Stroke: diagnosis and initial management of acute stroke and transient ischaemic attack

National Institute for Health and Clinical Excellence

Introduction

• Stroke is a major health problem in the UK. It accounts for around 11% of deaths, results in significant morbidity in people who survive, and represents a substantial health and resource burden. Symptoms of stroke include numbness, weakness or paralysis, slurred speech, blurred vision, confusion and severe headache. A transient ischaemic attack (TIA) is defined as stroke symptoms and signs that resolve within 24 hours

• This guideline covers interventions in the acute stage of a stroke (‘acute stroke’) or TIA. Most of the recommendations relate to interventions in the first 48 hours after onset of symptoms, although some interventions up to 2 weeks are covered. There is evidence that rapid diagnosis, admission to a specialist stroke unit, and immediate brain imaging and use of thrombolysis where indicated can all contribute to a better outcome for patients. For people who have had a TIA, rapid assessment for risk of subsequent stroke allows appropriate treatment to be initiated to reduce the likelihood of stroke occurring

Patient-centred care

• Stroke has a sudden and sometimes dramatic impact on the person and their family. Treatment and care should take into account peoples’ individual needs and preferences where possible. Good communication is essential, supported by evidence-based information, to allow people to reach informed decisions about their care when they are able to do so. If the person agrees, families and carers should have the opportunity to be involved in decisions about treatment and care. However, the person’s consent may be difficult to obtain at the time of an acute episode, or where the stroke or TIA results in communication problems. If the person does not have the capacity to make decisions, follow the Department of Health guidelines—‘Reference guide to consent for examination or treatment’ (2001) (available from www.dh.gov.uk/consent). Also follow the code of practice accompanying the Mental Capacity Act: a summary is available from www.publicguardian.gov.uk, which also gives details about lasting power of attorney and advance decisions about treatment

• All aspects of care must be patient-centred, and where possible based on full discussion with the person and/or their families and carers. It should be borne in mind that some recommendations in the guideline may not be appropriate for people who are dying or who have severe co-morbidities

Key priorities for implementation

Rapid recognition of symptoms and diagnosis

• 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 TIA

• People who have had a suspected TIA who are at high risk of stroke (that is, with an ABCD² score of 4 or above) should have:
• 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 below

Specialist care for people with acute stroke

• All people with suspected stroke should be admitted directly to a specialist acute stroke unit following initial assessment, either from the community or from the A&E department
• Brain imaging should be performed immediately for people with acute stroke if any of the following apply:
• indications for thrombolysis or early anticoagulation treatment
• on 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

Nutrition and hydration

• On admission, people with acute stroke should have their swallowing screened by an appropriately trained healthcare professional before being given any oral food, fluid or medication

full guideline available from…
National Institute for Health and Clinical Excellence, MidCity Place, 71 High Holborn, London WC1V 6NA
guidance.nice.org.uk/CG68

National Institute for Health and Clinical Excellence. Diagnosis and initial management of acute stroke and transient ischaemic attack. Quick Reference Guide. July 2008