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The National Stroke Strategy,1 published in 2007, outlined a “National Ambition for Stroke” where every patient with stroke or transient ischaemic attack (TIA) receives timely and evidence-based stroke care from the moment of symptom onset. The recent publication of the NICE guideline on diagnosis and initial management of acute stroke and TIA2 provides clinicians, service providers and commissioners with the evidence to support acute and hyperacute care following a neurovascular episode. The challenge is now to implement the evidence in every acute and primary care trust across the country. Stroke clinicians are working alongside their cardiological colleagues now in managed clinical “cardiac and stroke” networks to develop systems of care that will implement the new evidence so that every patient, wherever and whenever they present, can have equal access to high-quality services.
The guideline emphasises the importance of early recognition of stroke symptoms, and recommends a validated diagnostic tool such as Face Arm and Speech Test (FAST). This will require a community awareness programme involving the public and front-line healthcare workers. The Stroke Association and Department of Health launched a national awareness programme in the spring of 2009 to develop awareness of FAST and encourage patients to seek urgent paramedic attention. Paramedics need to have clear protocols for the management of “FAST-positive” patients, and clinical networks have a vital role to play in ensuring that the right services are available in the right place and at the right time. This may involve transporting patients to designated “stroke centres” rather than to a local district hospital, if this means more ready availability of urgent assessment and treatment. A number of different stroke centre models are being developed across the country, depending on local geography and availability of services. On arrival in the Emergency Department, it is essential that the patient can be rapidly triaged to the appropriate clinical team. A simple diagnostic tool such as Review of Stroke in the Emergency Room (ROSIER) can be used to “fast track” patients into emergency stroke treatment. It can be performed by acute stroke nurses, and in some parts of the country its use by paramedics is being evaluated. For many people, access to specialist services can be delayed even after assessment in A&E. Trusts receiving patients with acute stroke will now need to have protocols in place to ensure that all patients receive high-quality acute stroke care, including brain imaging, at any time of the day or night. Everyone with residual neurological symptoms needs a brain scan as soon as possible and certainly within 24 h, but some people, including those with indications for thrombolysis or reversal of anticoagulation, need immediate scanning. The improved outcome after thrombolysis in acute ischaemic stroke has been the driver for many changes in service provision. It is a treatment not without hazard and must only be administered within an organised stroke service where staff are appropriately trained to manage complications and where there is access to immediate reimaging where necessary. Intravenous thrombolysis using alteplase is a licensed treatment once haemorrhage has been excluded on CT brain scan, up to 3 h postsymptom onset. The ECASS-III trial published in September 20083 suggests that intravenous thrombolysis is safe up to 4.5 h poststroke, although outcomes are better the earlier treatment is started; the European license remains for treatment up to 3 h. Intra-arterial thrombolysis is an option used in some centres for patients presenting outside the 3 h time window (up to 6 h) or those with occlusion not likely to benefit from intravenous (eg, proximal carotid occlusion). This depends on availability of neuroradiologists and theatres, and is as yet not routinely available.
The guideline recommends admission to an acute stroke unit directly from A&E, so that whether thrombolysed or not, patients can benefit from early swallow and nutritional assessment, aspirin where appropriate and early mobilisation, as part of specialist stroke management. Some patients with acute stroke may be eligible for surgical intervention, including management of acute intracerebral haemorrhage or decompressive craniectomy for severe middle cerebral artery infarction. Stroke teams in all hospitals need to be aware of the indications for these procedures, and agree protocols for the monitoring, referral and transfer of eligible patients with their regional neurosurgical centres.
Main points of the guideline
Rapid recognition of symptoms and diagnosis
In people with sudden onset of neurological symptoms a validated tool such as FAST should be used to screen for a diagnosis of stroke or TIA outside hospital
Establish the diagnosis in A&E using the ROSIER assessment
Management of acute stroke
Admit anyone with acute stroke directly to acute stroke unit after assessment
Perform brain imaging immediately where indicated in the guideline or as soon as possible but certainly within 24 h of symptom onset
Consider thrombolysis with alteplase if intracerebral haemorrhage excluded on CT scan and within 3 h of symptom onset: treatment must be administered by an appropriately trained physician specialised in neurological care
Screen the person’s swallowing before giving any food, fluid or medication
Consider enteral feeding or modified diet and fluids in those unable to swallow normally
Reverse anticoagulation in intracerebral haemorrhage
Treat ischaemic stroke with aspirin 300 mg within 24 h (at 24 h if thrombolysed)
Maintain blood glucose 4–11 mmol/l
Screen for malnutrition on admission and weekly using a validated tool
Stroke services should agree protocols for monitoring, referral and transfer of people to regional neurosurgical centres for the management of symptomatic hydrocephalus after stroke
Patients with intracerebral haemorrhage should be monitored by specialists in neurosurgical or stroke care for deterioration in function and referred for further brain imaging when necessary
Consider decompressive hemicraniectomy for severe middle cerebral artery infarction within guideline criteria
Management of TIA
Assess risk of subsequent stroke using a validated score such as ABCD2
Start aspirin immediately (provided neurological signs have resolved)
Manage vascular risk factors
Candidates for carotid endarterectomy need carotid imaging within 1 week and surgery within 2 weeks
The risk of stroke in the first few days after a TIA is much higher than was once thought, and the guideline emphasises the importance of early recognition and management. Patients with a diagnosis of TIA (by definition where neurological signs have resolved completely) need aspirin 300 mg immediately. Secondary prevention measures, including discussion of risk factors, should be initiated as soon as the diagnosis is confirmed. Scoring systems such as ABCD2 provide a simple method of assessing risk, and those at high risk (ABCD2 score 4 or more) should have specialist assessment within 24 h. ABCD2 scores risk at presentation according to age, blood pressure, clinical symptoms, duration and presence or absence of diabetes. Those at lower risk require assessment within a week. There has been uncertainty within the clinical community about which patients with TIA require brain imaging. The guideline recommends imaging where the pathology or vascular territory is uncertain; diffusion-weighted (DWI) MRI yields the most useful information. DWI where indicated should be performed within 24 h but should not delay treatment. Carotid imaging is essential in appropriate patients within 1 week, usually using Doppler ultrasound, although CT and MR angiography also yield useful information. Patients with symptomatic carotid stenosis (defined as 50–99% on NASCET criteria or 70–99% using ECST criteria) require referral for endarterectomy within 1 week and an operation within 2 weeks. ABCD2 assessment can be done out of hospital, by GPs or paramedics, to decide who needs urgent assessment. Immediate aspirin and risk assessment, and specialist assessment with 24 h for high-risk patients with TIA will involve significant changes in service provision, and was found to be cost-effective. Some trusts may choose to provide daily TIA clinics, while others may use the Trust acute stroke team to triage patients with same-day investigations. Some patients may score a low risk on ABCD2 but still need urgent assessment such as those with ocular or crescendo (more than two in a week) TIAs.
Guidelines are of no value unless they are implemented. Quality stroke care requires that all people with stroke and TIA have access to the care outlined in national guidelines. Stroke care in the UK, while improving rapidly, is nowhere near to achieving equity of access to high-quality stroke care for all of our patients. Clinicians, providers and commissioners will need to work together to review service provision, sometimes sharing resources across providers, in order to implement a high-quality service for everyone who needs it. Clinical cardiac and stroke networks are ideally placed to coordinate service provision across healthcare economies. The NICE guidelines are an invaluable tool to determine expected standards of care, but stroke clinicians need to be the drivers of service implementation on behalf of their patients.
Competing interests: None.
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