practice Recommendations (CSBPR) levels of evidence
    • Evidence Level A
      • meta-analysis of randomized controlled trials or consistent findings from ≥ 2 randomized trials
      • desirable effects clearly outweigh undesirable effects or vice versa
    • Evidence Level B
      • single randomized controlled trial or consistent findings from ≥ 2 well-designed nonrandomized and/or uncontrolled trials, and large observational studies
      • desirable effects outweigh or are closely balanced with undesirable effects or vice versa
    • Evidence Level C
      • writing group consensus and/or supported by limited research evidence
      • desirable effects outweigh or are closely balanced with undesirable effects or vice versa
    • Reference - CSBPR Overview and Methodology (CSBPR 2014 PDFPictureAsPdf)
  • European Stroke Organisation (ESO) grades of recommendation
    • classification of evidence
      • Class I
        • adequately powered, prospective, randomized controlled trial (RCT) with masked outcome assessment in representative population
        • adequately powered systematic review of prospective RCTs with masked outcome assessment in representative populations
      • Class II
        • prospective matched-group cohort study in representative population with masked outcome assessment
        • RCT in representative population that lacks 1 criterion for Class I evidence
      • Class III - all other controlled trials in representative population where outcome assessment independent of patient treatment
      • Class IV - evidence from uncontrolled studies, case series, case reports, or expert opinion
    • levels of evidence
      • Level A
        • established either as useful/predictive or not useful/predictive for diagnostic measure
        • established as effective, ineffective, or harmful for therapeutic intervention
        • requires ≥ 1 convincing Class I study or ≥ 2 consistent, convincing Class II studies
      • Level B
        • established either as useful/predictive or not useful/predictive for diagnostic measure
        • established as effective, ineffective, or harmful for therapeutic intervention
        • requires ≥ 1 convincing Class II study or overwhelming Class III evidence
      • Level C
        • established either as useful/predictive or not useful/predictive for diagnostic measure
        • established as effective, ineffective, or harmful for therapeutic intervention
        • requires ≥ 2 class III studies
      • Good Clinical Practice (GCP) - recommended best practice based on experience of guideline development group
    • Reference - ESO guideline on ischaemic stroke and transient ischaemic attack (ESO 2011 PDFPictureAsPdf)
  • European Society of Cardiology (ESC) grading system for recommendations
    • classes of recommendations
      • Class I - evidence and/or general agreement that given treatment or procedure is beneficial, useful, and effective
      • Class II - conflicting evidence and/or divergence of opinion about usefulness/efficacy of given treatment or procedure
        • Class IIa - weight of evidence/opinion in favor of usefulness/efficacy
        • Class IIb - usefulness/efficacy less well-established by evidence/opinion
      • Class III - evidence or general agreement that given treatment or procedure is not useful/effective, and in some cases may be harmful
    • levels of evidence
      • Level A - data derived from multiple randomized clinical trials or meta-analyses
      • Level B - data derived from single randomized trial or large nonrandomized studies
      • Level C - consensus of opinion of experts and/or small studies, retrospective studies, registries
    • References

Synthesized Recommendation Grading System for DynaMed

  • DynaMed systematically monitors clinical evidence to continuously provide a synthesis of the most valid relevant evidence to support clinical decision-making (see 7-Step Evidence-Based MethodologyOpenInNew).
  • Guideline recommendations summarized in the body of a DynaMed topic are provided with the recommendation grading system used in the original guideline(s), and allow DynaMed users to quickly see where guidelines agree and where guidelines differ from each other and from the current evidence.
  • In DynaMed (DM), we synthesize the current evidence, current guidelines from leading authorities, and clinical expertise to provide recommendations to support clinical decision-making in the Overview & Recommendations section.
  • We use the Grading of Recommendations Assessment, Development and Evaluation (GRADE)OpenInNew to classify synthesized recommendations as Strong or Weak.
    • Strong recommendations are used when, based on the available evidence, clinicians (without conflicts of interest) consistently have a high degree of confidence that the desirable consequences (health benefits, decreased costs and burdens) outweigh the undesirable consequences (harms, costs, burdens).
    • Weak recommendations are used when, based on the available evidence, clinicians believe that desirable and undesirable consequences are finely balanced, or appreciable uncertainty exists about the magnitude of expected consequences (benefits and harms). Weak recommendations are used when clinicians disagree in judgments of relative benefit and harm, or have limited confidence in their judgments. Weak recommendations are also used when the range of patient values and preferences suggests that informed patients are likely to make different choices.
  • DynaMed (DM) synthesized recommendations (in the Overview & Recommendations section) are determined with a systematic methodology:
    • Recommendations are initially drafted by clinical editors (including ≥ 1 with methodological expertise and ≥ 1 with content domain expertise) aware of the best current evidence for benefits and harms, and the recommendations from guidelines.
    • Recommendations are phrased to match the strength of recommendation. Strong recommendations use "should do" phrasing, or phrasing implying an expectation to perform the recommended action for most patients. Weak recommendations use "consider" or "suggested" phrasing.
    • Recommendations are explicitly labeled as Strong recommendations or Weak recommendations when a qualified group has explicitly deliberated on making such a recommendation. Group deliberation may occur during guideline development. When group deliberation occurs through DynaMed-initiated groups:
      • Clinical questions will be formulated using the PICO (Population, Intervention, Comparison, Outcome) framework for all outcomes of interest specific to the recommendation to be developed.
      • Systematic searches will be conducted for any clinical questions where systematic searches were not already completed through DynaMed content development.
      • Evidence will be summarized for recommendation panel review including for each outcome, the relative importance of the outcome, the estimated effects comparing intervention and comparison, the sample size, and the overall quality rating for the body of evidence.
      • Recommendation panel members will be selected to include at least 3 members that together have sufficient clinical expertise for the subject(s) pertinent to the recommendation, methodological expertise for the evidence being considered, and experience with guideline development.
      • All recommendation panel members must disclose any potential conflicts of interest (professional, intellectual, and financial), and will not be included for the specific panel if a significant conflict exists for the recommendation in question.
      • Panel members will make Strong recommendations if and only if there is consistent agreement in a high confidence in the likelihood that desirable consequences outweigh undesirable consequences across the majority of expected patient values and preferences. Panel members will make Weak recommendations if there is limited confidence (or inconsistent assessment or dissenting opinions) that desirable consequences outweigh undesirable consequences across the majority of expected patient values and preferences. No recommendation will be made if there is insufficient confidence to make a recommendation.
      • All steps in this process (including evidence summaries which were shared with the panel, and identification of panel members) will be transparent and accessible in support of the recommendation.
    • Recommendations are verified by ≥ 1 editor with methodological expertise, not involved in recommendation drafting or development, with explicit confirmation that Strong recommendations are adequately supported.
    • Recommendations are published only after consensus is established with agreement in phrasing and strength of recommendation by all editors.
    • If consensus cannot be reached then the recommendation can be published with a notation of "dissenting commentary" and the dissenting commentary is included in the topic details.
    • If recommendations are questioned during peer review or post publication by a qualified individual, or reevaluation is warranted based on new information detected through systematic literature surveillance, the recommendation is subject to additional internal review.

DynaMed Editorial Process

Special acknowledgements

  • Alexander Rae-Grant, MD, FRCPC, FAAN (Deputy Editor, Neurology DynaMed Plus; Neurologist, Cleveland Clinic; Ohio, United States)
  • Dr. Rae-Grant declares no relevant financial conflicts of interest.
  • Eddy Lang, MDCM, CCFP(EM), CSPQ (Zone Clinical and Academic Department Head for Emergency Medicine and Professor of Emergency Medicine, University of Calgary; Senior Researcher, Alberta Health Services; Alberta, Canada)
  • Dr. Lang declares his position as Chair of the Canadian Association of Emergency Physicians Stroke Practice Committee.
  • Dr. Lang declares no relevant financial conflicts of interest.
  • Alan Ehrlich, MD (Executive Editor; Associate Professor of Family Medicine, University of Massachusetts Medical School; Massachusetts, United States)
  • Dr. Ehrlich declares no relevant financial conflicts of interest.
  • DynaMed topics are written and edited through the collaborative efforts of the above individuals. Deputy Editors, Section Editors, and Topic Editors are active in clinical or academic medical practice. Recommendations Editors are actively involved in development and/or evaluation of guidelines.
  • Editorial Team role definitions
    Topic Editors define the scope and focus of each topic by formulating a set of clinical questions and suggesting important guidelines, clinical trials, and other data to be addressed within each topic. Topic Editors also serve as consultants for the internal DynaMed Editorial Team during the writing and editing process, and review the final topic drafts prior to publication.
    Section Editors have similar responsibilities to Topic Editors but have a broader role that includes the review of multiple topics, oversight of Topic Editors, and systematic surveillance of the medical literature.
    Recommendations Editors provide explicit review of DynaMed Overview and Recommendations sections to ensure that all recommendations are sound, supported, and evidence-based. This process is described in "Synthesized Recommendation Grading."
    Deputy Editors are employees of DynaMed and oversee DynaMed internal publishing groups. Each is responsible for all content published within that group, including supervising topic development at all stages of the writing and editing process, final review of all topics prior to publication, and direction of an internal team.

How to cite

National Library of Medicine, or "Vancouver style" (International Committee of Medical Journal Editors):

  • DynaMed [Internet]. Ipswich (MA): EBSCO Information Services. 1995 - . Record No. T143427, Stroke (Acute Management); [updated 2018 Dec 03, cited place cited date here]. Available from https://www.dynamed.com/topics/dmp~AN~T143427. Registration and login required.
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    Overview and Recommendations

    • Background

    • Evaluation

    • Management

  • Related Summaries

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    General Information

    • Description

    • Also Called

    • Definitions

    • Types

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    Initial Evaluation

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      History

      • Chief concern (CC)

      • History of present illness (HPI)

      • Medication history

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      Physical

      • General physical

      • Skin

      • HEENT

      • Neck

      • Cardiac

      • Neuro

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    Diagnosis

    • Making the Diagnosis

    • Differential Diagnosis

    • Testing Overview

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      Clinical Prediction Rules

      • Prehospital Prediction

      • Emergency Department Prediction

      • Predicting Ischemic vs. Hemorrhagic Stroke

    • Blood Tests

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      Imaging Studies

      • Neuroimaging

      • Echocardiography

      • Chest X-ray

    • Electrocardiography (ECG)

    • Cerebrospinal Fluid (CSF) Analysis

    • Other Diagnostic Testing

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    Treatment

    • Treatment Overview

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      Treatment Setting

      • Prehospital Management

      • Acute Stroke Units

      • Home Hospitalization

      • Immediate Treatment if Outpatient Care

    • Diet

    • Activity

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      Medications

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        For Ischemic Stroke

        • Thrombolytics

        • Antiplatelet Therapy

        • Anticoagulation

        • Antihypertensives

        • Statins

        • Oxygen

        • Antipyretics

        • Antibiotics

        • Anticonvulsants

        • Insulin

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        For Hemorrhagic Stroke

        • Antihypertensives

        • Statins

        • Oxygen

        • Antipyretics

        • Antibiotics

        • Insulin

        • Anticonvulsants

        • Additional Medications for Subarachnoid Hemorrhage

      • Alternative and Experimental Medications for Acute Stroke

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      Surgery and Procedures

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        For Ischemic Stroke

        • Endovascular Therapy

        • Decompressive Surgery / Hemicraniectomy

        • Ventricular Drain for Hydrocephalus

        • Carotid Endarterectomy

        • Neurostimulation

      • For Hemorrhagic Stroke

    • Consultation and Referral

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      Other Management

      • General Supportive Care

      • Patient Education

      • Swallowing Dysfunction

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        Venous Thromboembolism Prophylaxis

        • Recommendations for Deep Vein Thrombosis (DVT) Prevention

        • Pharmacologic Thromboprophylaxis in Stroke

        • Mechanical Compression

      • Cerebral Edema

      • Augmentation of Cerebral Blood Flow

      • Alternative and Experimental Nonpharmacologic Therapies

    • Follow-up

  • Prevention

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    Quality Improvement

    • American Heart Association/American Stroke Association

    • Medicare/Joint Commission National Hospital Inpatient Quality Measures

    • Medicare Hospital Outpatient Department Quality Measures

    • Physician Quality Reporting System Quality Measures

    • Quality and Outcomes Framework Indicators

    • Choosing Wisely Australia

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    Guidelines and Resources

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      Guidelines

      • United States guidelines

      • United Kingdom guidelines

      • Canadian guidelines

      • European guidelines

      • Asian guidelines

      • Mexican guidelines

      • Central and South American guidelines

      • Australian and New Zealand guidelines

      • African guidelines

      • Quality indicators

    • Review articles

    • MEDLINE search

  • Patient Information

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    ICD Codes

    • ICD-10 codes

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    References

    • General references used

    • Recommendation grading systems used

    • Synthesized Recommendation Grading System for DynaMed

    • DynaMed Editorial Process

    • Special acknowledgements

    • How to cite

Topic Editor
Alexander Rae-Grant MD, FRCPC, FAAN
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Affiliations

Deputy Editor Neurology, DynaMed Plus; Massachusetts, United States; Neurologist, Cleveland Clinic; Ohio, United States

Conflicts of Interest

Dr. Rae-Grant declares no relevant financial conflicts of interest.

Recommendations Editor
Eddy Lang MDCM, CCFP(EM), CSPQ
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Affiliations

Zone Clinical and Academic Department Head for Emergency Medicine and Professor of Emergency Medicine, University of Calgary; Alberta, Canada; Senior Researcher, Alberta Health Services; Alberta, Canada

Conflicts of Interest

Dr. Lang declares no relevant financial conflicts of interest.

Deputy Editor
Alan Ehrlich MD
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Affiliations

Executive Editor, DynaMed; Associate Professor of Family Medicine, University of Massachusetts Medical School; Massachusetts, United States

Conflicts of Interest

Dr. Ehrlich declares no relevant financial conflicts of interest.

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