Dr Anthony Rudd and colleagues explain how early treatment of stroke and well-organised stroke services will benefit a significant number of patients each year

New guidance from NICE1,2 and the Royal College of Physicians (RCP) Intercollegiate Stroke Working Party,3 published in July 2008, provides a comprehensive set of standards of care for stroke and transient ischaemic attack (TIA). The guidance covers the whole care pathway from acute care to the longer term management of disability in the community and secondary stroke prevention. The role of the primary care team is crucial in stroke management, particularly in the organisation and delivery of prevention, rehabilitation, and supporting stroke patients with their long-term disability.

 

Prevalence and cost of stroke

Stroke is a common disease, and approximately 10% of the patients on a GP’s practice list will die as a result.1,2 It remains one of the most important causes of disability in the community. Although stroke is predominantly a disease of older people—50% of cases occurring in people aged 75 years and over—it is also one of the commonest causes of neurological disease in young people and children.4


Each year in England approximately 110,000 people have a first or recurrent stroke, and a further 20,000 people experience a TIA.1,2 In England, stroke is estimated to cost the economy around £7 billion per year comprising: direct costs to the NHS of £2.8 billion; costs of informal care of £2.4 billion, for example from loss of earnings of carers; and costs due to lost productivity and disability of £1.8 billion.5

 

Attitudes to stroke management

Despite the high prevalence of stroke and TIA there remains a significant lack of knowledge among healthcare professionals about how these patients should be managed. Individuals are still regularly seen in secondary care who have had strokes that could have been avoided if their TIAs had been recognised and treated appropriately. It is also common to see stroke patients who have arrived in hospital too late for thrombolysis because the primary care provider has not recognised the urgency of response required. While stroke is still perceived by many as an untreatable condition, patients will continue to suffer unnecessarily.

Organisation of care and rehabilitation

It is known from repeated rounds of the National Sentinel Audit of Stroke6 that the quality of stroke care varies considerably around the country, with few, if any, stroke services offering high-quality comprehensive care across the whole pathway. The Department of Health National Stroke Strategy,7 which was published in 2007, has stimulated considerable activity and it is hoped there will be major improvements as a result of commissioners and providers committing to implementing change over the next few years.

Key guideline recommendations

  • Commissioning organisations should ensure that their commissioning portfolio encompasses the whole stroke pathway from prevention through acute care, early rehabilitation and initiation of secondary prevention, on to palliation, later rehabilitation in the community, and long-term support3

  • Any patient with a stroke who cannot be admitted to hospital and who is not receiving palliative care should be seen by the specialist team at home or on an outpatient basis as soon as possible for diagnosis, treatment, rehabilitation, and risk-factor reduction at a standard comparable to patients who are admitted3

  • Any patient with residual impairment after the end of initial rehabilitation should be offered a formal review at least every 6 months, to consider whether further interventions are warranted, and should be referred for specialist assessment if:3
    • new problems, not present when last seen by the specialist service, are present
    • the patient’s physical or social environment has changed

  • The carer(s) of every patient with a stroke should be involved with the management process from the outset, specifically:3
    • as an additional source of important information about the patient, both clinically and socially
    • to be given accurate information about the stroke, its nature and prognosis, and what to do in the event of a further stroke
    • to receive emotional and practical support as required

  • All patients not suitable for transfer home after completion of their acute diagnosis and treatment should be treated in a specialist stroke rehabilitation unit, which should fulfil the following criteria:3
    • it should be a geographically identified unit
    • it should have a coordinated multidisciplinary team that meets at least once a week for the interchange of information about individual patients
    • staff should have specialist expertise in stroke and rehabilitation
    • educational programmes and information should be provided for staff, patients, and carers

  • All patients discharged home directly after acute treatment but with residual problems should be followed up by specialist stroke rehabilitation services3

  • Hospital services should have a locally negotiated protocol to ensure that before discharge:3
    • patients and families are fully prepared, and have been involved in every aspect of planning discharge
    • general practitioners, primary healthcare teams, and social services departments (adult services) are all informed before or at the time of discharge
    • all equipment and support services necessary for a safe discharge are in place
    • any continuing treatment required will be provided without delay by an appropriate specialist service
    • patients and families are given information about and offered contact with appropriate statutory and voluntary agencies.

Early recognition and treatment of stroke

Stroke and TIA should be managed as medical emergencies. The NICE guideline contains an algorithm for assessment and treatment of stroke.

There is now good evidence that thrombolysis for acute ischaemic stroke is an effective treatment for selected patients as detailed in NICE Technology Appraisal 122,8 significantly reducing the risk of long-term disability. However, it needs to be given within a maximum of 3 hours of the onset of symptoms, with the benefit increasing sharply the earlier it is given.2 During that time the patient needs careful specialist assessment to identify whether this treatment is appropriate, and he or she should have brain imaging to exclude haemorrhage—CT scanning is usually sufficient. The cliché ‘Time is Brain’ is true and, therefore, it is vital that patients are admitted directly to a hospital that is capable of delivering the right care without impedance.

Key guideline recommendations

  • In people with sudden onset of neurological symptoms, a validated tool, such as FAST (Face Arm Speech Test), should be used outside hospital to screen for a diagnosis of stroke or TIA1,2
  • In people with sudden onset of neurological symptoms, hypoglycaemia should be excluded as the cause of symptoms1,2
  • Brain imaging should be performed immediately (ideally the next slot or within 1 hour, whichever is sooner) for people with acute stroke who have any one of the following: 1,2
    • indications for thrombolysis or early anticoagulation treatments
    • currently prescribed anticoagulant treatment
    • a known bleeding tendency
    • a depressed level of consciousness (Glasgow Coma Score below 13)
    • unexplained progressive or fluctuating symptoms
    • papilloedema, neck stiffness, or fever
    • severe headache at onset of stroke symptoms
  • For all people with acute stroke without indications for immediate brain imaging, scanning should be performed as soon as possible (within 24 hours after onset of symptoms)1,2
  • Alteplase should only be administered within a well organised stroke service with staff trained in delivering thrombolysis and in monitoring for any associated complications7
  • All people presenting with acute stroke in whom primary intracerebral haemorrhage has been excluded by brain imaging should be given as soon as possible but certainly within 24 hours:1,2
    • aspirin 300 mg orally if they are not dysphagic
    • or aspirin 300 mg rectally or by enteral tube if they are dysphagic
  • Thereafter aspirin 300 mg should be continued until 2 weeks after the onset of stroke symptoms, at which time definitive long-term antithrombotic treatment should be initiated. Patients being discharged before 2 weeks can be started on long-term treatment earlier (consensus from RCP stroke working party)
  • Any person with acute ischaemic stroke who reports previous dyspepsia associated with aspirin should be given a proton pump inhibitor in addition to aspirin (consensus from RCP stroke working party)
  • In case of allergy to or genuine intolerance of aspirin, a patient with acute ischaemic stroke should be given an alternative antiplatelet agent.

Management of TIA

Key guideline recommendations

  • People who have had a suspected TIA (that is, they have no neurological symptoms at the time of assessment [within 24 hours]) should be assessed as soon as possible for their risk of subsequent stroke using a validated scoring system, such as ABCD2 (see Box 1)—although scoring systems exclude high stroke risk patients such as those with recurrent events, and may also be irrelevant for patients presenting late1
  • People who have had a suspected TIA and with an ABCD2 score of 4 or above, should have:1
    • aspirin (300 mg daily) started immediately
    • specialist assessment and investigation within 24 hours of onset of symptoms
    • measures for secondary prevention introduced as soon as the diagnosis is confirmed, including discussion of individual risk factors
  • People with crescendo TIA (two or more TIAs in a week) should be treated as being at high risk of stroke, even though they may have an ABCD2 score of 3 or below1
  • People who have had a suspected TIA who are at low risk of stroke (that is, an ABCD2 score of 3 or below) should receive:1
    • aspirin (300 mg daily) started immediately
    • specialist assessment and investigation as soon as possible, but definitely within 1 week of onset of symptoms
    • measures for secondary prevention introduced as soon as the diagnosis is confirmed, including discussion of individual risk factors
  • People who have had a TIA but who present late (more than 1 week after their last symptom has resolved) should be treated as though they are at lower risk of stroke using the low risk pathway.1

Box 1: ABCD2 score to evaluate stroke risk

Prognostic scores to identify people at high risk of stroke after a transient ischaemic attack.

It is calculated based on:

A — age (?60 years = 1 point)

B — blood pressure at presentation (?140/90 mmHg = 1 point)

C — clinical features (unilateral weakness = 2 points, or speech disturbance without weakness = 1 point)

D — duration of symptoms (?60 minutes = 2 points, or 10–59 minutes = 1 point)

The calculation of ABCD2 also includes the presence of diabetes (1 point).

 

Total scores range from 0 (low risk) to 7 (high risk).

Implementation

There is a great deal that needs to be changed in order to deliver these guidelines consistently. Perhaps the key areas that need changing first are in:

  • setting up services that can deliver high-quality acute care to all patients regardless of where they live. This includes rapid access to brain imaging, acute stroke units, and thrombolysis
  • raising public and professional awareness of the causes and symptoms of stroke and TIA, and how to respond if they happen
  • provision of neurovascular services that are able to meet the very challenging recommendations for the management of TIA
  • establishing specialist rehabilitation services in the community, both to provide early supported discharge and longer term treatment.

Additional resources are likely to be needed in order to deliver these changes, at least in the short term. However, the future benefits of reducing the number of people with stroke and reducing the burden of living with and having to fund long-term disability should more than offset the additional healthcare costs.

Summary

Many of the changes in the guidelines from NICE and the RCP can be achieved by changing the attitudes of healthcare professionals and reorganising existing services. Resources are being wasted as patients are receiving care when it is too late. For example, it is known that carotid endarterectomy ceases to be of any value if it is performed more than 12 weeks after the TIA, and yet we know that in one-third of cases this is what happens.

Believing that treatment for stroke can be effective is perhaps the biggest change that is needed. It requires a more positive approach to teaching about stroke at all levels within medical schools and the health services.

NICE implementation tools

NICE has developed the following tools to support implementation of its guideline on the diagnosis and acute management of stroke and transient ischaemic attacks. The tools are now available to download from the NICE website: www.nice.org.uk.

Costing tools

National cost reports and local cost templates for the guideline have been produced:

  • costing reports are estimates of the national cost impact arising from implementation based on assumptions about current practice, and predictions of how it might change following implementation of the guideline
  • costing templates are spreadsheets that allow individual NHS organisations and local health economies to estimate the costs of implementation taking into account local variation from the national estimates, and they quickly assess the impact the guideline may have on local budgets.

Slide set

The slides are aimed at supporting organisations to raise awareness of the guideline at a local level and can be edited to cater for local audiences. They do not cover all the recommendations from the guideline but contain key messages, and should be used in conjunction with the Quick Reference Guide.

Click here for CPD questions on this article and the NICE guideline on stroke

written by Dr David Jenner, NHS Alliance PBC Lead
  • The new stroke strategy from the DH outlines a model for optimal stroke care
  • To achieve this, commissioners will need to commission pathways of care that specify services to be provided across organisational boundaries
  • Significant investment is likely to be made to meet these standards—especially in emergency departments and imaging services
  • Practice-based commissioners should discuss with secondary care and emergency clinicians how the challenges of the stroke strategy can best be met in their locality
  • Tariff prices can be unbundled to allow for portions of care for acute stroke to be completed outside acute hospital settings (e.g. rehabilitation)
  • Rapid direct access to outpatient specialist stroke clinics and diagnostics could reduce the need for costly admissions for patients presenting with TIAs
  • Tariff prices:
    • TIA (age >69 years) emergency admission = £1628
    • non-transient stroke (age >69 years) = £4102
    • general medical outpatient: £194 (new); £96 (follow up)
  1. National Institute for Health and Care Excellence. The diagnosis and acute management of stroke and transient ischaemic attack. Clinical Guideline 68. London: NICE, 2008.
  2. National Collaborating Centre for Chronic Conditions. Stroke. National clinical guideline for diagnosis and initial management of acute stroke and transient ischaemic attack (TIA). London: Royal College of Physicians, 2008.
  3. Royal College of Physicians Intercollegiate Stroke Working Party. National clinical guidelines for stroke. Third edition. London: RCP, 2008.
  4. Fullerton H, Chetkovich D, Wu Y et al. Deaths from stroke in US children, 1979 to 1998. Neurology 2002; 59 (1): 34–39.
  5. National Audit Office. Department of Health. Reducing brain damage: faster access to better stroke care (HC 452 Session 2005–2006). London: NAO, 2005.
  6. Royal College of Physicians. National sentinel stroke audit: Phase 1 (organisational audit) 2006, Phase 2 (clinical audit) 2006. London: RCP, 2007.
  7. Department of Health. National Stroke Strategy. London: DH, 2007.
  8. National Institute for Health and Care Excellence. Alteplase for the treatment of acute ischaemic stroke. Technology Appraisal 122. London: NICE, 2007.
  9. Giles M, Rothwell P. Risk of stroke early after transient ischaemic attack: a systematic review and meta-analysis. Lancet Neurol 2007; 6 (12): 1063–1072.
  10. Rothwell P, Giles M, Chandratheva A et al. Effect of urgent treatment of transient ischaemic attack and minor stroke on early recurrent stroke (EXPRESS study): a prospective population-based sequential comparison. Lancet 2007; 370 (9596): 1432–1442. G