The European Stroke Organisation (ESO) guidelines.

Abstract

In 2008, the European Stroke Organisation (ESO) updated theEuropean Stroke Initiative (EUSI) recommendations for themanagement of ischemic stroke and transient ischemic attack,initially published in 2000 and updated in 2003 (1–3). Since then,the ESO has begun the process of implementing a new standard-ized system for the production and presentation of evidence-based clinical guidelines. The ESO guidelines committee agreedon two major developments: use of the Grading of Recommen-dations Assessment, Development and Evaluation (GRADE)system (4–7); and the transition to a model in which severalguideline documents deal with specific topics of interest calledmodules rather than a single document on a large topic.The GRADE system has a series of advantages over othersystems that include clear separation between quality of evidenceand strength of recommendation, explicit comprehensive criteriafor downgrading and upgrading quality of evidence ratings,transparent process of moving from evidence to recommenda-tions, explicit evaluation of the importance of outcomes of alter-native management strategies, explicit acknowledgment of valuesand preferences, and clear pragmatic interpretation of strongversus weak recommendations for clinicians, patients, and policymakers (4–7). In summary, the GRADE approach starts with theformulation of the PICO (population, intervention, comparator,and outcome) questions. The selected outcomes are rated using a9-degree scale (7–9: critical; 4–6: important; 1–3: of limitedimportance) and a search strategy is formulated.After a thoroughliterature search leading to the identification of all available evi-dence, eligible studies are then selected and their data areextracted and analyzed. The results can be imported into theGRADEPro software (8), allowing for efficient quality grading ofthe available evidence for each outcome and each clinical ques-tion. Then we determine the direction (either ‘against’ or ‘for’)and strength of the recommendation (either ‘strong’ or ‘weak’),and finally the recommendation is formulated using a standard-ized language (4–7).The second major development in the ESO guidelines policywas to move from the classical model of a single guideline docu-ment on a major topic – e.g. management of ischemic stroke,transient ischemic attack, and hemorrhagic stroke – to subdivi-sion of the major topic into focused modules. This enables theESO Guidelines Committee to react quickly when new develop-ments in a specific area of stroke medicine occur, and updaterecommendations on the related module with speed. With theprevious approach of a single large guideline document, an entirerevision had to be completed before an updated publication,delaying the production of up-to-date guidelines for use in clini-cal practice.For each module, the ESO Guidelines Committee invites anESO member to organize a working group that follows the afore-mentioned road map to prepare the guidelines for this specificmodule. Prior to submission for publication, each guidelinedocument is submitted for review to the ESO Guidelines Com-mittee, the ESO Executive Committee, and two external review-ers. For transparency, all authors and reviewers report theirpotential conflicts of interest.The first ESO guideline document using this new approach isthe management of spontaneous intracerebral hemorrhage(ICH), published in the present issue of the