Reading between the guidelines Acute stroke and TIA

Peter Langhorne

Professor of Stroke Care

University of Glasgow

NICE / RCP guidelines for stroke

Clinical practice guidelines on the

management of stroke and TIA (2008)

• Recognition and diagnosis

• Acute care

– Reperfusion

– Maintain homeostasis

– Prevent complications

• Early rehabilitation

• Secondary prevention

• Early Supported Discharge/community

rehabilitation

• Long term support and review

• Service governance

General principles – pathway approach

A&E

service

Hyperacute

stroke area

Comprehensive

stroke unit

Early

supported

discharge

service

Inpatient

rehabilitation Outpatient

service

Ongoing

support/

Rehab’n

What might an excellent stroke service look like?

Suspected

Stroke/

TIA

Specialist

services

TIA pathway

Clinical stroke?

TIA pathway

Start aspirin (300mg)

Specialist assessment <24 hrs Clinical stroke?

Brain imaging in TIA

Examples where brain imaging is helpful in the

management of TIA:

– people with TIA where haemorrhage needs to be

excluded, for example long duration symptoms or people

on anticoagulants (early CT scan; MRI)

– where alternative diagnosis (for example migraine,

epilepsy or tumour) is being considered (MRI; CT?)

– people being considered for carotid endarterectomy

(CEA) where it is uncertain whether the stroke is in the

anterior or posterior circulation (MRI)

TIA pathway

Carotid endarterectomy

Absolute stroke risk reduction vs delay to operation

Benefit of surgery Severe stenosis Moderate stenosis

0-2 2-4 4-12 >12

Time from symptoms to operation (weeks)

Performed within 1 week of first presentation

(deferred for 72 hours in people treated with intravenous thrombolysis)

Secondary prevention

• Great improvements in stroke management and outcome

• Main benefits from prevention and stroke units

• Developments now need to focus on rapid delivery of treatments

• Need to ensure service developments do not undo the gains achieved thus far

• Regional networking may offer benefits and “future-proofing”

TIA and Ischaemic stroke

Blood pressure

(Aim for <130/80 )

Thiazide, Calcium antagonists

ACE inhibitor

Statin therapy Atorvastatin

(Simvastatin)

Antiplatelet therapy

(sinus rhythm)

Clopidogrel

Aspirin/ DP retard

Anticoagulant therapy

(AF/cardioembolic)

Warfarin

(Direct Acting Oral Anticoagulants)

Surgical/ radiological Severe carotid stenosis (CEA)

Lifestyle Smoking cessation, diet, exercise, driving

Stroke pathway Clinical stroke?

Stroke pathway

Most within 1 hr

Indications for immediate imaging

Brain imaging should be performed immediately

for people with acute stroke if :

– indications for thrombolysis

– on anticoagulation treatment

– depressed level of consciousness

– progressive or fluctuating symptoms

– papilloedema, neck stiffness or fever

– severe headache at onset of stroke symptoms

Plain CT scanning is the main emergency modality

Indications for immediate imaging

Brain imaging should be performed immediately

for people with acute stroke if :

– indications for thrombolysis

– on anticoagulation treatment

– depressed level of consciousness

– progressive or fluctuating symptoms

– papilloedema, neck stiffness or fever

– severe headache at onset of stroke symptoms

Access to CT angiography etc

Stroke pathway

Percutaneous clot removal

Mechanical

thrombectomy

Proximal intracranial

large vessel occlusion

NIHSS >5

Procedure within 5hrs

Intracerebral haemorrhage

Reverse clotting disorder

Lower BP to 140mmHg for 7 days

(if onset <6hrs with systolic BP

>150mmHg)

(unless GCS<5, death expected, surgery

planned)

Acute stroke - general care

Dysphagia management

(early NG + bridle)

Early mobilisation (24-48hr)

Manage hydration,

pyrexia, oxygen, blood

sugar (blood pressure)

Aspirin if no contraindication

Intermittent Pneumatic Compression

Stockings to prevent DVT if immobile

MDT care in

stroke unit

Secondary prevention

• Great improvements in stroke management and outcome

• Main benefits from prevention and stroke units

• Developments now need to focus on rapid delivery of treatments

• Need to ensure service developments do not undo the gains achieved thus far

• Regional networking may offer benefits and “future-proofing”

TIA and Ischaemic stroke

Blood pressure

(Aim for <130/80 )

Thiazide, Calcium antagonists

ACE inhibitor

Statin therapy Atorvastatin

(Simvastatin)

Antiplatelet therapy

(sinus rhythm)

Clopidogrel

Aspirin/ DP retard

Anticoagulant therapy

(AF/cardioembolic)

Warfarin

(Direct Acting Oral Anticoagulants)

Surgical/ radiological Severe carotid stenosis (CEA)

Lifestyle Smoking cessation, diet, exercise, driving

Cervical artery dissection, paroxysmal AF, PFO, intracranial stenosis

Secondary prevention

• Great improvements in stroke management and outcome

• Main benefits from prevention and stroke units

• Developments now need to focus on rapid delivery of treatments

• Need to ensure service developments do not undo the gains achieved thus far

• Regional networking may offer benefits and “future-proofing”

Haemorrhagic stroke

Blood pressure

(Aim for <130/80 )

Thiazide, Calcium antagonists

ACE inhibitor

Statin therapy -

Antiplatelet therapy

(sinus rhythm)

??

Anticoagulant therapy

(AF/cardioembolic)

-

Surgical/ radiological (Aneurysm or arteriovenous malformation)

Lifestyle Smoking cessation, diet, exercise, driving

The management of stroke

• Focus on rapid delivery of treatments while maintaining effective pathway of care

– Multidisciplinary stroke unit care

– Rapid secondary prevention

• New focus on recent major improvements in stroke management

– Reperfusion (mechanical thrombectomy/ iv thrombolysis) for subset of ischaemic stroke patients

– Selective neurosurgical interventions

• Greater use of new direct oral anticoagulants, improved reperfusion strategies, early rehabilitation