NICE clinical guidelines
Issued: July 2008
CG68

Stroke: Diagnosis and initial management of acute stroke and transient ischaemic attack (TIA)

This is an extract from the guidance. The complete guidance is available at guidance.nice.org.uk/cg68

Introduction

Stroke is a preventable and treatable disease. Over the past two decades a growing body of evidence has overturned the traditional perception that stroke is simply a consequence of aging that inevitably results in death or severe disability. Evidence is accumulating for more effective primary and secondary prevention strategies, better recognition of people at highest risk, and interventions that are effective soon after the onset of symptoms. Understanding of the care processes that contribute to a better outcome has improved, and there is now good evidence to support interventions and care processes in stroke rehabilitation.

In the UK, the National Sentinel Stroke Audits have documented changes in secondary care provision over the last 10 years, with increasing numbers of patients being treated in stroke units, more evidence-based practice, and reductions in mortality and length of hospital stay. In order for evidence from research studies to improve outcomes for patients, it needs to be put into practice. National guidelines provide clinicians, managers and service users with summaries of evidence and recommendations for clinical practice. Implementation of guidelines in practice, supported by regular audit, improves the processes of care and clinical outcome.

This guideline covers interventions in the acute stage of a stroke ('acute stroke') or transient ischaemic attack (TIA). Most of the evidence considered relates to interventions in the first 48 hours after onset of symptoms, although some interventions up to 2 weeks are covered. The Intercollegiate Stroke Working Party (ICSWP) National Clinical Guidelines for Stroke (published July 2008), which is an update of the 2004 edition, includes all of the recommendations from this NICE guideline.

This NICE guideline should also be read alongside the Department of Health National Stroke Strategy[1]. There are some differences between the recommendations made in the NICE guideline and those in the National Stroke Strategy. However, the NICE Guideline Development Group (GDG) feel that their recommendations are based on evidence derived from all of the relevant literature as identified by systematic methodology.

Stroke has a sudden and sometimes dramatic impact on the patient and their family, who need continuing information and support. Clinicians dealing with acute care need to be mindful of the rehabilitation and secondary care needs of people with stroke to ensure a smooth transition across the different phases of care. In addition, it should be borne in mind that some recommendations in the guideline may not be appropriate for patients who are dying or who have severe comorbidities.

Incidence and prevalence

Stroke is a major health problem in the UK. It accounted for over 56,000 deaths in England and Wales in 1999, which represents 11% of all deaths[2]. Most people survive a first stroke, but often have significant morbidity. Each year in England, approximately 110,000 people have a first or recurrent stroke and a further 20,000 people have a TIA. More than 900,000 people in England are living with the effects of stroke, with half of these being dependent on other people for help with everyday activities[3].

Health and resource burden

In England, stroke is estimated to cost the economy around £7 billion per year. This comprises direct costs to the NHS of £2.8 billion, costs of informal care of £2.4 billion and costs because of lost productivity and disability of £1.8 billion[4]. Until recently, stroke was not perceived as a high priority within the NHS. However, a National Stroke Strategy was developed by the Department of Health in 2007. This outlines an ambition for the diagnosis, treatment and management of stroke, including all aspects of care from emergency response to life after stroke.

Drugs

The guideline assumes that prescribers will use a drug's summary of product characteristics to inform their decisions for individual patients.

Definitions

Symptoms of stroke include numbness, weakness or paralysis, slurred speech, blurred vision, confusion and severe headache. Stroke is defined by the World Health Organization[5] as a clinical syndrome consisting of 'rapidly developing clinical signs of focal (at times global) disturbance of cerebral function, lasting more than 24 h or leading to death with no apparent cause other than that of vascular origin'. A transient ischaemic attack (TIA) is defined as stroke symptoms and signs that resolve within 24 hours. However, there are limitations to these definitions. For example, they do not include retinal symptoms (sudden onset of monocular visual loss), which should be considered as part of the definition of stroke and TIA. The symptoms of a TIA usually resolve within minutes or a few hours at most, and anyone with continuing neurological signs when first assessed should be assumed to have had a stroke. The term 'brain attack' is sometimes used to describe any neurovascular event and may be a clearer and less ambiguous term to use. A non-disabling stroke is defined as a stroke with symptoms that last for more than 24 hours but later resolve, leaving no permanent disability.



[1] Department of Health (2007) National Stroke Strategy. London: Department of Health.

[2] Mant J, Wade DT, Winner S (2004) Health care needs assessment: stroke. In: Stevens A, Raftery J, Mant J et al., editors, Health care needs assessment: the epidemiologically based needs assessment reviews, First series, 2nd edition. Oxford: Radcliffe Medical Press, p141–244.

[3] National Audit Office (2005) Reducing brain damage: faster access to better stroke care. (HC 452 Session 2005–2006). London: The Stationery Office.

[4] Mant J, Wade DT, Winner S (2004) Health care needs assessment: stroke. In: Stevens A, Raftery J, Mant J et al., editors, Health care needs assessment: the epidemiologically based needs assessment reviews, First series, 2nd edition. Oxford: Radcliffe Medical Press, p141–244.

[5] Hatano S (1976) Experience from a multicentre stroke register: a preliminary report. Bulletin of the World Health Organization 54: 541–53.