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December 2008
KEY TO EVIDENCE STATEMENTS AND GRADES OF RECOMMENDATIONS
LEVELS OF EVIDENCE
1++ High quality meta-analyses, systematic reviews of RCTs, or RCTs with a very low risk of bias
1
+
Well conducted meta-analyses, systematic reviews, or RCTs with a low risk of bias
1 - Meta-analyses, systematic reviews, or RCTs with a high risk of bias
2++ High quality systematic reviews of case control or cohort studies
High quality case control or cohort studies with a very low risk of confounding or bias and a
high probability that the relationship is causal
2+ Well conducted case control or cohort studies with a low risk of confounding or bias and a
moderate probability that the relationship is causal
2 - Case control or cohort studies with a high risk of confounding or bias and a significant risk that
the relationship is not causal
3 Non-analytic studies, eg case reports, case series
4 Expert opinion
GRADES OF RECOMMENDATION
Note: The grade of recommendation relates to the strength of the evidence on which the
recommendation is based. It does not reflect the clinical importance of the recommendation.
NHS Quality Improvement Scotland (NHS QIS) is committed to equality and diversity. This guideline
has been assessed for its likely impact on the six equality groups defined by age, disability, gender,
race, religion/belief, and sexual orientation.
For the full equality and diversity impact assessment report please see the published guidelines section
of the SIGN website at www.sign.ac.uk/guidelines/published/numlist.html. The full report in paper form
and/or alternative format is available on request from the NHS QIS Equality and Diversity Officer.
Every care is taken to ensure that this publication is correct in every detail at the time of publication.
However, in the event of errors or omissions corrections will be published in the web version of this
document, which is the definitive version at all times. This version can be found on our web site www.
sign.ac.uk.
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Scottish Intercollegiate Guidelines Network
December 2008
Management of patients with stroke or TIA: assessment, investigation, immediate management and secondary prevention
Contents
1 Introduction........................................................................................................................ 1
1.1 The need for a guideline....................................................................................................... 1
1.2 Remit of the guideline.......................................................................................................... 1
1.3 Definitions........................................................................................................................... 2
1.4 Statement of intent............................................................................................................... 3
2 Key recommendations......................................................................................................... 4
2.1 Management of suspected stroke or TIA............................................................................... 4
2.2 In-hospital care..................................................................................................................... 4
2.3 Assessment, diagnosis and investigation............................................................................... 4
2.4 Treatment of ischaemic stroke.............................................................................................. 4
2.5 Preventing recurrent stroke in patients with ischaemic stroke or TIA..................................... 5
2.6 Carotid intervention............................................................................................................. 5
2.7 Provision of information....................................................................................................... 5
3 Management of suspected stroke or TIA.............................................................................. 6
3.1 Systems of care..................................................................................................................... 6
3.2 Pre-hospital.......................................................................................................................... 7
3.3 In-hospital............................................................................................................................ 7
4 Assessment, diagnosis and investigation.............................................................................. 10
4.1 Clinical assessment.............................................................................................................. 10
4.2 Brain imaging for suspected acute stroke or TIA................................................................... 11
4.3 Carotid evaluation................................................................................................................ 12
4.4 Cardiac imaging................................................................................................................... 14
4.5 Diagnostic tests.................................................................................................................... 15
5 Treatment of ischaemic stroke............................................................................................. 16
5.1 Thrombolysis....................................................................................................................... 16
5.2 Antiplatelet agents................................................................................................................ 17
5.3 Anticoagulants..................................................................................................................... 18
5.4 Neuroprotectants.................................................................................................................. 20
5.5 Reducing raised intracranial pressure................................................................................... 20
5.6 Decompressive surgery........................................................................................................ 21
5.7 Mechanical reperfusion........................................................................................................ 22
5.8 Prior statin therapy............................................................................................................... 23
6 Treatment of primary intracerebral haemorrhage............................................................... 24
6.1 Haematoma evacuation........................................................................................................ 24
6.2 Thrombolysis....................................................................................................................... 24
6.3 Haemostatic therapies.......................................................................................................... 25
6.4 Reducing raised Intracranial pressure................................................................................... 25
7 Other causes of stroke......................................................................................................... 26
7.1 Cerebral venous thrombosis................................................................................................. 26
7.2 Extracranial cervical arterial dissection...................................................................................... 26
8 Physiological monitoring and intervention.......................................................................... 28
8.1 Physiological monitoring...................................................................................................... 28
8.2 Physiological intervention.................................................................................................... 28
Control of
Management ofpain in adults
patients with
with stroke or cancer
TIA: assessment, investigation, immediate management and secondary prevention
1 Introduction
1.1 the need for a guideline
Stroke is the third biggest cause of mortality and the main cause of disability in Scotland. The
Scottish Borders Stroke study measured the community based crude incidence of first-ever-in-
a-lifetime stroke (FES) in Scotland at 2.8/1,000 of the population.1 Around 8,500 FESs occur
per annum in Scotland,2 with around 130,000 in the UK.
Stroke is an age-dependent illness and approximately 80% of people with FES present at 65
years of age and over.1,2 The predicted increase in this proportion of the Scottish population
and the greater increase in the older old (over 80 years),3 will be paralleled by a continuing
increase in the number of strokes in Scotland.
1
Management of patients with stroke or TIA: assessment, investigation, immediate management and secondary prevention
1.3 definitions
The definitions of some terms vary from one study to another and these outlines are not
rigid.
2
1 INTRODUCTION
3
Management of patients with stroke or TIA: assessment, investigation, immediate management and secondary prevention
2 Key recommendations
The following recommendations were highlighted by the guideline development group as being
clinically very important. They are the key clinical recommendations that should be prioritised
for implementation. The clinical importance of these recommendations is not dependent on
the strength of the supporting evidence.
A All patients with suspected stroke should have brain imaging immediately on
presentation.
A All patients with non-disabling acute stroke syndrome/TIA in the carotid territory who
are potential candidates for carotid surgery should have carotid imaging.
2.4.1 Thrombolysis
A Patients admitted with stroke within four and a half hours of definite onset of symptoms,
who are considered suitable, should be treated with 0.9 mg/kg (up to maximum 90 mg)
intravenous rt-PA.
A For individuals aged up to 60 years who suffer an acute MCA territory ischaemic stroke
complicated by massive cerebral oedema, surgical decompression by hemicraniectomy
should be offered within 48 hours of stroke onset.
4
2 KEY RECOMMENDATIONS
A Low-dose aspirin (75 mg daily) and dipyridamole (200 mg modified release twice daily)
should be prescribed after ischaemic stroke or TIA for secondary prevention of vascular
events.
2.5.2 statins
A A statin should be prescribed to patients who have had an ischaemic stroke, irrespective
of cholesterol level.
A Statin therapy after haemorrhagic stroke is not routinely recommended unless the risk
of further vascular events outweighs the risk of further haemorrhage.
A All patients with carotid artery territory stroke (without severe disability, mRS2)
or transient ischaemic attack should be considered for carotid endarterectomy as soon
as possible after the index event.
A Carotid endarterectomy (on the internal carotid artery ipsilateral to the cerebrovascular
event) should be considered in all:
male patients with a carotid artery stenosis of 50-99% (by NASCET method)
female patients with a carotid artery stenosis of 70-99%.
B For all patients, carotid endarterectomy should be performed as soon as the patient is
stable and fit for surgery, ideally within two weeks of event.
5
Management of patients with stroke or TIA: assessment, investigation, immediate management and secondary prevention
6
3 MANAGEMENT OF SUSPECTED STROKE OR TIA
3.2 pre-hospital
C Standard assessment scales such as FAST or MASS are recommended for pre-hospital
assessment to:
increase the accuracy of the initial stroke diagnosis
assist with more rapid diagnosis
speed up consideration for treatment
assist with more rapid referral to specialist services.
3.3 in-hospital
7
Management of patients with stroke or TIA: assessment, investigation, immediate management and secondary prevention
;; Patients with TIA requiring admission to hospital should be admitted directly to a stroke
unit staffed by a coordinated multidisciplinary team with a special interest in stroke
care.
Evidence from three studies of very early assessment and initiation of secondary prevention
therapy after TIA or minor stroke strongly suggests that early intervention (within 24 hours)
reduces the risk of early stroke recurrence, although the studies do not directly address the
question of admission.24-26 In a before and after study based on a community cohort, early 2+
active management at a daily TIA clinic was associated with an 80% drop in the risk of stroke
recurrence.24 A study of a 24 hour access TIA clinic from which 74% of patients were sent
home the same day showed that stroke recurrence was less than expected.26
Assessing the risk of recurrence is covered in section 4.1.1 and Annex 7.
B Patients with TIA and minor stroke, who are at high risk of early recurrence, should
undergo specialist assessment and begin treatment promptly.
B The routine implementation of care pathways for acute stroke management or stroke
rehabilitation is not recommended where a well organised multidisciplinary model of
care exists.
8
3 MANAGEMENT OF SUSPECTED STROKE OR TIA
9
Management of patients with stroke or TIA: assessment, investigation, immediate management and secondary prevention
The revised score ABCD2, which includes history of diabetes, has been extensively tested and
shown to be reliable (see Annex 7).34
C The ABCD2 score should be used to identify patients who are at highest risk of recurrent
stroke to allow very rapid investigation and treatment.
C Impairment scales should be considered to help discussion of likely outcomes after stroke
with patients and carers.
;; Patients in the acute phase of stroke should not be denied treatment based on an impairment
score.
;; The use of impairment scales may be considered for audit and benchmarking.
10
4 ASSESSMENT, DIAGNOSIS AND INVESTIGATION
A All patients with suspected stroke should have brain imaging immediately on
presentation.
B MRI with diffusion weighted and gradient echo sequences is recommended (where
available and practical) for the diagnosis of acute stroke syndromes in patients who:
are not severely ill, especially where either neurological deficit is mild and the
clinical likelihood is that the lesion is small or lies in the posterior fossa or
present late (after one week).
The advantages and disadvantages of using CT and MRI are summarised in Annex 8.
11
Management of patients with stroke or TIA: assessment, investigation, immediate management and secondary prevention
4.2.6 teleradiology
Teleradiology links allow electronic transfer of brain images to a remote reader and have been
widely used for several years. One small observational study demonstrated its validity and
reliability compared to reading hard copies on a view box.55
4.3.1 carotid imaging in Patients with carotid territory TIA or Stroke and/or
retinal event
A good quality meta-analysis showed that the most cost-effective diagnostic strategies for carotid
stenosis are those that offer surgery to a larger proportion of patients quickly after the warning
TIA/minor stroke.56 The benefit of performing carotid endarterectomy (CEA) diminishes with time
from the event (see section 11), reinforcing the need for early assessment. The nearer to the time
of stroke/TIA, the less important the actual degree of stenosis is in predicting benefit from CEA. 1+
The time of highest risk for recurrence of stroke/TIA is in the first hours or days after the primary
warning event as stroke related to carotid bifurcation disease relates to stability of the plaque. TIA
carries at least as high a risk of subsequent disabling stroke as minor stroke and its investigation
and treatment should be treated with equivalent urgency. Cost-effectiveness modelling shows
the best strategy is to offer surgery to a larger proportion of patients earlier than is currently the
case in Scotland.56
12
4 ASSESSMENT, DIAGNOSIS AND INVESTIGATION
A systematic review found that Doppler ultrasound, computed tomography angiography (CTA),
magnetic resonance angiography (MRA) or contrast-enhanced MRA (CE-MRA) all have high
sensitivities and specificities for diagnosing 70-99% carotid artery stenosis (by the NASCET method,
see Annex 9) in patients with ipsilateral carotid territory ischaemic symptoms.57 Data were too
limited to provide reliable estimates of accuracy for patients with 50-69% stenosis.57 Non-invasive
imaging avoids potential complications of invasive arteriography, but there is consistent evidence 1+
that imaging tests which produce angiographic images have better reproducibility, lower inter-
observer variation and higher accuracy in assessing/quantifying carotid disease than ultrasound
techniques.57 Of the non-invasive options contrast-enhanced magnetic resonance angiography
(CE-MRA) is the most accurate modality (see Table 1).57 Ultrasound has high sensitivity for detecting
carotid bifurcation disease and a normal ultrasound excludes disease. The poor specificity of
ultrasound for degree of disease when present, high inter-observer variability and insensitivity
for disease at other sites in the extracranial vasculature means that when an initial carotid duplex
examination is abnormal secondary corroborative imaging is required.57
Table 1 Sensitivity and specificity of non-invasive imaging for patients with 70-99% carotid
artery stenosis (by the NASCET method)57
A All patients with non-disabling acute stroke syndrome/TIA in the carotid territory who
are potential candidates for carotid surgery should have carotid imaging.
;; Duplex ultrasound criteria for grading of carotid disease should be standardised and
regularly audited against another modalities and surgical findings.
13
Management of patients with stroke or TIA: assessment, investigation, immediate management and secondary prevention
;; Patients undergoing cardiac surgery who are asymptomatic for stroke or TIA should not
be screened for carotid disease.
B The routine use of echocardiography with contrast media for evaluation of patients
with stroke is not recommended.
;; The use of cardiac CT and MRI should be limited to secondary specialist investigations
for specific problem solving where other tests are inconclusive.
14
4 ASSESSMENT, DIAGNOSIS AND INVESTIGATION
;; Standard haematological and biochemical tests such as a full blood count, erythrocyte
sedimentation rate, blood glucose, renal biochemistry and cholesterol level should be
performed on patients with a stroke or TIA as a minimum.
15
Management of patients with stroke or TIA: assessment, investigation, immediate management and secondary prevention
A Patients admitted with stroke within four and a half hours of definite onset of symptoms,
who are considered suitable, should be treated with 0.9 mg/kg (up to maximum 90 mg)
intravenous rt-PA.
A Onset to treatment time should be minimised.
Systems should be optimised to allow the earliest possible delivery of intravenous
rt-PA within the defined time window.
A Streptokinase should not be used for treatment of patients in the acute phase of
stroke.
16
5 TREATMENT OF ISCHAEMIC STROKE
Basilar artery occlusive stroke has a high mortality (approximately 90%) without 2++
recanalisation.73
In a systematic review of case series of intravenous (n=76) and intra-arterial (n=344) treatment
recanalisation was reported more often with IA treatment but survival rates and favourable
outcomes were similar.75 Treatment was started within 12 hours of symptom onset in 73-77%
of patients, but within six hours in 29%.75 One RCT of IA urokinase included only 16 patients. 1-
Four out of eight patients receiving UK had good outcome compared with only one out of 2+
eight in the control group.76 Combined IA alteplase and treatment with the glycoprotein IIb/IIIa 2-
inhibitor abciximab achieved higher recanalisation rates and a higher proportion of favourable
clinical outcomes compared to a historical control series receiving IA alteplase alone, with or
without stenting in either group.77
Recanalisation rates are known to be significantly poorer with certain sites of occlusion (for
example, carotid T occlusions) and reocclusion more common with others (for example, basilar
artery). Combined IV-IA treatment can be planned from the outset. Since recanalisation is the 1+
major determinant of successful outcome in stroke patients treated with IV thrombolytic therapy,
and the majority of recanalisation occurs within two hours of drug administration, rescue IA
therapy is a logical development of treatment.70
One RCT comparing IV plus IA alteplase (IV 0.6 mg/kg plus IA maximum 20 mg) with placebo
plus IA alteplase, two retrospective and two prospective case series (n=63) were included in a
systematic review.73 A further prospective study of IV plus IA therapy reported a higher proportion
of favourable clinical outcomes than historical controls from published IV thrombolysis RCTs 2++
with similar rates of symptomatic intracerebral haemorrhage.78 2-
3
A prospective case series reported comparable outcomes in patients treated with standard IV
alteplase who recanalised (as defined by ultrasound) and those who failed to recanalise after
30 minutes of IV treatment who subsequently received IA alteplase.79
B Intra-arterial thrombolysis may be considered for patients with proximal middle cerebral
artery occlusion or basilar artery occlusion that presents beyond four and a half
hours.
B Treatment should be delivered within six hours of symptom onset in patients with
middle cerebral artery occlusion.
5.2.1 aspirin
A systematic review of twelve RCTs of over 40,000 patients showed that aspirin at 160 or 300
mg daily reduced death and disability, recurrent stroke, and improved the likelihood of full
recovery in patients with ischaemic stroke.80 Two trials of aspirin (160 or 300 mg) given within
1++
48 hours of stroke onset contributed 94% of the data analysed in the review. One was an open
label trial and did not require a CT scan before randomisation. Exclusion criteria for these RCTs
were vague and in all of the included trials mortality was lower than in the placebo arm (4-9%),
suggesting that major strokes were under-represented.
A Aspirin 300 mg daily should be commenced within 48 hours of ischaemic stroke and
continued for at least 14 days.
;; In patients with dysphagia aspirin (300 mg) should be administered rectally or by enteral
tube.
17
Management of patients with stroke or TIA: assessment, investigation, immediate management and secondary prevention
Guidelines are available covering the identification and management of dysphagia following
stroke,7 and for administration of medication to patients with enteral feeding tubes or swallowing
difficulties.81
Standard protocols for IV and IA thrombolytic therapy presently advise avoidance of aspirin for
24 hours after thrombolytic drug treatment.80
Aspirin for preventing recurrent stroke is discussed in section 9.1.
5.3 anticoagulants
The administration of anticoagulants is contraindicated during the first 24 hours after IV
thrombolytic therapy.83 Although recanalisation may be more successful, the risk of haemorrhage 4
increases. Evidence on adjunctive anticoagulation is limited and neither the safety nor efficacy
has been established.83
18
5 TREATMENT OF ISCHAEMIC STROKE
5.3.4 Warfarin
In one trial 100 patients received warfarin within two weeks of stroke onset and none had
haemorrhagic worsening.89 Large, disabling strokes were under-represented. An arbitrary time
1+
limit of two weeks is recommended for delaying warfarin treatment for AF following acute
stroke.89
A The routine use of anticoagulants (UFH, LMWH, heparinoids, oral anticoagulants, direct
thrombin inhibitors, fibrinogen-depleting agents) is not recommended for the treatment
of acute ischaemic stroke.
Anticoagulants are not recommended in patients with progressing stroke.
C For patients in atrial fibrillation following stroke, anticoagulation with warfarin can be
introduced early in patients with minor stroke or TIA, but should be deferred for two
weeks after onset in those with major stroke.
19
Management of patients with stroke or TIA: assessment, investigation, immediate management and secondary prevention
5.4 Neuroprotectants
Many agents have been studied for a potential neuroprotective effect in patients with stroke.
There are systematic reviews of glutamate antagonists,92 calcium antagonists,93, 94 the free radical
scavenger tirilazad,95 vinca alkaloids,96 oral citicoline,97 the sodium antagonist lubeluzole,98
corticosteroids,99 methylxanthine derivatives (pentoxiffyline, propentofylline and pentofylline),100
aminophylline,101 and piracetam102 and phase III RCTs of the free radical spin trap NXY 059,103
5HT1a agonist repinotan,104 neutrophil chemotaxis inhibitors enlimomab105 and UK-279,276,106
magnesium,107 nalmefene,108 diazepam,109 chlomethiazole,110 cerebrolysin,111 and the free radical
scavenger edaravone.112
These agents have widely differing pharmacological actions. For the majority of agents, there was
no evidence of benefit or harm. The exceptions are:
Definite harm (increase in odds of death or dependence)
1++
tirilazad (OR=1.23; 95% CI 1.01 to 1.50)95 1+
enlimomab (adjusted p=0.004 for worse distribution of Rankin grade).105
Possible harm
aptiganel hydrochloride (mortality OR=1.32; 95% CI 0.91 to 1.93)92
selfotel (mortality OR=1.19; 95% CI 0.81 to 1.74)92 1+
corticosteroids (OR=1.08; 95% CI 0.68 to 1.72)99
calcium antagonists (OR 1.07 0.97 to 1.18)94
gavestinel (mortality OR=1.12; 95% CI 0.95 to 1.32).92
Possible benefit (reduced odds of death or dependence)
1++
citicoline (good outcome OR=1.38; 95% CI 1.10 to1.72)97
1+
non-cortical stroke syndromes treated with magnesium (poor outcome OR=0.75; 95% CI
0.58 to 0.97).107
For other agents, there was insufficient evidence to define benefit or harm.
;; Neuroprotectant agents should be used only within the context of randomised controlled
trials.
5.5.1 mannitol
A systematic review of mannitol in acute stroke included only one RCT of 77 patients, reported
in 1978.113 Temporary reduction in intracranial pressure (ICP) in patients with cerebral oedema 1++
in massive middle cerebral artery (MCA) infarction (malignant MCA syndrome) was reported, but
there was no effect on clinical outcomes.
20
5 TREATMENT OF ISCHAEMIC STROKE
5.5.3 glycerol
A systematic review of 10 RCTs (n=945) of glycerol to reduce raised ICP showed a trend
towards reduced mortality within the treatment period (typically seven days, OR=0.78; 95%
CI 0.58 to 1.06), which was significant when analysis was restricted to five truly randomised
1++
trials. 115 There was no reduction in mortality at the end of follow up.116 Only two trials reported 2+
functional outcomes and there was no significant effect seen (OR=0.73; 95% CI 0.37 to 1.42).
A subsequent retrospective cohort study of 442 patients found no effect on mortality, and
significantly increased mortality when glycerol was co-administered with corticosteroids.115
5.5.5 CORTICOSTEROIDS
A systematic review of seven trials of corticosteroids in acute stroke showed no evidence of
1++
benefit.99 In a small retrospective study of corticosteroids in acute stroke 30 day mortality was
2-
increased.115
A For individuals aged up to 60 years who suffer an acute MCA territory ischaemic stroke
complicated by massive cerebral oedema, surgical decompression by hemicraniectomy
should be offered within 48 hours of stroke onset.
It is uncertain whether selected patients older than 60 years will benefit from surgical
decompression.
21
Management of patients with stroke or TIA: assessment, investigation, immediate management and secondary prevention
Using lower frequencies of ultrasound causes less heating and gives better penetration, but
there is an excess risk of inrtacerebral haemorrhage.127 1+
22
5 TREATMENT OF ISCHAEMIC STROKE
;; Patients with ischaemic stroke on prior statin therapy should continue treatment, via a
nasogastric tube, if necessary.
23
Management of patients with stroke or TIA: assessment, investigation, immediate management and secondary prevention
6.2 thrombolysis
Intraventricular haemorrhage (IVH) is an established independent risk factor for poor prognosis
in ICH. External ventricular drain (EVD) placement allows monitoring and intracranial pressure
management.136
A single RCT of patients with PICH and hydrocephalus requiring EVD, randomising to urokinase
(n=7) or placebo was identified.137 Intraventricular urokinase speeds up radiological resolution
of IVH clots. Treatment reduced the half-time of radiological resolution by a mean of 3.8 days, 1-
from 8.5 in the placebo group to 4.7 in the urokinase treated group The trial was too small to
assess the effect on functional outcomes and mortality and did not have a non-surgical control
group for comparison.
Case series identified by a systematic review report more favourable outcomes than historical
controls, where used, with IVH lysis either by rt-PA or urokinase administered either continuously 3
or intermittently via an external ventricular drain.136 There was no reported increase in risk of
haemorrhage or other adverse outcomes.
24
6 TREATMENT OF PRIMARY INRTACEREBRAL HAEMORRHAGE
6.4.1 corticosteroids
A systematic review of corticosteroids in primary intracerebral haemorrhage included five RCTs,
all of which used dexamethasone 4-12 mg for 2-16 days.140 Two trials conducted in the 1970s
did not confirm the diagnosis radiologically and in one, 28% of patients were found to have
had ischaemic stroke at autopsy.140 1++
At one month, dexamethasone had no significant effect on mortality (RR=1.14; 95% CI 0.91
to 1.42) or death or dependence (RR=0.95; 95% CI 0.83 to 1.09). A non-significantly higher
number of complications was reported in patients treated with dexamethasone.140
6.4.2 mannitol
One RCT compared IV mannitol infusions to placebo for control of raised ICP in spontaneous
primary intracerebral haemorrhage.141 Four-hourly infusions of 100 ml of 20% mannitol for
five days in patients with spontaneous supratentorial ICH did not affect one-month mortality
1+
(16 out of 65 mannitol-treated patients compared to 16 out of 63 untreated patients, OR=0.96;
95% CI 0.40 to 2.31 as calculated by guideline development group) or three month death or
dependence on the Barthel Index (39 out of 65 patients compared to 34 out of 63, OR=1.28;
95% CI 0.60 to 2.74).
B Intravenous mannitol should not be used routinely for treatment of raised intracranial
pressure in patients with primary intracerebral haemorrhage.
25
Management of patients with stroke or TIA: assessment, investigation, immediate management and secondary prevention
7.1.1 anticoagulants
Anticoagulation appears to be safe following cerebral venous thrombosis and may be associated
with an improvement in outcome and reduced mortality.
A systematic review identified one poor quality and one small RCT (80 patients in total) to
include in a meta-analysis. Treatment with anticoagulation (dose adjusted unfractionated heparin
and the LMWH, nadroparin) commenced within 10 to 32 days of diagnosis and continued for 1++
three weeks, followed by warfarin therapy for 10 weeks, appears to be relatively safe. No new
symptomatic inrtacerebral haemorrhages occurred during treatment with anticoagulants.144
A case series reported the rate of ICH in patients with CVT at between 0% and 5.4%.143
Anticoagulation resulted in non-significant reductions in death or dependency at three months 3
and non-significant reductions in death from any cause.
;; Anticoagulation with warfarin (target INR 2-3) should usually be continued for 6-12
months following the recommendations for treatment of deep vein thrombosis and
pulmonary thromboembolism.
7.1.2 thrombolysis
A Cochrane review of thrombolysis for cerebral venous thrombosis identified no RCTs.145
A retrospective non-randomised study of local urokinase suggested that thrombolysis in
cerebral venous thrombosis appears safe but its routine clinical use cannot be supported.146 It
2++
may be indicated in selected cases where there is ongoing clinical deterioration despite other 4
therapy.142,147
There is insufficient evidence to support thrombolysis for cerebral venous thrombosis.
26
7 OTHER CAUSES OF STROKE
The most likely cause of stroke in cervical artery dissection is embolism from the dissection
flap but some cases may be due to haemodynamic compromise from the dissection itself.150 It
is important to be aware of the possibility of intracranial extension of the dissection resulting in 3
subarachnoid haemorrhage. This diagnosis should be excluded in the usual way if symptoms are 4
suggestive prior to initiating treatment with antiplatelets or anticoagulation.151
;; Further imaging of the cervical arteries may be required to assess healing or progression
of the vascular lesion.
;; Stenting may be considered if recurrent ischaemic events occur despite medical therapy
or where traumatic dissection has occurred with a high risk of stroke.
27
Management of patients with stroke or TIA: assessment, investigation, immediate management and secondary prevention
;; Monitoring should be balanced against other important aspects of stroke unit care,
particularly early mobilisation and rehabilitation.
The available evidence consistently showed no benefit from haemodilution in the acute phase of
stroke, rather there was a modest trend towards harm, except in patients with polycythaemia.161
A meta-analysis of studies of haemodilution using plasma expanders (dextran, hydroxyethyl 1++
starch and albumin) compared to standard fluid replacement therapy found no evidence of
benefit over standard regimens in terms of reducing mortality or improving functional outcome
in survivors.161
28
8 PHYSIOLOGICAL MONITORING AND INTERVENTION
Whilst not designed as an efficacy study, a study of the effects of hydroxyl ethyl starch showed
1-
no benefit over crystalloid solution.162
The use of standard IV saline infusion was associated with a significant fall in plasma glucose
1+
within the first 24 hours after acute ischaemic stroke.160
A small study of 34 stroke patients with dysphagia randomised to either intravenous or subcutaneous
fluid replacement therapy suggests that the latter will satisfactorily maintain plasma osmolality 2+
within normal limits.163
There are no RCTs directly comparing saline to other crystalloids.
C For patients in whom IV fluids are not appropriate, subcutaneous fluids can be used
to maintain plasma osmolality within the normal range.
Nimodipine has a negative effect on outcomes associated with a reduction in diastolic blood
1+
pressure but not with lowering of systolic blood pressure.169
Lisinopril appears to be safe in the acute phase of stroke but its clinical benefit is uncertain. Given
orally to patients with hypertension (140/90 mmHg), 5 mg within 24 hours of stroke onset 1+
significantly lowered blood pressure within four hours of administration. No difference was found
in neurological or functional outcomes at 90 days.173
29
Management of patients with stroke or TIA: assessment, investigation, immediate management and secondary prevention
Ongoing trials are exploring whether BP should be lowered acutely following stroke, and whether
antihypertensive therapy should be continued or stopped in the first few days after stroke.174,175
A Blood pressure should not be actively managed as a routine in patients in the acute
phase of ischaemic stroke.
B Routine use of insulin regimens to lower blood glucose in patients with moderate
hyperglycaemia after acute stroke is not recommended.
C Patients with hyperglycaemia (random blood glucose >7 mmol/L) should be formally
assessed (by OGTT) to exclude or confirm a diagnosis of impaired glucose tolerance
or diabetes.
8.2.4 feeding
Oropharyngeal dysphagia affects a large proportion of patients in the acute phase of stroke.
Swallowing difficulties can result in serious complications such as aspiration pneumonia,
undernutrition, dehydration and missed medication. It is important that early screening for
symptoms of dysphagia is carried out on admission and before giving food, drink or administering
oral medications.
Guidelines are available on the identification and management of dysphagia following stroke,7
and for the administration of medication to patients with enteral feeding tubes or swallowing
difficulties.81
In patients who have difficulty taking food and oral medication safely due to a low consciousness
level and/or the presence of dysphagia, nutrition may be provided via a nasogastric (NG) tube
or a percutaneous gastrostomy (PEG) tube. There is no clear guidance on how quickly feeding
should be initiated and which feeding tube is more suitable.
30
8 PHYSIOLOGICAL MONITORING AND INTERVENTION
A multicentre RCT investigated the timing and method of enteral feeding for patients with
dysphagia in the acute phase of stroke. There was no statistically significant difference between
early and delayed feeding on mortality and morbidity. Early tube feeding showed a non-significant
absolute risk reduction in death of 5.8% (95% CI -0.8 to 12.5; p=0.09).182 There was a borderline
statistically significant increase of 7.8% in the absolute risk of death or poor outcome in the use of 1++
PEG compared with NG (95% CI 0.0 to 15.5; p= 0.05).182 An RCT investigating the routine use
of oral nutritional supplements recruited non-dysphagic patients who were adequately nourished
prior to their stroke.183 No significant difference was identified between the study groups, although
no evidence was identified for withholding the focused use of nutritional supplements in patients
recognised at risk through nutritional screening. 183
A Hyperbaric oxygen therapy for patients with acute ischaemic stroke is not recommended
outwith the setting of a clinical trial.
Three small trials studying the effect of paracetamol (166 patients in total) and ibuprofen (24) in
lowering temperature in patients with acute stroke showed the limitations of antipyretic medications 1-
in achieving normothermia for patients with fever.190-192 Treatment with a daily dose of 6,000 mg
of paracetamol resulted in a small reduction in body temperature.191
31
Management of patients with stroke or TIA: assessment, investigation, immediate management and secondary prevention
A Early mobilisation, including positioning in bed, sitting on the edge of the bed, or standing
up should be considered for patients within the first three days after a stroke.
32
8 PHYSIOLOGICAL MONITORING AND INTERVENTION
33
Management of patients with stroke or TIA: assessment, investigation, immediate management and secondary prevention
34
9 PREVENTING RECURRENT STROKE IN PATIENTS WITH ISCHAEMIC STROKE OR TIA
An RCT in 20,332 patients followed up for a mean of 2.5 years, compared aspirin 25 mg plus
dipyridamole extended release 200 mg twice daily with clopidogrel 75 mg with the primary
outcome of first recurrent stroke. The net risk of recurrent stroke did not differ between the two 1+
groups (11.7% in the aspirin/dipyridamole group compared to 11.4% in the clopidogrel group;
95% CI 0.95 to 1.11).209
In patients with aspirin-related gastrointestinal intolerance there is no evidence that clopidogrel is
better tolerated than aspirin or that addition of a proton pump inhibitor (PPI) improves symptoms, 1+
with the exception of those with a previously healed peptic ulcer.210
A Low-dose aspirin (75 mg daily) and dipyridamole (200 mg modified release twice daily)
should be prescribed after ischaemic stroke or TIA for secondary prevention of vascular
events.
A The combination of aspirin and clopidogrel is not recommended for long term secondary
prevention of ischaemic stroke or TIA.
9.1.2 triflusal
A meta-analysis showed no significant difference between aspirin and triflusal for secondary
prevention of serious vascular events, including ischaemic stroke and TIA.211 Two doses of
triflusal were used in the included trials (600 mg and 900 mg). The confidence intervals of the
meta-analysis were wide and cannot exclude the possibility that triflusal is significantly better or 1++
worse than aspirin. Triflusal was associated with a significantly lower risk of minor and major
bleeding episodes but had a higher risk of non-haemorrhagic gastrointestinal episodes.211 A
significant number of patients discontinued the study medication early for reasons other than the
primary outcome.
Trifusal is not currently licensed in the UK.
9.2 statins
There is consistent evidence from two systematic reviews212, 213 and a subsequent RCT214
that treatment with a statin significantly reduces the relative risk of ischaemic stroke by 21%
(OR=0.79; 95% CI 0.73 to 0.85) although stroke death is not significantly reduced (OR=0.91;
1++
95% CI 0.76 to 1.10). The effect was seen without an associated increase in haemorrhagic stroke
(OR=0.90; 95% CI 0.65 to 1.22). The reduction in stroke risk is proportional to the lowering of
low density lipoprotein (LDL) cholesterol and occurs irrespective of baseline cholesterol level.215
Treatment with a statin also significantly reduces coronary events and all-cause mortality.215
Atorvastatin at 80 mg daily given to patients with recent stroke or TIA reduced ischaemic stroke
and cardiovascular events after TIA or ischaemic stroke. Over a median follow up of 4.9 years
the absolute risk reduction in fatal or non-fatal stroke was 2.2% (95% CI 0.2 to 4.2%) giving an
NNT over five years of 45 to prevent one fatal or non-fatal stroke. There were more haemorrhagic
strokes in the atorvastatin group giving a hazard ratio of 1.66 (95% CI 1.08 to 2.55). The absolute
risk increase was 0.9% giving a number needed to harm (NNH) of 107 over five years.215
35
Management of patients with stroke or TIA: assessment, investigation, immediate management and secondary prevention
Simvastatin at 40 mg daily given to patients with prior cerebrovascular disease reduced the
incidence of any major vascular event (RRR=20%; 95% CI 8 to 29%; p=0.01), but did not 1++
reduce the risk of subsequent stroke.215
A systematic review pooled 8,832 individual patients with prior cerebrovascular disease treated
with a statin, including simvastatin (40 mg), atorvastatin (80 mg) and pravastatin (40 mg).216 The
overall relative risk reduction for any type of stroke in statin users was 0.88 (95% CI 0.78 to 1++
0.99). The relative risk of ischaemic stroke is reduced to 0.8 (95% CI 0.70 to 0.92) but there is an
increased risk of haemorrhagic stroke with a hazard ratio of 1.73 (95% CI 1.19 to 2.50).
A A statin should be prescribed to patients who have had an ischaemic stroke, irrespective
of cholesterol level.
A Atorvastatin (80 mg) should be considered for patients with TIA or ischaemic stroke.
A Other statins (such as simvastatin 40 mg) may also be considered as they reduce the
risk of major vascular events.
A Statin therapy for prevention of further vascular events post-haemorrhagic stroke is not
recommended routinely unless the risk of further vascular events outweighs the risk of
further haemorrhage.
9.3 anticoagulants
36
9 PREVENTING RECURRENT STROKE IN PATIENTS WITH ISCHAEMIC STROKE OR TIA
Despite the increased incidence of AF and the higher stroke risk in the elderly (>75 years)
anticoagulation is underused in this age group. One trial comparing dose-adjusted warfarin (INR
2.0-3.0) to aspirin 300 mg daily in a group of octogenarians found more adverse events in the
aspirin group (33% compared to 6%, p=0.002).221 Compared to aspirin 75 mg in patients aged 1+
>75 years with AF, warfarin significantly reduced the risk of stroke, arterial embolism or other 1-
ICH (21 events with warfarin, 48 events with aspirin; yearly risk 1.8% versus 3.8%; RRR=0.48
95%, CI 0.28 to 0.8; p= 0.003; ARR=2%; 95% CI 0.7 to 3.2; NNT=50 over one year).222 This
benefit takes into account any intracranial haemorrhages and occurs without any increase in the
risk of extracranial haemorrhage (1.4% warfarin, 1.6% aspirin per annum).
A Patients with ischaemic stroke or TIA who are in atrial fibrillation should be offered
warfarin with target INR 2.0-3.0.
No evidence was identified to support benefit from the routine use of aspirin in addition to
warfarin.
9.4 Antihypertensives
There is a well established link between blood pressure and stroke,223 and between blood pressure
treatment and reduction in stroke risk.224
Current guidelines for management of hypertension from the British Hypertension Society suggest
systolic BP should be treated to <140 mm Hg and diastolic BP to <85 mm Hg,225 with a target 4
of 130/80 mm Hg for patients with diabetes.226
While many studies have included small numbers of patients with previous stroke, there have
been relatively few studies looking at secondary prevention in patients presenting with ischaemic
or haemorrhagic stroke.
A systematic review identified seven RCTs looking at prevention of recurrent vascular events in
patients with previous stroke or TIA.227 Lowering BP or treating established hypertension reduced
stroke (OR=0.76; 95% CI 0.63 to 0.92), non-fatal stroke (OR=0.79, 95% CI 0.65 to 0.95),
myocardial infarction (OR=0.79; 95% CI 0.63 to 0.98) and total vascular events (OR=0.79; 95% 1++
CI 0.66 to 0.95). No effect was seen on vascular or all-cause mortality. There was heterogeneity
in the studies due to the class of drugs used, with beta blockers having no discernible effect.
Reduction in stroke was related to the difference in systolic BP between treatment and control
groups (p=0.002).
One study of patients with a history of stroke (ischaemic or haemorrhagic) looked at blood
pressure lowering with perindopril (an ACE inhibitor) alone, perindopril in combination with
indapamide (a thiazide) or placebo. Patients unable to tolerate the combination were excluded
during run in. BP lowering with perindopril and indapamide in combination resulted in a 1+
reduction in recurrent stroke and major vascular events. Five years of treatment resulted in one
less fatal or non-fatal vascular event for every 11 patients treated (95% CI 9 to 16). BP lowering
with a combination of perindopril and indapamide was shown to be safe in patients who have
had a stroke or TIA and who are either hypertensive or normotensive.228
In an open label study comparing eprosartan and nitrendipine for secondary prevention of
stroke/TIA both drugs achieved target BP reductions. The cerebrovascular and cardiovascular 1+
end points were not significantly different.229
A All patients with a previous stroke or TIA should be considered for treatment with an
ACE inhibitor (for example, perindopril) and thiazide (for example, indapamide)
regardless of blood pressure, unless contraindicated.
37
Management of patients with stroke or TIA: assessment, investigation, immediate management and secondary prevention
38
9 PREVENTING RECURRENT STROKE IN PATIENTS WITH ISCHAEMIC STROKE OR TIA
B Patients with cryptogenic stroke and PFO should be treated with antiplatelet therapy
to reduce the risk of recurrence.
D Transcatheter closure of PFO may be considered for patients with recurrent cryptogenic
stroke on optimal medical management.
39
Management of patients with stroke or TIA: assessment, investigation, immediate management and secondary prevention
B The use of aspirin following ICH is not recommended to prevent further vascular events
when the risk of recurrence is low.
C The use of aspirin following ICH may be considered when there is a high risk of cardiac
ischaemic events.
10.3 anticoagulants
No clinical trials were identified describing the use of anticoagulants after ICH. A decision analysis
based on assumptions of risk of recurrent ICH and the risks associated with aspirin and warfarin
therapy concluded that anticoagulation cannot be safely recommended for atrial fibrillation 4
following either a lobar or deep ICH unless an individual is at very high risk of ischaemic stroke.241
Aspirin may be a reasonable strategy for treating those with a prior deep ICH and an intermediate
or higher risk of ischaemic stroke.241
;; In patients with a very high risk of further thrombotic or cardiac ischaemic events specialist
advice should be sought.
40
10 PREVENTING RECURRENT STROKE IN PATIENTS WITH PRIMARY INRTACEREBRAL HAEMORRHAGE
10.4 statins
An RCT of statin therapy to prevent recurrent stroke included 4,731 patients, 93 of whom had
haemorrhagic stroke. Forty five patients were recruited to the treatment arm and received 80 mg
of atorvastatin and forty eight received placebo.214 Individual outcomes for these patients were not
reported and the numbers were too small to be meaningful. In the treatment group there were 218 1++
ischaemic strokes and 55 haemorrhagic strokes compared to 278 ischaemic and 33 haemorrhagic
strokes in the placebo group. There were more haemorrhagic strokes in the atorvastatin group
giving a hazard ratio of 1.66 (95% CI 1.08 to 2.55). The absolute risk increase was 0.9% giving
an NNH of 107 over five years.
There are risks and benefits of statin treatment in this population and the potential risk of
intracerebral haemorrhage should be considered (see section 9.2).
A Statin therapy after haemorrhagic stroke is not routinely recommended unless the risk
of further vascular events outweighs the risk of further haemorrhage.
;; In this group of patients, their overall vascular risk profile should be taken into
account when considering the risks and benefits of statin.
41
Management of patients with stroke or TIA: assessment, investigation, immediate management and secondary prevention
11 Carotid intervention
11.1 Carotid endarterectomy
Published risks from carotid endarterectomy did not significantly change between 1985 and
2001,247 with a 1.4%-2.9% risk of death and a 4.2%-6.5% risk of death or stroke combined.
Reported complication rates were lower in studies where non-neurologists made the postoperative
assessment.
In patients with a progressing neurological deficit or stuttering stroke, there is a lack of evidence
about whether surgery should be performed as an emergency and no recommendation can be
made to support this.
Pooled analysis showed greater benefit of CEA in older patients (in patients with 50-99% stenosis
by NASCET method).243 The absolute risk reduction with surgery in terms of five-year cumulative
risk of ipsilateral carotid ischaemic stroke and any stroke or death within 30 days after surgery 1++
was 19.2% (95% CI 10.2% to 28.2%) in those aged 75 or over, 8.6% (95% CI 4.2% to 13.0%)
in those aged 65-74 and 5.6% (95% CI 1.6% to 9.6%) in those less than 65 years of age. This is
despite an increase in postoperative mortality in older patients.248
Only 10% of patients in the analysis were over 75 years of age and very few were over 80
years.
42
11 CAROTID INTERVENTION
Meta-analysis and subgroup analysis of pooled data show that women gain less benefit than men
from carotid endarterectomy (for patients with 50-99% stenosis).243, 248 The NNT to prevent one
stroke at five years is nine for men and 36 for women. There is clear benefit in women with 70- 1++
99% stenosis but not in those with 50-69% stenosis.243 This is driven by a higher operative risk
in women243, 248 and more rapid reductions in risk of stroke recurrence on medical therapy with
time in women.243
A All patients with carotid artery territory stroke (without severe disability, mRS2)
or transient ischaemic attack should be considered for carotid endarterectomy as soon
as possible after the index event.
A Carotid endarterectomy (on the internal carotid artery ipsilateral to the cerebrovascular
event) should be considered in all:
male patients with a carotid artery stenosis of 50-99% (by NASCET method)
female patients with a carotid artery stenosis of 70-99%.
B For all patients, carotid endarterectomy should be performed as soon as the patient is
stable and fit for surgery, ideally within two weeks of event.
A All patients undergoing carotid endarterectomy should receive optimal medical therapy
in addition to surgery.
A proportion of patients who are severely disabled immediately following their stroke event
can make rapid recovery such that they meet the criteria used in the studies (mRS2).
;; Patients who are severely disabled immediately following their stroke event should
be considered for carotid endarterectomy if they recover sufficiently to meet the criteria
for surgery.
43
Management of patients with stroke or TIA: assessment, investigation, immediate management and secondary prevention
Table 3 Number of patients with asymptomatic carotid artery disease needed to treat with CEA
to prevent an unfavourable outcome within three years249
Outcome NNT
Perioperative stroke or death or ipsilateral stroke 59
Perioperative stroke or death or any subsequent 36
stroke (primary outcome)
Any stroke or death 49*
*not significant
A CEA should be considered for asymptomatic patients with high grade carotid stenosis
and no ipsilateral event for at least six months.
B CEA should only be performed by operators with a low (<3%) perioperative stroke or
death rate.
;; Routine carotid endarterectomy prior to coronary artery bypass graft (CABG) is not
recommended in patients with asymptomatic carotid artery stenosis.
A Patch angioplasty should be used as the closure method in all carotid endarterectomies
performed by conventional methods.
44
11 CAROTID INTERVENTION
A meta-analysis of seven RCTs (554 operations) and 41 non-randomised controlled trials (25,622
operations) found no reliable evidence to guide the choice between local or general anaesthesia 1+
for patients undergoing carotid surgery.252
A The choice of anaesthetic technique for patients undergoing surgery should be made by
the individual operator/anaesthetist.
A systematic review found no data to support or refute the use of routine shunting over selective
shunting in CEA. 253
;; Angioplasty and stenting may be considered for patients with high risk of stroke
recurrence and a hostile surgical neck (for example, previous radical neck dissection
or radiotherapy).
45
Management of patients with stroke or TIA: assessment, investigation, immediate management and secondary prevention
;; Patients should be encouraged to take responsibility for their own health and be supported
to identify, prioritise, and manage their risk factors.
A Diets low in total and saturated fats should be recommended to all for the reduction
of cardiovascular risk.
46
12 PROMOTING LIFESTYLE CHANGES
;; All individuals should eat at least two portions of fish per week, one of which should be
a fatty fish.
No evidence was identified to advise people to stop taking supplemental omega-3 fats.
A People with hypertension should be advised to reduce their salt intake as much as
possible to lower blood pressure.
;; All individuals should aim to consume less than 6 g of salt per day.
47
Management of patients with stroke or TIA: assessment, investigation, immediate management and secondary prevention
B Patients and individuals at risk of cardiovascular disease, who are overweight, should
be targeted with interventions designed to reduce weight, and to maintain this
reduction.
12.7 smoking
Tobacco smoking is strongly and dose-dependently associated with all cardiovascular events,
including coronary heart disease (CHD), stroke, peripheral arterial disease (PAD) and cardiovascular 2++
death.268,269 Smoking cessation reduces these risks substantially, although the decrease is dependent 4
on the duration of cessation.270,271
B All people who smoke should be advised to stop and offered support to help facilitate
this in order to minimise cardiovascular and general health risks.
12.8 alcohol
;; When giving advice to patients with stroke, the current general advice of no more than
two to three units of alcohol per day for women and no more than three to four units of
alcohol per day for men, with at least two drink-free days per week for both men and
women, should be recommended.272,273
48
12 PROMOTING LIFESTYLE CHANGES
12.9 exercise
Physical activity is an important aspect of lifestyle that patients at risk of recurrent stroke can
modify.274 A meta-analysis of epidemiological data from large observational studies looking at
primary prevention (not stroke specific) indicated that physical activity may reduce the risk of
stroke.274 Increased occupational activity was associated with a lower risk of ischaemic stroke 2+
compared to a moderate or inactive occupation. Overall moderate occupational activity gave a 15%
lower risk in total stroke compared to inactive people. The majority of these studies were carried
out at least six months, and in some cases up to 12 years post stroke and involved participants who
were ambulatory. It may be reasonable to extrapolate this information to secondary prevention.
There may be many reasons why older people do not participate in physical activities.275
lack of interest
lack of access to a car
shortness of breath 4
joint pain
dislike of going out alone
perceived lack of fitness
lack of energy
doubting that exercise can lengthen life.
A systematic review of physical fitness training after stroke identified 12 trials (289 patients) with
an intervention to improve either muscle strength with or without cardiorespiratory fitness.276
Many of the trials had participants who volunteered and were ambulatory. Trial quality was
varied and outcome measures were very diverse. The benefits of physical fitness training
appeared to be short term only. Consequently, few conclusions can be drawn about the impact
of physical fitness training. A second systematic review of the same data showed no evidence
1++
of effect rather than evidence of no effect.277 Individual studies showed an increase in quality 1+
of life and reduction in the level of impairment. Secondary prevention was not an outcome but
positive effects from cardiovascular training on gait speed, stair climbing, human activity profile,
motor function, workload and exercise time were reported. A study comparing three 40 minute
sessions of treadmill training a week for six months with a programme of common components of
conventional rehabilitation showed that treadmill training was superior at improving cardiovascular
fitness.278 In a small study (13 participants) patients in a water-based programme of three one hour
sessions per week for eight weeks showed significant improvement in cardiovascular fitness over
the control group at least one year post stroke.279
An observational study of 25 patients one to 12 years post stroke taking part in an exercise group
demonstrated that improvement in balance and functional activity could be acquired well after
the initial stroke episode and improvement was retained at least one month after the programme 3
stopped.280 The benefits of physical exercise, in terms of function and quality of life, tend to be
lost after the formal programme of exercise stops.281,282
Nationally recognised recommendations state that all adults should accumulate 30 minutes
of moderate activity on most days of the week.283 National guidance is available on the most 4
effective way to promote physical activity.284,285
Many stroke patients are more disabled than those included in these studies, have language and
cognitive problems, coexisting physical disease and are elderly. There is a paucity of data on
more disabled patients.
49
Management of patients with stroke or TIA: assessment, investigation, immediate management and secondary prevention
13 Provision of information
This section reflects the issues likely to be of most concern to patients and their carers. These
points are provided for use by health professionals when discussing the acute phase of stroke with
patients and carers and in guiding the production of locally produced information materials.
13.1.1 information needs of patients and carers in the acute phase of stroke
The information needs of patients with stroke change over time.
The overall effectiveness of information provision has not been conclusively demonstrated.
Evaluation of structured information provision and the strategies used to provide it are sparse.286
Verbal and written information may be more effective than either format alone and information
individualised to the patient rather than general information more beneficial. No conclusive
evidence was identified on how to tailor information.286
A systematic review suggested that information provision and educational sessions are more
effective than provision of a leaflet alone.286 Success can be limited if strategies of information
1++
provision are unacceptable. In one study, 58% of patients failed to attend three or more outpatient
educational sessions, although the reason for non-attendance was not detailed.
One study showed that younger patients required more medical information as well as having
questions concerning exercise and post-stroke sexual activities. Women ranked receiving
information on post-stroke management higher than men.287 Carers information requirements 3
also differ with age and sex.288 Female relatives place more importance on information. Relatives
with higher educational level place less importance on counselling.
In hospital 77% of patients and carers wanted information on preventing further strokes, 65%
on where to obtain further information, 65% on causes of stroke, 61% on risk factors for stroke,
60% on recovery, 54% on what a stroke is and 53% on stroke-related medications.289 Seventy
five per cent of carers wanted information on the emotional or psychological effects of stroke.289 3
At six months the most frequently desired topic by both patients and carers was prevention
of further strokes (67% of people surveyed), where to obtain more information (33%) and the
cognitive effects of stroke (33%).289
In one study patients were given a guide on discharge, which they could use as a reference
tool. Patients and carers suggested topics for the guide. The patients were all younger with few
disabilities and had healthy carers. The study showed that 59% of patients and caregivers wanted
to receive information once or twice, 22% three to six times or more frequently,19-59% would
like to receive information within 24 hours and 22% on day one to two weeks after the event. 3
The preferred information was medical information about the course of the disease, its cause,
consequences and treatment (see Table 5).290 At six months patients and carers still require
information and in a self reporting study some people may have forgotten between discharge
and six months that they had received information.289 A questionnaire of knowledge of stroke
showed that family members do not retain information offered concluding that information
should be given frequently.291
In one study 119 out of 252 patients responded to a questionnaire about the usefulness of a
patient-held record. Twenty seven per cent had lost it, only 59% read it and two thirds said that 2+
they had difficulty in getting staff to record in it. Half of patients thought it was more trouble
than benefit.292
Material given to patients and carers may not be suitable. One study showed that the readability
and accessibility of material was equivalent to 11th grade (UK equivalent of fourth year at
secondary school, age 15). The average ability of the carers was 9th grade (second year at 3
secondary school, age 13) and the patients 7-8th grade (primary 7-first year at secondary school,
age 11-12).289
50
13 PROVISION OF INFORMATION
Table 5 The five most important issues identified by patients and carers looking for
information290
Issue
Medical Information
Consequences of stroke
Experiences of other patients and caregivers
Home recovery
Advice for the partner and the social circle
D Healthcare professionals should take a patients age, gender, educational status and
communication support needs into account when assessing their need for
information.
Counselling programmes appeared to have most positive outcomes in terms of health related
quality of life, satisfaction, confidence and knowledge, problem solving skills, emotional state,
burden and caregiver preparedness. The aim of counselling was to teach caregivers coping
strategies to reduce stress. Counselling was more effective than education alone. Up to three
years after counselling confidence and knowledge about patient care and use of active coping
strategies were increased. Counselling is a time consuming intervention with around about
eight hours of individual counselling given. More research is required taking into account the
needs of caregivers.295
51
Management of patients with stroke or TIA: assessment, investigation, immediate management and secondary prevention
Training care givers in basic skills reduces the burden of care and improves quality of life for
patients and carers.296 Three to five 30-40 minute sessions of training defined by the needs of
the patient were effective. The type of training offered in the study is shown in Table 6. At three
and 12 months patients whose caregivers had received training reported significantly improved
1++
quality of life and mood outcomes and burden of care was reduced and quality of life and
mood outcomes were improved in caregivers. The study was biased towards middle class, fit
participants and may not be applicable to all patients with stroke and their carers. There were
no data on which type of training was most useful. The study was in the rehabilitation setting
but the results may be extrapolated to the acute setting.
Table 6 Caregiver training provided by healthcare professionals296
;; Healthcare professionals should discuss the caring role and its implications with
relatives.
D Healthcare professionals should actively involve carers and find out what support they
need.
;; Carers should be given advice about where to seek support (for example, GP, voluntary
organisations, etc).
52
13 PROVISION OF INFORMATION
Connect
16-18 Marshalsea Road, London, SE1 1HL
Tel: 020 7367 0840
www.ukconnect.org
Works to promote effective services, new opportunities and a better quality of life for people
living with aphasia. Useful publications for people with aphasia and carers of people with
aphasia are available.
Different Strokes (Scotland)
53 Elmore Avenue, Glasgow, G44 5BH
Tel: 0141 569 3200
www.differentstrokes.co.uk Email: glasgow@differentstrokes.co.uk
Helps stroke survivors of working age to optimise their recovery, take control of their own lives
and regain as much independence as possible by providing a national network of weekly exercise
classes, practical, easy to use information, newsletters, interactive website and StrokeLine
telephone service.
DIPEX. Personal experiences of health and illness
www.dipex.org/stroke
The High Blood Pressure Foundation
Department of Medical Sciences, Western General Hospital, Crewe Road South,
Edinburgh, EH4 2XU
Tel: 0131 332 9211
Speakability
1 Royal Street, London SE1 7LL
Helpline: 080 8808 9572
www.speakability.org.uk
Offers impartial information and support for people with aphasia and their carers through its
helpline, website and training courses, and distributes its own fact sheets, low-cost publications
and videos.
The Stroke Association
Links House, 15 Links Place, Edinburgh EH6 7EZ
Tel: 0131 555 7240 Fax: 0131 555 7259 National Stroke Helpline: 0845 30 33 100
www.stroke.org.uk Email: scotland@stroke.org.uk
Funds research into prevention, treatment and better methods of rehabilitation, and helps
stroke patients and their families directly through its Rehabilitation and Support Services. It
also produces publications including patient leaflets, Stroke News (a quarterly magazine) and
information for health professionals.
strokeinfoplus
www.strokeinfoplus.scot.nhs.uk
Provides access to stroke patient leaflets, and information on stroke support groups, social
security benefits, medicines and treatment, and the evidence and clinical trials on which
treatment is based.
53
Management of patients with stroke or TIA: assessment, investigation, immediate management and secondary prevention
54
14 IMPLEMENTING THE GUIDELINE
55
Management of patients with stroke or TIA: assessment, investigation, immediate management and secondary prevention
56
15 THE EVIDENCE BASE
57
Management of patients with stroke or TIA: assessment, investigation, immediate management and secondary prevention
58
15 THE EVIDENCE BASE
59
Management of patients with stroke or TIA: assessment, investigation, immediate management and secondary prevention
60
16 DEVELOPMENT OF THE GUIDELINE
16.2.2 acknowledgements
SIGN is grateful to the following former members of the guideline development group.
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Management of patients with stroke or TIA: assessment, investigation, immediate management and secondary prevention
62
ABBREVIATIONS
Abbreviations
ABCD/ABCD2 age, blood pressure, clinical features, and duration of symptoms
ACE angiotensin converting enzyme
AF atrial fibrillation
ALA -linolenic acid
ARR absolute risk reduction
BI Barthel index
BNF British National Formulary
BP blood pressure
CABG coronary artery bypass graft
CaNS Canadian neurological scale
CAS carotid angioplasty and stenting
CCB calcium channel blockers
CC common carotid
CCA common carotid artery
CEA carotid endarterectomy
CE-MRA contrast-enhanced MRA
CHARISMA Clopidogrel for High Atherothrombotic Risk and Ischaemic Stabilisation,
Management and Avoidance
CHD coronary heart disease
CI confidence interval
CPASS Cincinnati pre-hospital stroke scale
CT computerised tomography
CTA computed tomography angiography
CVT cerebral venous thrombosis
DVT deep vein thrombosis
DWI diffusion weighted imaging
EDV end diastolic velocity
ECG electrocardiogram
ECST European Carotid Surgery Trial
ESPRIT European/Australasian Stroke Prevention in Reversible Ischaemia
Trial
EVD external ventricular drain
FAST face arm speech test
FASTER Fast Assessment of Stroke and Transient ischaemic attack to prevent
Early Recurrence
FAM functional assessment measure
FES first-ever-in-a-lifetime stroke
63
Management of patients with stroke or TIA: assessment, investigation, immediate management and secondary prevention
64
ABBREVIATIONS
65
Management of patients with stroke or TIA: assessment, investigation, immediate management and secondary prevention
Annex 1
Key questions used to develop the guideline
2. In patients with symptoms suggestive of acute stroke or TIA does the use 3.2, 3.3.1
of a standard assessment scale/method/tool compared to a standard history
and examination, improve:
a. accuracy, sensitivity, specificity of diagnosis
b. speed of referral to specialist services
c. time to diagnosis and treatment?
Consider: ambulance service, accident and emergency, nursing, primary care
and general practice
3. In patients with suspected stroke or TIA which form of hospital care 3.3.2
reduces death or dependency?
a. general ward vs home
b. stroke unit vs home
c. stroke unit vs general ward
d. stroke team vs general ward
e. acute stroke unit vs general ward
f. neurology unit vs general ward.
Consider: medical receiving units, acute medical units and high dependency
units
66
ANNEXES
7. In patients with likely acute stroke or TIA what is the evidence that brain 4.2.2
imaging (CT, MRI) results in change of management, is cost effectiveness
and reduces disability or death?
Consider: no imaging, early, late (<3, <6, <14, <48 hours, <1 week, >1
week
8. In patients with likely acute stroke or TIA what is the evidence that 4.2.3
brain imaging within 3, 6, 24, 48, >48 hours results in a change of
management, increased diagnostic accuracy in terms of differentiation
of infarct from haemorrhage (sensitivity and specificity for infarct AND
haemorrhage)?
Consider: CT, CT perfusion, MRI perfusion, MRI diffusion
9. In patients with confirmed diagnosis of primary intracerebral haemorrhage 4.2.4
which modality of brain imaging (no imaging, MRI, MRA, cerebral
angiography, CTA) affects management, diagnostic accuracy and diagnosis
of underlying cause of stroke?
Consider: intracranial aneurysm, cavernoma, ICVM
10. In patients with likely acute stroke or TIA who have undergone brain 4.2.5
imaging with CT or MRI how does interpretation of imaging by interpreters
with different levels of expertise, including radiographer, general physician,
stroke physician, general radiologist, neuroradiologist (with or without use
of scoring system eg ASPECT) change management and affect diagnostic
accuracy eg detection of early infarction?
11. In patients with likely acute stroke or TIA does the use of remote diagnostic 4.2.6
aids such as teleradiology or telemedicine change management, diagnostic
accuracy, time to diagnosis, disability, death, use of thrombolysis, time to
treatment or use of surgery?
67
Management of patients with stroke or TIA: assessment, investigation, immediate management and secondary prevention
12. In patients with carotid territory TIA or stroke and/or retinal event
(including amaurosis fugax, transient monocular blindness and retinal
artery occlusion) does carotid imaging improve accuracy of diagnosis for
carotid disease on the symptomatic side (sensitivity, specificity, accuracy,
NPV & PPV) for the following outcomes?
a. plaque burden
b. plaque composition
c. plaque morphology
d. stenosis degree
e. stenosis extent
f. tandem disease (ipsilateral at site other than carotid bifurcation/carotid
bulb/internal carotid origin).
Consider:
a. ultrasound (greyscale)
b. duplex/Doppler ultrasound
c. contrast-enhanced ultrasound
d. CT angiography
e. MR angiography
f. contrast-enhanced MR angiography
g. angiography/arteriography
h. rotational angiography/arteriography.
13. In patients scheduled for cardiac surgery and who are asymptomatic 4.3.2
for TIA/stroke which modality of carotid imaging is most effective for
improving the outcomes of recurrent stroke/dependency/death?
a. duplex ultrasound
b. CT angiography
c. MR angiography
d. contrast-enhanced MR angiography
e. angiography/arteriography
f. rotational angiography.
Consider:
14. In patients with confirmed stroke or TIA does imaging of the heart change 4.4
management?
Consider:
a. trans-thoracic echo
b. trans-oesophageal echo (TOE, TEE)
c. contrast-enhanced echo
d. trans-cranial Doppler
e. cardiac CT
f. cardiac MRI.
68
ANNEXES
15. In patients with confirmed stroke or TIA which diagnostic tests change 4.5
management/treatment?
a. thrombophilia screen (anti-thrombin, protein C, protein S, APC
resistance, Factor V Leiden genotyping, prothrombin 20210
mutation)
b. auto-antibody screen
c. rheumatoid factor
d. anti-nuclear factor
e. ANCA
f. anti-DNA
g. anti-cardiolipin antibodies
h. lupus anticoagulant
i. genetic testing
j. coagulation screen
k. serum protein electrophoresis
l. immunoglobulin levels
m.homocysteine levels
n. syphilis serology
o. sickle cell screen.
TREATMENT OF ISCHAEMIC STROKE
See guideline
Key question
section
16. Which therapeutic interventions in acute ischaemic stroke patients reduce 5.1-5.7
death or dependence, compared with placebo/standard management?
a. thrombolysis (IV) vs placebo
b. thrombolysis (IA) vs IV thrombolysis or vs placebo
c. general (anterior circulation)
d. basilar artery occlusion
e. antiplatelet agents vs control/placebo
f. heparin (UF or LMWT): heparin vs control or UF vs LMWT
g. neuroprotectants vs placebo
h. r educing raised ICP (positioning, hyperventilation, mannitol,
hypertonic saline, glycerol vs control)
i. decompressive surgery
j. hemicraniectomy vs control
k. post fossa decompression vs control
l. post fossa decompression vs EVD
m.EVD vs control
n. mechanical reperfusion vs control
clot retrieval
transcranial Doppler plus thrombolysis vs thrombolysis only
microbubbles.
17. In patients with acute ischaemic stroke, does temporary withdrawal of 5.8
intervention reduce death or dependence?
Consider:
a. antiplatelet agents (aspirin, clopidogrel, dipyridamole)
b. warfarin
c. antihypertensive therapy (beta blockers, calcium channel blockers,
angiotensin converting enzyme inhibitors, angiotensin II antagonists,
alpha blockers, centrally acting agents)
d. statins.
69
Management of patients with stroke or TIA: assessment, investigation, immediate management and secondary prevention
19. In patients with cerebral venous sinus thrombosis which interventions 7.1
reduce death or dependence vs control?
a. anticoagulation (warfarin or heparin) vs placebo
b. anticoagulation vs antiplatelet agents
c. antiplatelet agents vs placebo
d. thrombolysis vs above therapies.
20. In patients with extracranial arterial dissection, which interventions 7.2
reduce death or dependency vs control?
a. warfarin vs aspirin
b. stenting vs control.
70
ANNEXES
22. In patients with acute stroke, which interventions vs control reduces death 8.2
or dependence?
a. intravenous fluids
- IV fluids vs oral fluids
- saline vs other (dextrose, Ringers, Hartmanns)
- high vs standard volume (>2 litres/24 hours vs <2 litres/24
hours)
b. blood pressure management
- active lowering vs control
- active elevating (sympathomimetic agents or plasma expanders
vs control)
- withdrawing antihypertensive drugs vs continuing
c. lowering blood glucose (insulin vs control)
d. f eeding (early vs deferred feeding, NG, PEG, supplementary
feeding)
e. s upplementary oxygen therapy vs standard, normobaric vs
hyperbaric
f. management of pyrexia (antipyretics vs control)
g. early mobilisation
h. active positioning
i. induction of hypothermia vs control.
71
Management of patients with stroke or TIA: assessment, investigation, immediate management and secondary prevention
24. In patients with patent foramen ovale and cryptogenic stroke, which 9.7
interventions reduce recurrent stroke or cardiovascular events?
a. antiplatelet vs warfarin
b. closure vs medical therapy (antiplatelets or warfarin).
72
ANNEXES
25. In patients with PICH what interventions prevent recurrent vascular events 10.1-10.4
(recurrent stroke or cardiovascular events (non-fatal MI, vascular death,
non-fatal recurrent stroke)?
a. blood pressure reduction
b. antiplatelet agents
c. anticoagulation
d. statins.
26. In patients with haemorrhagic transformation of an ischaemic infarction does withdrawal
of antiplatelet agent (aspirin/clopidogrel/dipyridamole) or anticoagulant (warfarin, heparin)
affect death or disability?
CAROTID INTERVENTION
See guideline
Key question
section
27. In patients with carotid territory TIA or stroke and/or retinal event 11.1.1, 11.2
(including amaurosis fugax, transient monocular blindness and retinal
artery occlusion) does carotid intervention reduce recurrent stroke/
dependency/death?
a. surgical carotid endarterectomy
b. carotid angioplasty and stent
c. carotid angioplasty and stent with cerebral protection.
28. Patients with carotid disease who are asymptomatic in that (ipsilateral) 11.1.2, 11.2
carotid territory does carotid intervention reduce recurrent stroke/
dependency/death?
a. surgical carotid endarterectomy
b. carotid angioplasty and stent
c. carotid angioplasty and stent with cerebral protection.
29. In patients scheduled for cardiac surgery with carotid disease and who are 11.1.3
asymptomatic for TIA/stroke which carotid intervention reduces recurrent
stroke/dependency/death?
a. surgical carotid endarterectomy
b. carotid angioplasty and stent
c. carotid angioplasty and stent with cerebral protection.
Consider:
a. coronary artery bypass grafting (CABG)
b.valve replacement (aortic and/or mitral valves, with/without CABG)
c. left ventricular aneurysmectomy (with/without CABG)
d. thoracic aortic aneurysm repair.
30. In patients undergoing surgical carotid endarterectomy which carotid 11.1.4
surgery techniques reduces recurrent stroke/dependency/death?
a. local versus general anaesthetic
b. shunt or no shunt
c. patch or no patch
d. monitor with transcranial Doppler vs none
e. monitor with EEG vs none
f. monitor with infra-red spectroscopy vs none.
73
Management of patients with stroke or TIA: assessment, investigation, immediate management and secondary prevention
32. In patients presenting with stroke, TIA, crescendo TIA or stuttering
stroke and/or retinal events (amaurosis fugax, transient monocular
blindness and retinal artery occlusion) and carotid disease suitable for
intervention does early intervention reduce recurrent stroke/dependency/
death compared to delayed intervention or late intervention?
PROVISION OF INFORMATION
See guideline
Key question
section
33. What evidence is there for when and how patients with suspected stroke/ 12.1.1
TIA and carers should be offered information?
34. What evidence is there that individualised information for patients 12.1.1
with suspected stroke/TIA and carers is more beneficial than generic
information?
Consider: literacy, age, ethnicity, risk factors, format (visually impaired,
aphasia, dysphasia.
35. What information do patients with stroke want? 12.1.1
a.Why have I had a stroke?
b.Will I have another stroke?
c.What caused the stroke?
36. What practical information can be given to carers about the day-to-day 12.1.2
living of a patient with acute stroke?
Consider: clothing, food and drink, eating, texture, dysphagia, impact of stroke
on lifestyle, mood, personality.
37. What early and ongoing support do carers need to help them cope with 12.1.2
caring for a patient with stroke?
Consider: who should be their contact (practically and emotionally), methods
of support
38. What evidence is there that encouraging independence in patients with 12.2.1
stroke is beneficial?
Consider: reducing dependence, self help, taking responsibility, patient centred
goal setting, informed decision making
39. What is the evidence that changing lifestyle prevents secondary stroke 12.2.2-12.2.8
(secondary prevention)?
Consider: obesity, exercise, smoking, diet (lower fat, lower salt, higher fruit and
vegetable.
74
ANNEXES
40. What are the best ways of motivating people to continue exercising after 12.2.9
discharge and are there any exercise programmes that link physiotherapist
led exercise and gym?
Consider: education, transition
41. What are the symptoms of stroke and who should the patient contact
under which circumstances?
42. How acceptable is telemedicine for patients with suspected stroke/TIA and
their carer/family?
Consider: specialist opinion, rural locations, communication between
healthcare professional and patient/carer
75
Management of patients with stroke or TIA: assessment, investigation, immediate management and secondary prevention
Annex 2
NIH stroke scale
The NIH stroke scale (NIHSS) is a 15-item neurologic examination stroke scale used to evaluate
the effect of acute cerebral infarction on the levels of consciousness, language, neglect, visual-
field loss, extra-ocular movement, motor strength, ataxia, dysarthria, and sensory loss. A trained
observer rates the patents ability to answer questions and perform activities. Ratings for each
item are scored with 3 to 5 grades with 0 as normal, and there is an allowance for untestable
items. The single patient assessment requires less than 10 minutes to complete.
A free educational website presented by the International Electronic Education Network
provides tutorials, assessment and accreditation on the use of the NIHSS. The target audiences
for this programme are first responders, physicians, neurologists, nurses, clinical raters and
medical students (www.nihstrokescale.org).
76
ANNEXES
Annex 2 (continued)
77
Management of patients with stroke or TIA: assessment, investigation, immediate management and secondary prevention
Annex 2 (continued)
78
ANNEXES
Annex 2 (continued)
79
Management of patients with stroke or TIA: assessment, investigation, immediate management and secondary prevention
Annex 2 (continued)
80
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Annex 2 (continued)
81
Management of patients with stroke or TIA: assessment, investigation, immediate management and secondary prevention
Annex 2 (continued)
82
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Annex 2 (continued)
83
Management of patients with stroke or TIA: assessment, investigation, immediate management and secondary prevention
Annex 2 (continued)
84
ANNEXES
Annex 2 (continued)
85
Management of patients with stroke or TIA: assessment, investigation, immediate management and secondary prevention
Annex 3
Modified Rankin score298
A record of the functional outcome after an event based upon the extent of any disability
or disabling symptoms experienced by the patient following the event, measured using the
modified Rankin score (mRS) tool.
86
ANNEXES
Annex 4
Face arm speech test (FAST) and instructions
Adapted from Harbison et al and reproduced by kind permission of Lippincott, Williams and
Wilkins, Baltimore18
AFFECTED SIDE L R
AFFECTED SIDE L R
FACIAL MOVEMENTS
Ask patient to smile or show teeth
- Look for NEW lack of symmetry - Tick the YES box if there is an unequal smile or
grimace or obvious facial asymmetry
- Note which side does not move well, and mark on the form whether it is the
patient's right or left side
ARM MOVEMENTS
- Lift the patient's arms together to 90 if sitting, 45 if supine and ask them to hold the
position for 5 seconds then let go
- Does one arm drift down or fall rapidly?
- If one arm drifts down or falls, note whether it is the patient's left or right arm
SPEECH
If the patient attempts a conversation
- Look for NEW disturbance of speech
- Check with companion
- Look for slurred speech
- Look for word-finding difficulties. This can be confirmed by asking the patient to
name commonplace objects that may be nearby, such as a cup, chair, table
keys, pen
- If there is a severe visual disturbance, place an object in the patient's hand and ask
him/her to name it
87
Management of patients with stroke or TIA: assessment, investigation, immediate management and secondary prevention
Annex 5
MASS Test
Adapted from Bray et al and reproduced by kind permission of S. Karger AG, Basel.22
Assessment
History items
Age>45 years
Absent history of seizure or epilepsy
At baseline not wheelchair bound or bedridden
Blood glucose level between 2.8 and 22.2 mmol/L
Physical assessment items (normal and abnormal outcomes)
Facial droop
Patient smiles or shows teeth
(both sides move equally, one side does not move)
Arm drift
Patient closes eyes and extends both arms out for 10 seconds
(both arms move/both arms do not move, one arm does not move/one arm drifts
compared to the other)
Hand grip
Place a hand in each hand of the patient and ask him/her to squeeze hands
(both grip equally/not at all, unilateral weak/no grip)
Speech
Repeats a sentence
(normal, slurred/incorrect words, unable to speak)
Criteria for identifying stroke
Presence of any physical assessment item
All history items answered yes
88
ANNEXES
Annex 6
ROSIER scale proforma
Reprinted from Lancet Neurology, 4 (11), Azlisham Mohd Nor, John Davis, Bas Sen, Dean
Shipsey, Stephen J Louw, Alexander G Dyker, Michelle Davis, Gary A Ford. The Recognition
of Stroke in the Emergency Room (ROSIER) scale: development and validation of a stroke
recognition instrument, 72734, Copyright (2005), with permission from Elsevier.20
89
Management of patients with stroke or TIA: assessment, investigation, immediate management and secondary prevention
Annex 7
ABCD/ABCD2
Reprinted from The Lancet, 366 (9479), Rothwell PM, Giles MF, Flossmann E, Lovelock CE,
Redgrave JN, Warlow CP, Mehta Z. A, A simple score (ABCD) to identify individuals at high
early risk of stroke after transient ischaemic attack, 29-36, Copyright (2005), with permission
from Elsevier.34, 299
90
ANNEXES
Annex 8
Brain imaging for stroke
The choice of imaging of the brain in the acute phase of stroke is between CT and MRI (see
section 4.2.3). It is difficult to recommend which modality to use exclusively, as this will depend
upon individual patient circumstances. The strengths and weaknesses of both modalities are
shown in the table below to help inform choice. For the purposes of this table CT brain imaging
is unenhanced (without contrast) and MRI while also unenhanced is assumed to include diffusion
weighted imaging (DWI) and some form of susceptibility weighted imaging (SWI) sequences.
CT MRI
Geographic availability Widely available throughout Increasing availability in
Scotland including some Scotland but still mainly
island locations. confined to the larger centres.
Out-of-hours availability Generally available out-of- Still very limited availability out-
hours. of-hours in Scotland.
Imaging unwell patients Images rapidly acquired and May present difficulties in
suitable for imaging acutely unwell or confused patients,
unwell or obtunded patients. longer examination times than
CT. Some patients ineligible for
MRI due to contraindications
such as for those patients
dependent upon pacemakers.
Sensitivity for ischaemia Insensitive in first few Highly sensitive for ischaemia at
hours with poor inter- all time points and in all brain
observer agreement for regions.
early ischaemic changes.
Increasing accuracy with
time and size of infarct.
Relatively insensitive for
small infarcts, especially in
posterior fossa structures.
Sensitivity for Highly sensitive for Sensitive for parenchymal
haemorrhage haemorrhage in first hours haemorrhage at all time points
and days but this decreases following stroke.
with time from ictus.
The high sensitivity of CT for haemorrhage, its rapid acquisition and applicability in unwell
patients allows diagnostic decision making in many of those presenting with acute stroke
syndrome, especially where a substantial territory of brain is likely to be involved. For patients
presenting at later time points (days) MRI has advantage in differentiating haemorrhage from
ischaemia. Patients presenting with limited or unusual neurology (NIHSS 3), especially
brainstem syndromes, may also be better served by MRI as the first imaging investigation.
MRI is also useful after initial negative CT scan, where there is diagnostic doubt or the
definitive depiction of ischaemic damage will aid future management.
91
Management of patients with stroke or TIA: assessment, investigation, immediate management and secondary prevention
Annex 9
Carotid stenosis
A
C
92
ANNEXES
Annex 10
Carotid Duplex Reporting
The degree of internal carotid artery stenosis as found with carotid duplex ultrasound should
be reported in broad categories. Attempts to grade carotid stenosis to more precise degrees by
ultrasound are inappropriate. The grade of stenosis reported should be based on a combination
of parameters and not just one variable. The report should state the velocity measurements
and also the gray-scale and colour Doppler findings. A degree of stenosis >50% should be
corroborated by a second imaging modality.300
Degree of stenosis ICA PSV Plaque estimate ICA/CCA PSV ICA EDV
(%) (cm/sec) (%) ratio (cm/sec)
Normal <125 None <2.0 <40
<50 >125 <50 <2.0 <40
50-69 125-230 50 2.0-4.0 40-100
70 but less than >230 50 >4.0 >100
near occlusion
Near occlusion High, low or Visible Variable Variable
undetectable
Total occlusion Undetectable Visible, no Not applicable Not
detectable lumen applicable
ICA internal carotid artery, PSV peak systolic velocity, CCA common carotid artery
EDV end diastolic velocity
Reprinted from Grant EG, Benson CB, Moneta GL, et al. Carotid artery stenosis: gray-scale
and Doppler US diagnosis-society of radiologists in ultrasound consensus conference.
Radiology 2003;229:340-346 with permission from The Radiological Society of North
America (RSNA)300
93
Management of patients with stroke or TIA: assessment, investigation, immediate management and secondary prevention
94
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