National Stroke Association guidelines for the management of transient ischemic attacks.
OBJECTIVE
Transient ischemic attacks are common and important harbingers of subsequent stroke. Management varies widely, and most published guidelines have not been updated in several years. We sought to create comprehensive, unbiased, evidence-based guidelines for the management of patients with transient ischemic attacks.


METHODS
Fifteen expert panelists were selected based on objective criteria, using publication metrics that predicted nomination by practitioners in the field. Prior published guidelines were identified through systematic review, and recommendations derived from them were rated independently for quality by the experts. Highest quality recommendations were selected and subsequently edited by the panelists using a modified Delphi approach with multiple iterations of questionnaires to reach consensus on new changes. Experts were provided systematic reviews of recent clinical studies and were asked to justify wording changes based on new evidence and to rate the final recommendations based on level of evidence and quality. No expert was allowed to contribute to recommendations on a topic for which there could be any perception of a conflict of interest.


RESULTS
Of 257 guidelines documents identified by systematic review, 13 documents containing 137 recommendations met all entry criteria. Six iterations of questionnaires were required to reach consensus on wording of 53 final recommendations. Final recommendations covered initial management, evaluation, medical treatment, surgical treatment, and risk factor management.


CONCLUSIONS
The final recommendations on the care of patients with transient ischemic attacks emphasize the importance of urgent evaluation and treatment. The novel approach used to develop these guidelines is feasible, allows for rapid updating, and may reduce bias.
Johnston
S Claiborne
SC
Department of Neurology, University of California, San Francisco, CA 94143-0114, USA. clay.johnston@ucsfmedctr.org
Nguyen-Huynh
Mai N
MN
Schwarz
Miriam E
ME
Fuller
Kate
K
Williams
Christina E
CE
Josephson
S Andrew
SA
Hankey
Graeme J
GJ
Hart
Robert G
RG
Levine
Steven R
SR
Biller
Jose
J
Brown
Robert D
RD
Sacco
Ralph L
RL
Kappelle
L Jaap
LJ
Koudstaal
Peter J
PJ
Bogousslavsky
Julien
J
Caplan
Louis R
LR
van Gijn
Jan
J
Algra
Ale
A
Rothwell
Peter M
PM
Adams
Harold P
HP
Albers
Gregory W
GW
D006287:Health Planning Guidelines; D006801:Humans; D002546:Ischemic Attack, Transient / Q000628:therapy*; D012196:Review Literature as Topic; D014481:United States