Diagnosis and initial management of acute stroke and transient ischaemic attack: summary of NICE guidanceBMJ 2008; 337 doi: https://doi.org/10.1136/bmj.a786 (Published 24 July 2008) Cite this as: BMJ 2008;337:a786
- Sharon Swain, health services research fellow in guideline development1,
- Claire Turner, senior project manager in guideline development for the development group1,
- Pippa Tyrrell, senior lecturer2, honorary consultant in stroke medicine3,
- Anthony Rudd, consultant stroke physician 4
- on behalf of the Guideline Development Group
- 1National Collaborating Centre for Chronic Conditions, Royal College of Physicians of London NW1 4LE
- 2Stroke Medicine, University of Manchester, Manchester
- 3Salford Royal NHS Foundation Trust, Salford M6 8HD
- 4St Thomas’s Hospital, London SE1 7EH
- Correspondence to: S Swain
Why read this summary?
In England, stroke is estimated to cost the economy about £7bn (€8.8bn; $13.9bn) a year. This total comprises direct costs to the National Health Service of about £2.8bn, cost of informal care of £2.4bn, and cost because of lost productivity and disability of £1.8bn.1 In the United Kingdom, the national sentinel stroke audits2 3 have shown that over the past 10 years increasing numbers of patients are being treated in stroke units, evidence based practice is increasing, and reductions in mortality and length of hospital stay have decreased. One of the main aims of the guidance issued by the National Institute for Health and Clinical Excellence (NICE) is to ensure that the specialist treatment and expertise recommended are available to all patients in England and Wales. This article summarises key recommendations in the NICE guideline for the diagnosis and initial management of acute stroke and transient ischaemic attack.4
NICE recommendations are based on systematic reviews of best available evidence. When minimal evidence is available, recommendations are based on the guideline development group’s opinion of what constitutes good practice. Evidence levels for the recommendations are given in italic in square brackets.
Rapid symptom recognition and diagnosis
For people with sudden onset of neurological symptoms, use a validated tool such as the face, arm, speech test (FAST)5 to screen for a diagnosis of stroke or transient ischaemic attack.[Based on moderate quality cohort studies and on the opinion of the Guideline Development Group (GDG)]
For people who are admitted to an accident and emergency department with a suspected stroke or transient ischaemic attack, establish the diagnosis rapidly using a validated tool such as ROSIER (Recognition of Stroke in the Emergency Room).6 [Based on moderate quality cohort studies and on the GDG’s opinion]
Brain imaging for suspected transient ischaemic attack
For people who have had a suspected transient ischaemic attack (that is, whose symptoms and signs have completely resolved within 24 hours), do the following:
Ensure they receive assessment by a specialist and best medical treatment before reaching a decision on brain imaging. [Based on the GDG’s opinion]
If they are at high risk of stroke (for example, with an ABCD2 score of ≥4 or with crescendo transient ischaemic attack) and the vascular territory or pathology is uncertain, ensure that they have urgent brain imaging within 24 hours of onset of symptoms. [Based on good quality cohort and observational studies and on the GDG’s opinion] (The ABCD2 score is a validated tool to assess subsequent stroke risk in patients with transient ischaemic attack, based on age, blood pressure, clinical features (such as unilateral weakness), presence of diabetes, and symptom duration.)
If they are at lower risk of stroke (for example, an ABCD2 score <4) and the vascular territory or pathology is uncertain, ensure that they have brain imaging within one week of onset of symptoms). [Based on good quality cohort and observational studies and on the GDG’s opinion]
Brain imaging for all the above patients should comprise diffusion weighted magnetic resonance imaging except where contraindicated, in which case computed tomography should be used. [Based on the GDG’s opinion]
Brain imaging for early assessment of acute stroke
Perform immediate brain imaging (ideally at the next scanning slot and definitely within one hour, whichever is the soonest) for people with acute stroke if any of the following apply [Based on the GDG’s opinion]:
Indications for thrombolysis or early anticoagulation treatment
They are receiving anticoagulant treatment
They have a known bleeding tendency
They have a depressed level of consciousness (Glasgow coma score <13)
They have unexplained progressive or fluctuating symptoms
They have papilloedema, neck stiffness, or fever
They had severe headache at onset of stroke symptoms.
For all people without indications for immediate brain imaging, perform scanning as soon as possible (within a maximum of 24 hours of onset of symptoms). [Based on the GDG’s opinion]
Urgent carotid endarterectomy and carotid stenting
For those with suspected non-disabling stroke or transient ischaemic attack, urgent carotid endarterectomy or carotid stenting may be appropriate.
For those who are considered candidates for carotid endarterectomy after specialist assessment, perform carotid imaging within one week of onset of symptoms. [Based on a systematic review and pooled analysis of high quality randomised controlled trials] For people who present more than one week after the last symptom of their transient ischaemic attack has resolved, use the “lower risk” pathway of management (that is, the same as for patients at a lower risk of stroke; see full guideline for recommendations on aspirin initiation, specialist assessment and intervention, and measures for secondary prevention). [Based on the GDG’s opinion]
For those with stable neurological symptoms and symptomatic carotid stenosis of 50-99% according to the criteria of the North American symptomatic carotid endarterectomy trial (NASCET)7 or 70-99% according to the criteria of the European Carotid Surgery Trialists’ (ECST) Collaborative Group8:
-Assess and refer for carotid endarterectomy within one week of onset of symptoms of stroke or transient ischaemic attack
-Provide treatment (carotid endarterectomy) within a maximum of two weeks of onset of symptoms of stroke or transient ischaemic attack
-Offer best medical treatment (control of blood pressure, antiplatelet agents, cholesterol lowering through diet and drugs, lifestyle advice).
[These three recommendations above are based on a systematic review and pooled analysis from large randomised controlled trials and on the GDG’s opinion]
For those with stable neurological symptoms and symptomatic carotid stenosis of less than 50% according to the NASCET criteria or less than 70% according to the ECST criteria:
-Surgery is not indicated
-Offer best medical treatment (control of blood pressure, antiplatelet agents, cholesterol lowering through diet and drugs, lifestyle advice).
[Both these recommendations are based on a systematic review and pooled analysis from large randomised controlled trials and on the GDG’s opinion]
No evidence for early carotid stenting (within the two week time period covered by the guideline) was identified. Further research is needed to determine the safety and efficacy of early carotid stenting compared with carotid endarterectomy.
Specialist care in acute stroke
After initial assessment either from the community or from the accident and emergency department, admit all patients with suspected stroke directly to a specialist acute stroke unit. [Based on moderate to good quality evidence from randomised controlled trials and cohort studies and on the GDG’s opinion]
Thrombolysis in people with acute ischaemic stroke
Alteplase (tPA) is recommended for treating acute ischaemic stroke when used by physicians trained and experienced in the management of acute stroke. It should be administered only in a well organised stroke service and in centres with facilities that enable it to be used in full accordance with its marketing authorisation.9 [Based on a NICE technology appraisal] Appropriately trained and supported staff in accident and emergency departments can administer alteplase provided that patients can be managed in an acute stroke service with appropriate support from neuroradiological staff and a stroke physician. [Based on the drug’s marketing authorisation and on a NICE technology appraisal] Protocols should be in place for the delivery and management of thrombolysis, including post-thrombolysis complications. [Based on a NICE technology appraisal]
Aspirin and anticoagulation treatment for acute ischaemic stroke
All patients with acute stroke in whom primary intracerebral haemorrhage has been excluded by brain imaging should, as soon as possible but certainly within 24 hours, be given [Based on a high quality systematic review and high quality evidence from randomised controlled trials]:
-Aspirin 300 mg orally if they are not dysphagic, or
-Aspirin 300 mg rectally or by enteral tube if they are dysphagic.
Thereafter they should continue taking aspirin 300 mg until two weeks after the onset of the stroke symptoms, at which time definitive long term antithrombotic treatment should be started. Patients being discharged before two weeks can start on long term treatment earlier. [Based on the GDG’s opinion]
Do not use anticoagulation treatment routinely to treat acute stroke. [Based on high quality systematic reviews and high quality evidence from randomised controlled trials]
Nutrition and hydration in acute stroke
Assessment of swallowing function
On admission, ensure that an appropriately trained healthcare professional screens the patient’s swallowing function before any oral food, fluid, or medication is offered. [Based on moderate quality evidence and on the GDG opinion] If the admission screen indicates problems with swallowing, provide a specialist assessment of swallowing, preferably within 24 hours of admission and not more than 72 hours afterwards[Based on the GDG’s opinion]
After specialist assessment of swallowing in patients with dysphagia, provide food and fluids in a form that can be swallowed without aspiration. [Based on the GDG’s opinion]
Reassess patients with suspected aspiration on specialist assessment or who require tube feeding or dietary modification for three days; consider instrumental examination (for example, video fluoroscopy). [Based on the GDG’s opinion]
Oral nutrition supplementation
For patients who are unable to take adequate nutrition and fluids orally:
-Provide tube feeding with a nasogastric tube within 24 hours of admission [Based on good quality evidence from randomised controlled trials and on the GDG’s opinion]
-Consider a nasal bridle tube or gastrostomy if patients are unable to tolerate a nasogastric tube [Based on the GDG’s opinion]
-Refer to an appropriately trained healthcare professional for detailed nutritional assessment, individualised advice, and monitoring. [Based on the GDG’s opinion]
When screening for malnutrition and the risk of malnutrition, be aware that dysphagia, poor oral health, and impaired ability to feed oneself will affect nutrition. [Based on the GDG’s opinion]
Start nutrition support for patients who can swallow safely and who are at risk of malnutrition. This may include oral nutritional supplements, specialist dietary advice, and/or tube feeding. [Based on the GDG’s opinion]
Routine nutritional supplementation is not recommended for patients who are adequately nourished on admission.
Assess hydration on admission in all patients, review this regularly, and ensure normal hydration is maintained. [Based on the GDG’s opinion]
Early mobilisation and optimum position of patients with acute stroke
Mobilise patients as soon as possible (when their clinical condition permits) as part of an active management programme on a specialist stroke unit. [Based on the GDG’s opinion]
Help patients to sit up as soon as possible (when their clinical condition permits). [Based on the GDG’s opinion]
Arguably two of the main barriers to implementation are the rapid recognition of symptoms and referral and timely access to brain imaging. One factor that is crucial to ensuring rapid recognition is raising public awareness of stroke and transient ischaemic attack. It is essential that patients present to healthcare services in time to receive optimum care. Resources have to be made available to ensure that patients have access to a specialist acute stroke team. The provision of brain imaging represents a huge challenge in improving stroke service, as current practice varies widely in terms of the time delay between presentation and imaging.
Further information on the guidance
A wealth of guidance now exists on the standards of care a patient should expect to receive. Evidence is accumulating in stroke care for more effective primary and secondary prevention strategies, improved recognition of people at highest risk (and thus most in need of active intervention), interventions that are effective soon after the onset of symptoms, and an understanding of the processes of care that contribute to a better outcome. The NICE stroke guideline covers the interventions in the acute stage of a stroke or transient ischaemic attack. Most of the evidence considered in the NICE guideline relates to interventions in the first 48 hours after onset of symptoms, although some interventions up to two weeks are covered.
The NICE guideline is a “stand alone” document but is designed to be read alongside the Intercollegiate Working Party’s guideline on stroke rehabilitation,10 which considers evidence for interventions from the acute stage into rehabilitation and life after stroke. The NICE guideline is also designed to be read alongside the Department of Health’s report National Stroke Strategy.11 Some differences exist between the recommendations in the NICE guideline and those in the National Stroke Strategy, but the Guideline Development Group believe that the NICE recommendations are derived from systematic methodology that identifies all of the relevant literature.
The methodology followed for this guideline used the current NICE process12 and included careful attention to issues of discrimination on the basis of language, culture, or disability. An economic analysis was constructed based on new modelling performed for evaluating the cost effectiveness of immediate specialist assessment in minor stroke and transient ischaemic attack. These are described in the full guideline published by the Royal College of Physicians of London.13 The web based external consultation drew 680 submitted comments, each of which was considered for its validity and usefulness.
The Guideline Development Group included people who had had a stroke or transient ischaemic attack and professionals drawn from the normal mix found in a stroke multidisciplinary team, both in primary and secondary care. Experts were invited to specific meetings if a gap in the expertise of the group was identified. The supporting technical team included those with specific expertise in literature search techniques, systematic evidence review, health economics, and project management.
Overall, there is a dearth of research evidence informing the management of acute stroke and transient ischaemic attack. Although high quality evidence exists to support the use of aspirin for acute stroke, evidence for the efficacy of aspirin combined with dipyridamole or clopidogrel is lacking. Evidence is also lacking for deciding whether a person who has a stroke or a transient ischaemic attack and who is already taking aspirin should be offered the same or an increased dose of aspirin after the stroke. The safety and efficacy of blood pressure manipulation in the acute phase also remains uncertain. Although the effectiveness of carotid interventions in stroke is well established, the question of whether it is safe and efficacious to perform carotid stenting within two weeks of a transient ischaemic attack or recovered stroke compared with carotid endarterectomy remains unanswered.
Clinical areas of additional significant importance to patient care but which have attracted limited research interest include screening for swallowing difficulty. This is a key part of the clinical assessment of a patient with acute stroke, and is one of the important process indicators for stroke. Similarly, the importance of early mobilisation after acute stroke is based on clinical experience rather than evidence and little is known about the type of interventions that should be adopted or the optimum time for using them. Finally, the lack of research into acute stroke and transient ischaemic attack is illustrated perfectly by the fact that a clinical trial is still needed to compare direct admission to an acute stroke unit with admission to a medical ward, at least while the latter remains standard clinical practice.
Cite this as: BMJ 2008;337:a786
This is one of a series of BMJ summaries of new guidelines, which are based on the best available evidence; they highlight important recommendations for clinical practice, especially where uncertainty or controversy exists.
Contributors: SS and CT wrote the initial draft of the article using material produced collectively by the entire guideline development group. PT and AR reviewed the content of the article and contributed to its revision and the final draft.
Funding: The National Collaborating Centre for Chronic Conditions was commissioned and funded by the National Institute for Health and Clinical Excellence to write this summary.
Competing interests: All authors were members of the Guideline Development Group for the NICE guideline.
Provenance and peer review: Commissioned; not externally peer reviewed.