Philippine Journal of Internal Medicine

Original Article

Adherence to the Clinical Practice Guidelines of the Stroke Society of the Philippines in the Management of Ischemic Stroke in Young Adults
Gerard Paul Espeleta, MD*, Paulynn Marie Pinzon, MD*, Beverly Baliguas, MD**, Cheryl Estores, MD***, Richelle Joy Diamante, MD****

Abstract
Background: The etiology of ischemic stroke in young adults is diverse and needs a thorough diagnostic approach. However, management may be similar to that of the older adults. The objective of this study is to determine the adherence of the different physicians in Bacolod City to the clinical practice guidelines of the Stroke Society of the Philippines (SSP). Research Design: descriptive study. This is a retrospective and Seven (28%) cases were managed by neurologists, 3 (12%) by internists, and 15 (60%) by IM residents. The mean age of ischemic stroke was 36.05 years old. The most common risk factors were oral contraceptive pill (OCP) use (42%) in females and hypertension (46%) in males. Majority of the physicians adhered to the recommended emergent diagnostic tests including cranial CT scan (100%), complete blood count (96%), random blood sugar (88%), electrocardiogram (92%), serum electrolytes (60%). Most physicians complied with the use of antiplatelet therapy (but with varied preference), neuroprotection and early rehabilitation for the therapeutic management of stroke. None complied with the early thrombolytic therapy in the management of moderate stroke. Conclusion: Majority of the physicians complied with the emergent diagnostics for ischemic stroke. In addition, with varied etiologies of ischemic stroke in the young, few were observed to have done further diagnostic work-up for this group of patients. Most physicians generally adhered to the therapeutic management as recommended by the practice guidelines except for the use of thrombolytic therapy in the first few hours from the onset of stroke. Few physicians complied with the use of antiplatelet therapy, particularly aspirin.

Methodology: Medical records of patients aged 19 to 45 years old diagnosed with ischemic stroke and admitted in three tertiary hospitals in Bacolod City from May 2010 to October 2010 were reviewed. The subjects were categorized as to mild, moderate or severe stroke as defined by the Guidelines for the Prevention, Treatment and Rehabilitation of Brain Attack, 7th Edition by the SSP. Demographic data of each patient and the diagnostic approach and therapeutic management by the attending physicians were evaluated. Results: There are 25 young adults in this were diagnosed with with moderate stroke cases of ischemic stroke in study. Fourteen (56%) cases mild stroke or TIA, 11 (44%) and none for severe stroke.

B ackground
Stroke in young adults is surprisingly common. 1 The prevalence of stroke among American adults age 20 and older was 6,400,000 with 2,5000,000 males and 3,900,000 in females. 19 In other countries, the annual stroke incidence was estimated at 34/100,000 in Swedish adults less than 55 years of age and 10.8/100,000 among Finnish patients aged

*Resident-in-training, Department of Internal Medicine, Corazon Locsin Montelibano Memorial Regional Hospital, Bacolod City **Consultant, Department of Internal Medicine, Corazon Locsin Montelibano Memorial Regional Hospital, Bacolod City ***Resident-in-training, Department of Internal Medicine, Don Pablo O. Torre Memorial Hospital, Bacolod City **** Resident-in-training, Department of Internal Medicine, The Doctors Hospital, Bacolod City

15-49. 1,2 According to Aquino, there is an estimated 15 million non-fatal stroke cases each year affecting Asian nations. 4 However, there is scarcity of data on stroke in young patients in our locality. The latest study on the prevalence rate of stroke patients in the Philippines in 2004 was 0.4 to 1.9%. 5 There is no specific age group in stroke in young adults. However, several studies show that the incidence was seen in ages 15-45 years old. 20,21 As reported in the 2010 American Stroke Associations International Stroke Conference, the average age of stroke patients in 2005 was nearly three years younger than the average age of stroke patients in 19931994. Moreover, the percentage of people 20 to 45 years old having a stroke was up to 7.3 % in 2005 from 4.5 % in

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19931994. 3 The range of potential etiologies for stroke in young adults is broader than that for older adults. 1 However, like in older adults, stroke in the young is typically categorized as primarily ischemic or hemorrhagic. Between the two, ischemic stroke (87%) is more common than hemorrhagic strokes (10%). 1 The most frequent risk factors for ischemic stroke in the young were dyslipidemia (60%), Local smoking (44%), and hypertension (39%). 2 studies reported that 90% of Filipino had one or more of the following risk factors including physical inactivity (60.5%), smoking, obesity (5%), overweight (20%), hypertension (22.5%) and a significant number for those with high blood cholesterol and blood sugar. 27 The most frequent etiologic subgroups are cardioembolism (20%) and cervicocerebral artery dissection (15%). Proportions of large-artery atherosclerosis (8%) and small-vessel disease (14%) began to enlarge at age 35, whereas frequency of undetermined etiology (33%) decreased along aging. 2 With a wide variety of etiology, the diagnostic approach in ischemic stroke in young adults differs from that of the older patients. However, the management is similar in both groups. 1 There are several published guidelines in the management of ischemic stroke in different countries. The AHA and American Stroke Association have published Guidelines for the Early Management of Adults with Ischemic Stroke which was revised in 2007 6 and has recently published an evidence based Updated Secondary Stroke Prevention Guidelines last October 2010. Other countries such as Canada 7 and United Kingdom 8 have published their respective practice guidelines The Canadian Best Practices Recommendations for Stroke Care and National Clinical Guideline for Stroke. A similar clinical practice guideline for the management of stroke called Guidelines for the Prevention, Treatment and Rehabilitation of Brain Attack was also made available in the Philippines by the SSP since 1999 with the latest edition in 2007. 9 The mortality of patients with ischemic stroke was reduced at the six-month followup, with risk of death directly related to the level of noncompliance with the AHA guideline recommendations for acute stroke and transient ischemic attack. Moreover, compliance with guideline recommendations in the acute phase was able to reduce the number of early deaths, while good compliance during both the acute and the early clinical phases improved stroke survival at six

Adherence to the Clinical Practice Guidelines

months. Thus, there is a strong association between adherence to guidelines and stroke outcome. 10 In our setting, there is paucity of local data looking at the adherence of the physicians in the management of stroke, particularly, ischemic stroke in young patients, hence this study.

O bjectives
General:
To evaluate the adherence of physicians in Bacolod City to the clinical practice guidelines of SSP in the management ischemic stroke in young adults

Specific:
1. 2. 3. To describe the demographic data of patients diagnosed with ischemic stroke in the young. To determine the adherence of physicians in diagnosis of ischemic stroke in the young. To determine the adherence of physicians to the therapeutic management of ischemic stroke in the young according to stroke severity or classification.

R esearch

Design

This is a retrospective and descriptive study.

M ethodology
Review of medical records of patients diagnosed with ischemic stroke in the young from May 2010 to October 2010 was performed. Subjects Inclusion Criteria Young adult patients (19-45 years old) admitted in all tertiary hospitals in Bacolod City from May 2010 to October 2010 with: o history and neurologic findings of stroke confirmed by the presence of acute infarction on plain cranial CT scan o history suggestive of stroke but with resolution of neurologic deficits within 24 hours with or without evidence of acute infarction on plain cranial CT scan Exclusion Criteria Patients with history and neurologic findings of stroke but with acute hemorrhage on plain cranial CT scan Patients with history and neurologic findings of

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stroke that resolved within 24 hours but was not confirmed through plain cranial CT scan. Patients with previous attack of stroke and the etiology was demyelinating in nature.

Espeleta GP, et al

D efinition

of Terms

Procedure 1. A memorandum of agreement was signed by following the hospitals included in the study a. Don Pablo O. Torre Memorial Hospital (DPOTMH) b. The Doctors Hospital-Bacolod (TDH) c. Corazon Locsin Montelibano Memorial Regional Hospital (CLMMRH) 2. Medical records of patients diagnosed with ischemic stroke in the young were retrieved and reviewed (Figure 1a). 3. We determined the following demographic data: a. A ge b. G ender c. Risk Factors (Hypertension, Diabetes Mellitus, Dyslipidemia, Cardiac Dysrhythmia, Myocardial Infarction, Smoking, Snoring, Stress and Frequent Alcohol Intake) 4. Patients were categorized as to mild stroke / transient ischemic attack (TIA), moderate stroke and severe stroke as seen in Appendix A. 5. The diagnostic and therapeutic management each physician in mild ischemic stroke/ TIA, moderate stroke and severe stroke was compared to the recommendations established by the SSP. 6. The results were collected and analysed.
Medical records of patients from CLMMRH Medical records of patients from DPOTMH Medical records of patients from TDH

1. Stroke - A neurological symptoms lasting for more than 24 hours or an acutely clinically relevant brain lesion on imaging in patients with rapidly vanishing symptoms. 2. Stroke in young - Stroke in patients 19 to 45 years old. 3. Transient Ischemic Attack (TIA) Neurological symptoms lasting more than 24 hours or an acute relevant lesion on imaging. It is also defined as transient episode of neurological dysfunction caused by focal brain, spinal cord or retinal ischemia, with clinical symptoms typically lasting less than 1 hour and without evidence of acute infarction 4. Cerebral Infarction - A cessation of blood flow that lasts for more than a few minutes then infarction or death to the brain tissue ensues. 5. Primary Prevention or Early Medical Management - Directed to preventing and providing medical and therapeutic management in the initial occurrence of acute stroke. 6. Secondary Prevention or Delayed Medical Management Refers to the diagnostic and therapeutic management that seeks to arrest an existing ischemic stroke and its effects, and to reduce the recurrence of relapses among survivors of acute stroke by controlling the risk factors.

A nalysis
Results means. are reported as percentages (%) and

R esults
A total of 25 cases of ischemic stroke in young adults were diagnosed from May to October 2010. Seven (28%) cases were managed by neurologists, 3 (12%) by internists, and 15 (60%) by IM residents. A. Demographic Data Fourteen (56%) cases were diagnosed with mild stroke or TIA, 11 (44%) with moderate stroke and none for severe stroke. According to age groups, the mean age of ischemic stroke is 36.05 years old. Eight (32%) cases were diagnosed at 31-35 years old, 6 (24%) cases at 36-40 years old, 7 (26%) cases at 41-45 years old, 2 (8%) cases at 26-30 years old and 2 (8%) cases at 19-25 years old (Table I). Thirteen (52%) cases are males and 12 (48%) are females (Table II). Among the females, 5 (42%) were using oral contraceptive pills (OCPs) making it the most common risk factor for stroke (Figure 1b). On the other hand, hypertension was the most common

Inclusion of subjects

Demographic data determined

Categorization of stroke according to severity

Mild Stroke / TIA

Moderate Stroke

Severe Stroke

Evaluation of diagnostic and therapeutic management of mild stroke / TIA

Evaluation of diagnostic and therapeutic management of moderate stroke

Evaluation of diagnostic and therapeutic management of severe stroke

Data collection and analysis

Figure 1a. Methodology

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risk factor in males affecting 6 (46%) of the cases (Figure 2). B. Diagnostics Different laboratory tests for ischemic stroke were requested by different physicians (Table III). For the emergent diagnostics (Figure 3), all patients had cranial CT scan. Ninety-six percent (24) of all physicians requested for complete blood count (CBC). All patients managed by neurologists had random blood sugar (RBS) determination while 2 (66%) of internists and 13 (87%) of the IM residents requested for the said test. Twenty-three of the 25 (92%) physicians requested for electrocardiogram (ECG). Prothrombin time (PT) and activated partial thromboplastin time (aPTT) were requested in 6 (24%) patients. Only 3 (43%) of neurologists, 1 (33%) of internists and 2 (14%) of IM residents ordered for the said test. Sixty percent (15) of the physicians requested for serum electrolytes which include 2 (28%) of neurologists, 1 (33%) of internists and 12 (80%) of IM residents Other ancillary diagnostics were also requested as shown in Table III. Twenty-two (88%) cases had blood urea nitrogen (BUN) / creatinine determination. Lipid profile was requested by 5 (71%) of neurologists, 1 (33%) of internists and 6 (40%) of IM residents. Five (71%) of neurologists, 2 (66%) of internists, and 3 (20 %) of IM residents requested for 2D echo in 11 (44%) cases. Carotid Doppler ultrasound was done in 6 (24%) of the total cases. Other laboratory tests for the diagnostic work-up of ischemic stroke in young adults were performed and individualized according to patients case and

Adherence to the Clinical Practice Guidelines

physicians preference. These include MRI, thyroid panel, and hematologic tests such as ESR, protein C, VDRL test.

OCP use Hypertension Risk Factors RHD Prev history of stroke Cardiac Dysrhythmia Diabetes Mellitus
0% 5% 8% 16% 25%

42%

8%

8%

10%

15%

20%

25%

30%

35%

40%

45%

% population

Figure 1b. Risk factors for stroke in the young in females

Hypertension Diabetes Mellitus Risk Factors Smoking Dyslipidemia Hyperthyroidism RHD

0% 8% 23% 30%

46%

15%

8%

10%

20%

30%

40%

50%

Table I. Distribution of stroke severity according to age

Mild Stroke / Age TIA (n=17) Moderate Stroke (n=13) Severe Stroke (n=0) Total n (%)

% population

Figure 2. Risk factors for stroke in the young in males

19-25 26-30 31-35 36-40 41-45

1 1 5 2 5

1 1 3 4 2

0 0 0 0 0

2 (8%) 2 (8%) 8 (32%) 6 (24%)

% Adherence
120% 100% 80% 60% 40% 20% 0% 60% 100% 96% 88% 92%

7 (26%)

Table II. Distribution of stroke cases according to gender

Mild Stroke Gender / TIA (n=14) Moderate Stroke (n=11) Severe Stroke (n=0) Total n=25 (%)

24%

Cranial CT Scan Complete Blood Random Blood Count Sugar

ECG

PT/aPTT

Electrolytes

Diagnostic Tests

Male Female

6 8

7 4

0 0

13 (52%) 12 (48%)

Figure 3. Adherence of the physicians on the emergent diagnostic work-up for ischemic stroke in young adults

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Table III. Summary of laboratory tests requested according to different physicians
Neurologists (n=7) Internists (n=3) IM Resident (n=15) Total n (%)

Espeleta GP, et al
from stroke or an intra-arterial thrombolysis, within six hours from stroke. Only 3 (37.5) patients were given antiplatelet therapy. All neurologists, 2 (40%) of the IM residents and an internist opted to give neuroprotectant. All neurologists, 1 (20%) of the IM residents and an internist referred their patients for early rehabilitation. Only 2 (40%) of the IM residents referred their patients to a specialist. In cardioembolic stroke, all of the cases were managed by the IM residents. Sixty-six percent were referred to a specialist. Intravenous rtPA and intra-arterial thrombolysis were not given on their patients. Aspirin was not started. Neuroprotection was given by 2 (66%) of the IM residents. Table V shows the summary of the early management of

Emergent diagnostics

Cranial CT Scan Complete Blood Count Random Blood Sugar Electrocardiogram PT/aPTT SerumElectrolytes Lipid Profile BUN/Creatinine 2D Echocardiogram Carotid Doppler studies MRI Thyroid Panel ESR CRP Protein C VDRL

7 7 7 7 3 2 5 6 5 2 1 0 1 1 0 0

3 2 2 2 1 1 3 3 2 2 0 0 1 0 0 1

15 15 13 14 2 12 6 13 3 2 1 1 0 0 1 0

25 (100%) 24 (96%) 22 (88%) 23 (92%) 6 (24%) 15 (60%) 14 (56%) 22 (88%) 11 (44%) 6 (24%) 2 (8%) 1 (4%) 2 (8%) 1 (4%) 1 (4%) 1 (4%)

Other Ancillary Tests

Table IV. Summary of the therapeutic management of mild stroke according to different physicians
Non-Cardioembolic (Thrombotic / Lacunar) stroke Neurologists (n=4) Internists (n=2) IM Residents (n=7)

Antiplatelets Aspirin* clopidogrel Cilostazol Neuroprotection Early Rehabilitation within 72 hours 2 (50%) 1 (25%) 1 (25%) 3 (72%) 1 (25%) Neurologist (n=1) Anticoagulation Heparin LMWH Antiplatelets Aspirin* clopidogrel Neuroprotection Early Rehabilitation within 72 hours Antibiotics if infective endocarditis is suspected (Specify)
*Recommended antiplatelet drug Cardioembolic stroke

4 (57%) 1 (50%) 1 (50%) 1 (50%) Internist (n=0) 4 2 7 (100%) 2 (28%) IM Resident (n=0) 0 0 0 0 0 0 0

C. Therapeutic Management of Mild Stroke There were 14 cases diagnosed with mild stroke 13 non-cardioembolic and 1ardioembolic stroke. For non-cardioembolic stroke patients (Figure 4), 9 (69%) patients were given antiplatelets. Aspirin was the preferred anti-platelet drug by 2 (50%) of the neurologists and 4 (57%) of the IM residents. Eleven (84%) patients received citicoline for neuroprotection, as given by all IM residents, 3 (72%) of the neurologists and 1 (50%) of the internists. Early rehabilitation was initiated in 4 (30%) patients by 1 (25%) of the neurologists, 1 (50%) of the internists and 2 (28%) of the IM residents. One case of mild cardioembolic stroke was managed by a neurologist and was given a low molecular weight heparin (LMWH), clopidogrel and citicoline for neuroprotection. Table IV shows the summary of the therapeutic management according to different physicians. D. Therapeutic Management of Moderate Stroke There were 11 cases of moderate stroke non-cardioembolic and 3 cardioembolic stroke.

1 1 3

1 1 0 0

4 2

moderate stroke according to different physicians. Delayed Management or Secondary Prevention In non-cardiogenic stroke (Figure 6), all physicians adhered to the control of risk factors. Five (62%) of the cases received antiplatelet medications. Aspirin was preferred by the internist, 1 (50%) of the neurologists and 2 (40%) of the IM residents. Fifty percent of neurologists preferred clopidogrel. Carotid Doppler ultrasound was requested by 1 (50%) of the neurologists and 2

Early Management In non-cardioembolic stroke (Figure 5), none were given intravenous recombinant tissue plasminogen activator (rtPA) within three hours

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90% 80% 70%
% Adherence

Adherence to the Clinical Practice Guidelines

70% 60% 8% 15% 84%
Cilostazol Clopidogrel Aspirin
% Adherence

50% 40% 30% 20% 10% 0%

IVrtPA

60% 50% 40% 30% 20% 10% 0%

Antiplatelets Neuroprotection Early Rehabilitation within 72 hours

63% 12% 12% 12% 0%

Intra-arterial thrombolysis

50%

Cilostazol Clopidogrel Aspirin

46%

30%

0%

Antiplatelets

Neuroprotection

Early Rehabilitation within 72 hours

Therapeutic Management

Therapeutic Management

Figure 5. Adherence of the physicians to the recommended early therapeutic management of moderate non-cardioembolic stroke.
100% 90%

Figure 4. Adherence of the physicians to the recommended therapeutic management of mild stroke

Table V. Summary of the early therapeutic management of moderate stroke according to different physicians
% Adherence

80% 70% 60% 50% 40% 30% 20%

Clopidogrel

Non-Cardioembolic (Thrombotic / Lacunar) stroke Neurologist (n=2) IM Resident (n=5) Internist (n=1)

12% 88%

Refer to specialist Intravenous recombinant tissue plasminogen activator (rtPA) within 3 hours from stroke Intra-arterial thrombolysis, within 6hours from stroke Antiplatelets Aspirin* clopidogrel Cilostazol Neuroprotection (Specify) Early Rehabilitation within 72 hours

NA

2 (40%) 0 0 0 0 1 (20%)

50%

Aspirin

38%

10% 0%
Control Risk Factors Antiplatelets Therapeutic Management Carotid Doppler Studies

1 (50%) 2 (100%) 2 (100%)

Neurologists (n=0) Cardioembolic stroke Internists (n=3) IM Residents (n=0)

Figure 6. Adherence of the physicians to the recommended delayed therapeutic management of moderate non-cardioembolic stroke. Table VI. Summary of the delayed therapeutic management of moderate stroke according to different physicians.
Non-Cardioembolic (Thrombotic / Lacunar) stroke Neurologist (n=2) IM Resident (n=5) Internist (n=1)

2 (40%) 1 (20%)

1 1

Refer to specialist Intravenous rtPA within 3hours of stroke onset & refer specialist Intra-arterial thrombolysis within 6 hours of stroke Anticoagulation Heparin LMWH Aspirin* Neuroprotection (Specify) Early Rehabilitation within 72 hours Antibiotics if infective endocarditis is suspected (Specify)
*Recommended antiplatelet drug

2 (66%) 0 0 0 0 0 0 2 (66%) 1 (33%) 0

Control of Risk Factors Antiplatelets Aspirin* clopidogrel Carotid Doppler Studies

2 (100%)

5 (100%) 0 1 (20%)

0 1 0
IM Residents (n=0)

1 (50%)
Cardioembolic stroke Neurologists (n=0)

2 (40%)
Internists (n=3)

Cardiology Consult Carotid Doppler Studies Anticoagulation with warfarin ( if INR is within 1.6-2.5)
*Recommended antiplatelet

1 (33%) 1 (33%)

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(40%) of the IM residents. In cardioembolic stroke, none of the IM residents referred for a cardiology consult. One (33%) of the IM residents requested for carotid doppler studies. Anticoagulation with warfarin was started by 1 (33%) of the IM residents. Table VI shows the summary of the delayed management of moderate stroke according to different physicians.

Espeleta GP, et al
Other suggested management in this study include early rehabilitation 17 and control of risk factors, which have been proven to improve patient outcome. Only some of our physicians complied with the former while majority of them adhered to the latter.

C onclusions
Majority of the physicians complied with the emergent diagnostics for ischemic stroke. However, considering the various etiologies of ischemic stroke in the young, only a few physicians were observed to have done further ancillary tests for this group of patients. Most physicians adhered to the therapeutic management as recommended by the practice guidelines except for the use of thrombolytic therapy in the first few hours from the onset of stroke. Few physicians complied with the use of antiplatelet therapy, particularly aspirin.

D iscussion
In this retrospective study, we investigated the adherence of different physicians to the guidelines in the management of ischemic stroke among young adults admitted in 3 tertiary hospitals in Bacolod City from May to October 2010. Other studies have reported that there is a strong association between compliance to the guidelines and stroke outcomes. 10,11 We considered cranial CT scan, CBC, RBS, ECG, PT/aPTT, and serum electrolytes as the emergent tests in the early diagnosis of ischemic stroke. Abnormalities in any of these tests are present in several conditions which can mimic stroke at the emergency room. 10 These conditions must be considered before proceeding with acute stroke treatment. 12 In this study, most of the physicians were adherent to these emergent diagnostics. The etiology of stroke in the young is broader than that of the older adults. 1 Studies reported that stroke in young patients are most commonly due to cardioembolism and few unknown etiologies that have led to further work-up such as coagulopathy tests. 13 We observed that there were only a few physicians who performed further ancillary tests, beyond the recommended diagnostic work-up, to investigate the cause of stroke in young adults. The use of aspirin in early and delayed medical management of stroke is of benefit for a wide range of patients as shown in several randomized trials. 14,15,16 Few physicians in this study used aspirin as anti-platelet drug. Others preferred other anti-platelet drugs. Trials demonstrate that patients started with neuroprotectants have prolonged neuronal survival and increases global recovery. 9 Majority of the physicians adhered to the recommendation of the use of neuroprotectants in the early medical management of both mild and moderate stroke. Several trials have shown that the use of thrombolytic therapy in the early management of stroke resulted in complete neurological recovery especially in young adults. 6,18 In this study, all physicians failed to administer thrombolytic therapy in the early management of stroke.

R ecommendations
We recommend further studies on the etiology of stroke in young adults in our local setting so as to establish specific clinical practice guidelines for this set of patients. We recommend a prospective study be done to determine associations between adherence to the practice guidelines and stroke outcomes.

References
1. Marc Marcoux, MD. Stroke in Young Adults. Stroke, 2000, 11:2 2. Jukka Putaala, MD, et al. Analysis of 1008 Consecutive Patients Aged 15 to 49 With First-Ever Ischemic Stroke, American Heart Association, Stroke. 2009; 40:1195 3. Brett M. Kissela, MD, et al. American Stroke Association International Stroke Conference: Stroke incidence rising among younger adults, decreasing among elderly. American Heart Association 2010 4. Abdias V. Aquino MD. Stroke - is it epidemic in Asia pacific region? Third Congress of the Asian Pacific Society of Atherosclerosis and Vascular Diseases, (Abstract). 2002 5. Cynthia Balana. Stroke Afflicts the Young, Too, Say Experts; Philippine Daily Inquirer, 2010 6. Harold P. Adams, Jr, MD, et al. Guidelines for the Early Management of Adults With Ischemic Stroke, American Heart Association/American Stroke Association, Circulation 2007;115;e478-e534 7. The Canadian Stroke Strategy. Performance Measurement Manual: A supplement to the Canadian Stroke Strategy Canadian Best Practices Recommendations for Stroke Care, 2008 8. Intercollegiate Stroke Working Party. National clinical guideline for stroke, 3rd edition. London: Royal College of Physicians, 2008 9. Stroke Society of the Philippines. Guidelines for the

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Prevention, Treatment and Rehabilitation of Brain Attack, 7th Edition. 2007 Giuseppe Micieli, MD, et al. Guideline Compliance Improves Stroke Outcome: A Preliminary Study in 4 Districts in the Italian Region of Lombardia, American Heart Association, Stroke. 2002;33:1341 Silvana Quaglini, et al. Evaluating the Impact of Clinical Practice Guidelines on Stroke Outcomes, Lecture Notes in Computer Science, 2001, Volume 2101/2001, 442-452 Lawrence R. Wechsler, MD. Medical Mannagement of acute ischemic stroke, American academy of neurology 58th Annual Meeting, 2006 Robert J. Adams, MD. Causes of stroke in young patients, Journal Watch, Neurology, 2004 Robert D. Brown, Jr., MD. Secondary prevention after acute ischemic stroke, Journal Watch, Neurology, 2004 ZhengMing Chen et al. Indications for Early Aspirin Use in Acute Ischemic Stroke, American Heart Association, Stroke. 2000;31:1240 Ralph L. Sacco, MD, et al. Guidelines for Prevention of Stroke in Patients With Ischemic Stroke or Transient Ischemic Attack, American Heart Association, Stroke. 2006;37:577 Louise E. Craig, MD, et al. Early Mobilization After Stroke, American Heart Association, Stroke. 2010;41:2632 Jukka Putaala, MD, et al. Thrombolysis in young adults

Adherence to the Clinical Practice Guidelines

with ischemic stroke, American Heart Association, Stroke. 2009; 40:2085-2091 Health Disease and Stroke Statistics, American Heart Association 2010 Update, 2010; 4:14-16 Bradley S. Jacobs, M.D, et al. Stroke in the Young in the Northern Manhattan Stroke Study, American Heart Association, Stroke. 2002;33:2789 Bo Kristensen, et al. Epidemiology and Etiology of Ischemic Stroke in the young Adults Aged 18 to 44 in Northern Sweden, American Heart Association, Stroke. 1997; 28:1702-1709 Wade S. Smith, Joey D. English,S. Claiborne Johnston; Cerebrovascular Disease, Harrisons Principles of Internal Medicine 17th Edition, 2008; 364:2513 Don Nutbeam, et al. Health Promotion Glossary, World Health Organization, 1998; 1:14 J. Donald Easton, et al. Definition and evaluation of Transient Ischemic Attack, American Heart Association, Stroke. 2009;40:2276 Hude Quan, et al. Validation of a Case Definition to Define Hypertension Using Administrative Data, American Heart Association, Hypertension. 2009;54:1423 Thomas Truelsen, et al. The Global Burden of Cerebrovascular Disease; World Health Organization. 2000 Country Health Information Profiles, World Health Organization Western Pacific Region, Philippines, 2009: 266-267

10.

19. 20. 21.

11. 12. 13. 14. 15. 16.

22. 23. 24. 25. 26. 27.

17. 18.

Appendix A.
Stroke categorization according to severityphysicians.

STROKE CLASSIFICATION (Check only one classification based on the patients presentation MILD STROKE/TIA MODERATE STROKE SEVERE STROKE Deficits resolve within 24 Awake patient with Comatose patient with hours or less significant motor and /or non-purposeful response, language and/or visual decorticate or decerebrate OR deficit posturing to painful stimuli. Alert patients with any of Disoriented, drowsy or the following: stuporous patient with Comatose patient with no purposeful response to response to painful stimuli Mild pure motor painful stimuli weakness of 1 side of the body, defined as can raise arm above shoulder, has clumsy hand, or can ambulate without assistance. Pure sensory deficit Slurred speech but intelligible Vertigo with incoordination Visual field defects Combination of motor rand sensory deficits

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