The Cochrane Library: a useful resource for evidence-based stroke medicine

1. The Cochrane Library: a useful resource for evidence-based stroke medicine Peter Sandercock, Hazel Fraser, Brenda Thomas, Alison McInnes & Sharon Dixon on behalf of the Cochrane Stroke Group

2. Cochrane Collaboration • International not-for-profit organisation • Aim: to help people make well- informed decisions about healthcare, by: • preparing systematic reviews of the effects of health care interventions. • keeping the reviews up to date • making the reviews accessible

3. Systematic review Systematic review Cochrane systematic review, a structured process: • Clear question • Search for all relevant trials • Select trials which meet eligibility criteria • Extract data from eligible studies • Synthesis of data (meta-analysis) • Update review every 2 years

4. Acute respiratory infections Airways Anaesthesia Back Breast cancer Colorectal cancer Consumers and communication Cystic fibrosis and genetic disorders Dementia & cognitive improvement Depression, anxiety & neurosis Developmental, psychosocial and learning problems Drugs and alcohol Ear, nose and throat disorders Effective practice and organisation of care Epilepsy Eyes and vision Fertility regulation Gynaecological cancer Heart Hepato-biliary Review Groups

5. Haematological malignancies HIV/AIDS Hypertension Incontinence Infectious diseases Inflammatory bowel disease Injuries Lung cancer Menstrual disorders and subfertility Metabolic and endocrine disorders Movement disorders Multiple sclerosis Muskuloskeletal Musculoskeletal injuries Neonatal Neuromuscular disease Oral health Pain, palliative and supportive care Peripheral vascular diseases Pregnancy and childbirth Prostatic diseases and urologic cancers Renal Review Groups

6. Schizophrenia Sexually transmitted diseases Skin Stroke Tobacco addiction Upper gastrointestinal and pancreatic diseases Wounds Review Groups

7. Access to Cochrane Library • Abstracts of the completed reviews are available free at the Group's website: http://www.dcn.ed.ac.uk/csrg/. • Free access to whole Cochrane Library in some countries, see: http://www.update-software.com/Cochrane/provisions.htm • Access by subscription at http://www.update-software.com/ • ‘La Cochrane Library Plus en español’ at: http://www.update-software.com/clibplus/

8. Free access to CLIB for all is now available in several countries

10. Cochrane Library Issue 2, 2003 contains: • Cochrane Database of Systematic Reviews: 1,600 Reviews • Database of Abstracts of Reviews of Effectiveness: 3,900 Abstracts • Cochrane Central Register of Controlled Trials (CENTRAL) : 354,000reports of RCTs and CCTs

11. Cochrane Stroke Review Group: • 220 reviewers from • 21 countries • preparing systematic reviews on interventions for stroke: • prevention • treatment • rehabilitation The Stroke Group is supported by a grant from the Chief Scientist’s Office, Scottish Executive

12. To find stroke trials, Stroke Group: • Searched • 20 Electronic bibliographic databases, • 50 specialist journals by hand • Many conference proceedings. • Translated non-English reports of trials • 46 people translating from 17 languages • Created a Specialised Register of stroke trials • Today it has > 6,750 references to > 3,000 trials • Updates register regularly • Publishes register on Cochrane Library

14. Cochrane systematic reviewspublished on therapies for: Number of reviews Acute stroke 29 Stroke prevention 10 Cerebral vascular surgery/ interventional neuroradiology 9 Stroke rehabilitation 8 Organisation of stroke services 6 Intracranial haemorrhage 6 Abstracts available free at: http://www.dcn.ed.ac.uk/csrg

15. Acute stroke therapies • Anticoagulants for acute ischaemic stroke • Anticoagulants versus antiplatelet agents for acute ischaemic stroke • Anticoagulation for cerebral sinus thrombosis • Antiplatelet therapy for acute ischaemic stroke • Antithrombotic drugs for carotid artery dissection • Calcium antagonists for acute ischaemic stroke • Cooling therapy for acute stroke1 • Corticosteroids for acute ischaemic stroke • Fibrinogen depleting agents for acute ischaemic stroke • Gangliosides for acute ischaemic stroke • Glycerol for acute stroke1 • Haemodilution for acute ischaemic stroke • Interventions for deliberately altering blood pressure in acute stroke1 • Interventions for dysphagia in acute stroke • Low-molecular-weight heparins or heparinoids versus standard unfractionated heparin for acute ischaemic stroke • Lubeluzole for acute ischaemic stroke • Mannitol for acute stroke1 • Nitric oxide donors (nitrates), L-arginine, or nitric oxide synthase inhibitors for acute stroke1 • Physical methods for preventing deep vein thrombosis in stroke1 • Pentoxifylline, propentofylline and pentifylline for acute ischaemic stroke • Piracetam for acute ischaemic stroke • Prostacyclin and analogues for acute ischaemic stroke • Surgical decompression for cerebral oedema in acute ischaemic stroke • Theophylline, aminophylline, caffeine and analogues for acute ischaemic stroke • Thrombolysis (different doses, routes of administration, and agents) for acute ischaemic stroke • Thrombolysis for acute ischaemic stroke • Tirilazad for acute ischaemic stroke • Vasoactive drugs for acute stroke • Vinpocetine for acute ischaemic stroke

16. Therapies for stroke prevention • Anticoagulants for preventing recurrence following presumed non-cardioembolic ischaemic stroke or transient ischaemic attack • Anticoagulants for preventing stroke in patients with nonrheumatic atrial fibrillation and a history of stroke or transient ischaemic attacks • Anticoagulants versus antiplatelet therapy for preventing stroke in patients with nonrheumatic atrial fibrillation and a history of stroke or transient ischaemic attacks • Antiplatelet therapy for preventing stroke in patients with nonrheumatic atrial fibrillation and a history of stroke or transient ischaemic attacks • Antiplatelet therapy for preventing stroke in patients with non-valvular atrial fibrillation and no previous history of stroke or transient ischaemic attacks • Dipyridamole for preventing stroke and other vascular events in patients with vascular disease • Interventions in the management of serum lipids for preventing stroke recurrence • Oral anticoagulants for preventing stroke in patients with non-valvular atrial fibrillation and no previous history of stroke or transient ischemic attacks • Oral anticoagulants versus antiplatelet therapy for preventing further vascular events after transient ischaemic attack or minor stroke of presumed arterial origin • Thienopyridine derivatives (ticlopidine, clopidogrel) versus aspirin for preventing stroke and other serious vascular events in high vascular risk patients

17. Cerebral vascular surgery/ interventional neuroradiology • Carotid endarterectomy for asymptomatic carotid stenosis • Carotid endarterectomy for symptomatic carotid stenosis • Eversion versus conventional carotid endarterectomy for preventing stroke • Local versus general anaesthesia for carotid endarterectomy • Patch angioplasty versus primary closure for carotid endarterectomy • Patches of different types for carotid patch angioplasty • Percutaneous transluminal angioplasty and stenting for carotid artery stenosis • Percutaneous transluminal angioplasty and stenting for vertebral artery stenosis • Routine or selective carotid artery shunting for carotid endarterectomy

18. Rehabilitation • Cognitive rehabilitation for attention deficits • Cognitive rehabilitation for memory deficits • Cognitive rehabilitation for spatial neglect • Electrical stimulation for preventing and treating post-stroke shoulder pain • Physiotherapy treatment approaches for the recovery of postural control and lower limb function following stroke • Pharmacological treatment for aphasia • Speech and language therapy for aphasia • Speech and language therapy for dysarthria due to non-progressive brain damage

19. Organisation of services • Information provision for stroke patients and their caregivers • In-hospital care pathways for stroke • Organised inpatient (stroke unit) care for stroke • Services for helping acute stroke patients avoid hospital admission • Services for reducing duration of hospital care for acute stroke patients • Therapy based rehabilitation services for stroke patients at home

20. Therapies for intracranial haemorrhage • Antifibrinolytic therapy • Calcium antagonists • Circulatory volume expansion • Fibrinolytic therapy for intraventricular hemorrhage • Surgery for primary supratentorial intracerebral haemorrhage • Timing of surgery for aneurysmal subarachnoid haemorrhage

21. Impact of Cochrane Stroke reviews • Cochrane reviews cited in national stroke guidelines and policy documents in UK, Europe, USA, Australia, New Zealand & Singapore • UK National Stroke Guideline states: 'In each hospital, the neurologist or physician with special responsibility for stroke should review the Cochrane Library regularly’. • ‘Cochrane Corner’ now a feature in Stroke