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ESOC 2021 | ESO and EAN joint guidelines on post-stroke cognitive impairment

Terence Quinn, MD, MRCP, MBCHB (hons), University of Glasgow, Glasgow, UK, discusses the newly developed European Stroke Organization (ESO) and European Academy Neurology (EAN) joint guidelines on post-stroke cognitive impairment. The optimal management of post-stroke cognitive impairment is controversial, with many variations in practice across different centers. The guidelines were put together to provide evidence-based recommendations and expert consensus statements to assist clinicians in decision making. Guidelines were established across four major areas: prevention, diagnosis, treatment, and prognosis. Limited high-level evidence from randomized controlled trials prevented recommendations in several areas, highlighting fundamental topics where further investigation is needed as a priority. This interview took place at the European Stroke Organisation Conference (ESOC), 2021.

Transcript (edited for clarity)

Let me start by telling you a little bit about why we felt we needed a guideline. In clinical practice guidelines are most useful where there has been new evidence that you need to synthesize, where there is variation in practice, and in conditions are recognized as being important. And all three of those conditions are met for the field of post-stroke cognitive impairment. It’s incredibly important...

Let me start by telling you a little bit about why we felt we needed a guideline. In clinical practice guidelines are most useful where there has been new evidence that you need to synthesize, where there is variation in practice, and in conditions are recognized as being important. And all three of those conditions are met for the field of post-stroke cognitive impairment. It’s incredibly important. What practitioners do across Europe varies substantially, and there have been some new trials published in the last few years. So, that was the rationale for commissioning a guideline, and two of the major societies in Europe, the European Stroke Organization and the European Academy of Neurology, both decided that they wanted to jointly work on a guideline that looked at this area of post-stroke cognitive impairment.
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I think that the second part of your question was about some of the major recommendations in the guideline. So when we formed our guideline writing group we realized that we couldn’t have a guideline that covers every aspect of post-stroke cognitive impairment and post-stroke dementia because that’s simply too big a topic, so we divided into four themes. Part of our guideline relates to prevention. Part of our guideline relates to diagnosis. Part of the guideline relates to treatment and the last part relates to prediction and prognosis. And so within those themes we then selected what we felt were the key questions that were of importance to practitioners.

The guideline’s long, it runs to over a hundred pages and we have 18 recommendations with sub recommendations so I can’t go through everything. I guess if I was to give an overview of the whole guideline, for many of the areas there really wasn’t strong randomized controlled trial evidence. We made a decision early on in writing the guideline that we would only make recommendations where we felt the evidence was sufficiently strong to allow for that recommendation. And actually for a lot of the things that we do in practice, particularly in fields like cognitive rehabilitation, the evidence isn’t that strong.

Now, some people criticized the guidelines saying that we’re being too harsh, saying that we should have lowered our threshold, but we stand by the guideline because you shouldn’t be less robust just because there’s no evidence there. And you shouldn’t say well just because post-stroke cognition is difficult, we’re going to make recommendations on poor quality evidence. I don’t think that’s fair and I don’t think that’s fair to people living with stroke. So we stood our ground, and for many of the areas where we had guideline questions we had to conclude that there wasn’t sufficient evidence to give a practice changing recommendation. But what we then did was we followed up each of those with some clinical practice pointers based on expert consensus, and also drawing on the evidence that was available, where perhaps there were randomized controlled trails.

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