bring together all NICE guidance, quality standards and other NICE information on a specific topic. are interactive and designed to be used online. They are updated regularly as new NICE guidance is published. To view the latest version of this pathway see: http://pathways.nice.org.uk/pathways/stroke Pathway last updated: 28 December 2016 This document contains a single pathway diagram and uses numbering to link the boxes to the associated recommendations. All rights reserved
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1 Person with suspected transient ischaemic attack No additional information 2 Assessing the risk of stroke People who have had a suspected TIA (that is, they have no neurological symptoms at the time of assessment [within 24 hours]) should be assessed as soon as possible for their risk of subsequent stroke using a validated scoring system, such as ABCD 2. These scoring systems exclude certain populations that may be at particularly high risk of stroke, such as those with recurrent TIAs and those on anticoagulation treatment, who also need urgent evaluation. They also may not be relevant to patients who present late. 3 Initial management High risk of subsequent stroke People who have had a suspected TIA who are at high risk of stroke (that is, with an ABCD 2 score of 4 or above) should have: aspirin (300 mg daily) started immediately specialist assessment (includes exclusion of stroke mimics, identification of vascular treatment, identification of likely causes, and appropriate investigation and treatment) and investigation within 24 hours of onset of symptoms measures for secondary prevention introduced as soon as the diagnosis is confirmed, including discussion of individual risk factors. People with crescendo TIA (two or more TIAs in a week) should be treated as being at high risk of stroke, even though they may have an ABCD 2 score of 3 or below. Lower risk of subsequent stroke People who have had a suspected TIA who are at lower risk of stroke (that is, an ABCD 2 score of 3 or below) should have: aspirin (300 mg daily) started immediately Page 3 of 10
specialist assessment (includes exclusion of stroke mimics, identification of vascular treatment, identification of likely causes, and appropriate investigation and treatment) and investigation as soon as possible, but definitely within 1 week of onset of symptoms measures for secondary prevention introduced as soon as the diagnosis is confirmed, including discussion of individual risk factors. People who have had a TIA but who present late (more than 1 week after their last symptom has resolved) should be treated as though they are at lower risk of stroke. Clopidogrel and modified-release dipyridamole The following recommendations are an extract from NICE technology appraisal guidance on clopidogrel and modified-release dipyridamole for the prevention of occlusive vascular events. Modified-release dipyridamole in combination with aspirin is recommended as an option to prevent occlusive vascular events for people who have had a transient ischaemic attack. Modified-release dipyridamole alone is recommended as an option to prevent occlusive vascular events for people who have had a transient ischaemic attack only if aspirin is contraindicated or not tolerated. People currently receiving modified-release dipyridamole either with or without aspirin outside these criteria (listed above) should have the option to continue treatment until they and their clinicians consider it appropriate to stop. NICE has written information for the public explaining its guidance on clopidogrel and modifiedrelease dipyridamole. NICE has published an evidence summary on transient ischaemic attack: clopidogrel. 4 Brain imaging While all people with symptoms of acute stroke need urgent brain scanning, there is less evidence to recommend brain scanning in those people whose symptoms have completely resolved by the time of assessment. People who have had a suspected TIA (that is, whose symptoms and signs have completely resolved within 24 hours) should be assessed by a specialist (within 1 week of symptom onset) before a decision on brain imaging is made. Page 4 of 10
People who have had a suspected TIA who are at high risk of stroke (for example, an ABCD 2 score of 4 or above, or with crescendo TIA) in whom the vascular territory or pathology is uncertain should undergo urgent brain imaging (preferably diffusion-weighted MRI). Urgent brain imaging is defined as imaging that takes place 'within 24 hours of onset of symptoms'. This is in line with the National Stroke Strategy. People who have had a suspected TIA who are at lower risk of stroke (for example, an ABCD 2 score of less than 4) in whom the vascular territory or pathology is uncertain should undergo brain imaging (preferably diffusion-weighted MRI). Brain imaging in people with a lower risk of stroke should take place 'within 1 week of onset of symptoms'. This is in line with the National Stroke Strategy. Examples where brain imaging is helpful in the management of TIA are: people being considered for carotid endarterectomy where it is uncertain whether the stroke is in the anterior or posterior circulation; people with TIA where haemorrhage needs to be excluded, for example long duration of symptoms or people on anticoagulants; where an alternative diagnosis (for example migraine, epilepsy or tumour) is being considered. Type of brain imaging People who have had a suspected TIA who need brain imaging (that is, those in whom vascular territory or pathology is uncertain) should undergo diffusion-weighted MRI except where contraindicated, in which case CT scanning should be used. Contraindications to MRI include people who have any of the following: a pacemaker, shrapnel, some brain aneurysm clips and heart valves, metal fragments in eyes, severe claustrophobia. 5 Assessing and managing carotid stenosis Early carotid imaging Some people who have had a TIA have narrowing of the carotid artery that may require surgical intervention. Carotid imaging is required to define the extent of carotid artery narrowing. All people with suspected TIA who after specialist assessment are considered as candidates for carotid endarterectomy should have carotid imaging within 1 week of onset of symptoms. People who present more than 1 week after their last symptom of TIA has resolved should be managed using the lower-risk pathway. Page 5 of 10
Urgent carotid endarterectomy People with stable neurological symptoms from TIA who have symptomatic carotid stenosis of 50 99% according to the NASCET criteria, or 70 99% according to the ECST criteria, should: be assessed and referred for carotid endarterectomy within 1 week of onset of TIA symptoms undergo surgery within a maximum of 2 weeks of onset of TIA symptoms receive best medical treatment (control of blood pressure, antiplatelet agents, cholesterol lowering through diet and drugs, lifestyle advice). People with stable neurological symptoms from TIA who have symptomatic carotid stenosis of less than 50% according to the NASCET criteria, or less than 70% according to the ECST criteria, should: not undergo surgery receive best medical treatment (control of blood pressure, antiplatelet agents, cholesterol lowering through diet and drugs, lifestyle advice). Carotid imaging reports should clearly state which criteria (ECST or NASCET) were used when measuring the extent of carotid stenosis. Interventional procedures NICE has published guidance on carotid artery stent placement for symptomatic extracranial carotid stenosis with normal arrangements for clinical governance and audit or research. NICE has published guidance on the following procedures with special arrangements for clinical governance, consent and audit or research: carotid artery stent placement for asymptomatic extracranial carotid stenosis laser-assisted cerebral vascular anastomosis without temporary arterial occlusion. Page 6 of 10
Glossary ABCD2 a prognostic score to identify people at high risk of stroke after a TIA acute stroke unit a discrete area in the hospital that is staffed by a specialist stroke multidisciplinary team; it has access to equipment for monitoring and rehabilitating patients and regular multidisciplinary team meetings occur for goal setting aphasia loss or impairment of the ability to use and comprehend language, usually resulting from brain damage Apraxia apraxia of speech is a difficulty in initiating and executing the voluntary movement needed to produce speech when there is no weakness of speech muscles; it may cause difficulty producing the correct speech or changes in the rhythm or rate of speaking Dysarthria difficulty in articulating words Dysphagia difficulty in swallowing Dyspraxia difficulty in planning and executing movement Early supported discharge a service for people after stroke which allows transfer of care from an inpatient environment to a primary care setting to continue rehabilitation, at the same level of intensity and expertise that they would have received in the inpatient setting Page 7 of 10
ECST European Carotid Surgery Trialists' Collaborative Group FAST face arm speech test, a test used to screen for a diagnosis of stroke or TIA GCS Glasgow coma score Hemianopia blindness in one half of the visual field of one or both eyes INR international normalised ratio neglect an inability to orient towards and attend to stimuli, including body parts, on the side of the body affected by the stroke NASCET North American symptomatic carotid endarterectomy trial NIHSS National Institutes of Health Stroke Scale non-disabling stroke a stroke with symptoms that last for more than 24 hours but later resolve, leaving no permanent disability Orthosis a device that supports or corrects the function of a limb or the torso Page 8 of 10
ROSIER Recognition of stroke in the emergency room, a scale used to confirm a diagnosis of stroke or TIA Screening a process of identifying people with particular impairments; people can then be offered information, further assessment and appropriate treatment, screening may be performed as a precursor to more detailed assessment Stroke rehabilitation service a stroke service designed to deliver stroke rehabilitation either in hospital or in the community Stroke inpatient unit an environment in which multidisciplinary stroke teams deliver stroke care in a dedicated ward which has a bed area, dining area, gym, and access to assessment kitchens TIA a TIA (transient ischaemic attack) is defined as stroke symptoms and signs that resolve within 24 hours Sources Stroke and transient ischaemic attack in over 16s: diagnosis and initial management (2008) NICE guideline CG68 Clopidogrel and modified-release dipyridamole for the prevention of occlusive vascular events (2010) NICE technology appraisal guidance 210 Your responsibility The guidance in this pathway represents the view of NICE, which was arrived at after careful consideration of the evidence available. Those working in the NHS, local authorities, the wider public, voluntary and community sectors and the private sector should take it into account when carrying out their professional, managerial or voluntary duties. Implementation of this guidance Page 9 of 10
is the responsibility of local commissioners and/or providers. Commissioners and providers are reminded that it is their responsibility to implement the guidance, in their local context, in light of their duties to avoid unlawful discrimination and to have regard to promoting equality of opportunity. Nothing in this guidance should be interpreted in a way which would be inconsistent with compliance with those duties. Copyright Copyright National Institute for Health and Care Excellence 2016. All rights reserved. NICE copyright material can be downloaded for private research and study, and may be reproduced for educational and not-for-profit purposes. No reproduction by or for commercial organisations, or for commercial purposes, is allowed without the written permission of NICE. Contact NICE National Institute for Health and Care Excellence Level 1A, City Tower Piccadilly Plaza Manchester M1 4BT www.nice.org.uk nice@nice.org.uk 0845 003 7781 Page 10 of 10