Stroke and Transient Ischaemic Attack in Over 16s: Diagnosis and Initial Management in Secondary Care

Overview

This specialist Guidelines summary covers interventions in the acute stage of a stroke or transient ischaemic attack (TIA). It offers the best clinical advice on the diagnosis and acute management of stroke and TIA in the 48 hours after onset of symptoms. 

Imaging for People who have had a Suspected TIA or Acute Non-disabling Stroke

Suspected TIA

• Do not offer computed tomography (CT) brain scanning to people with a suspected transient ischaemic attack (TIA) unless there is clinical suspicion of an alternative diagnosis that CT could detect
• After specialist assessment in the TIA clinic, consider magnetic resonance imaging (MRI) (including diffusion-weighted and blood-sensitive sequences) to determine the territory of ischaemia, or to detect haemorrhage or alternative pathologies. If MRI is done, perform it on the same day as the assessment. 

Carotid Imaging

• Everyone with TIA who after specialist assessment is considered as a candidate for carotid endarterectomy should have urgent carotid imaging. 

Urgent Carotid Endarterectomy

• Ensure that people with stable neurological symptoms from acute non-disabling stroke or TIA who have symptomatic carotid stenosis of 50% to 99% according to the NASCET (North American Symptomatic Carotid Endarterectomy Trial) criteria:
  • are assessed and referred urgently for carotid endarterectomy to a service following current national standards (NHS England's service specification on neurointerventional services for acute ischaemic and haemorrhagic stroke)
  • receive best medical treatment (control of blood pressure, antiplatelet agents, cholesterol lowering through diet and drugs, lifestyle advice) 
• Ensure that people with stable neurological symptoms from acute non-disabling stroke or TIA who have symptomatic carotid stenosis of less than 50% according to the NASCET criteria, or less than 70% according to the European Carotid Surgery Trial (ECST) criteria:
  • do not have surgery
  • receive best medical treatment (control of blood pressure, antiplatelet agents, cholesterol lowering through diet and drugs, lifestyle advice)
• Ensure that carotid imaging reports clearly state which criteria (ECST or NASCET) were used when measuring the extent of carotid stenosis. 

Specialist Care for People with Acute Stroke

Specialist Stroke Units

• Admit everyone with suspected stroke directly to a specialist acute stroke unit after initial assessment, from either the community, the emergency department, or outpatient clinics.

Brain Imaging for the Early Assessment of People with Suspected Acute Stroke

• Perform brain imaging immediately with a non-enhanced CT for people with suspected acute stroke if any of the following apply:
  • indications for thrombolysis or thrombectomy
  • on anticoagulant treatment
  • a known bleeding tendency
  • a depressed level of consciousness (Glasgow Coma Score below 13)
  • unexplained progressive or fluctuating symptoms
  • papilloedema, neck stiffness or fever
  • severe headache at onset of stroke symptoms.

If thrombectomy might be indicated, perform imaging with CT contrast angiography following initial non-enhanced CT. Add CT perfusion imaging (or magnetic resonance equivalent) if thrombectomy might be indicated beyond 6 hours of symptom onset. 

• Perform scanning as soon as possible and within 24 hours of symptom onset in everyone with suspected acute stroke without indications for immediate brain imaging. 

NHS England and NHS Improvement have produced the National Stroke Service Model, which contains an updated patient-centred national optimal stroke imaging pathway.

Pharmacological Treatments and Thrombectomy for People with Acute Stroke

Thrombolysis with Alteplase for People with Acute Ischaemic Stroke

• Alteplase is recommended within its marketing authorisation for treating acute ischaemic stroke in adults if:
  • treatment is started as soon as possible within 4.5 hours of onset of stroke symptoms and
  • intracranial haemorrhage has been excluded by appropriate imaging techniques.

This recommendation is from NICE's technology appraisal guidance on alteplase for treating acute ischaemic stroke.

• Administer alteplase only within a well-organised stroke service with:
  • staff trained in delivering thrombolysis and in monitoring for any complications associated with thrombolysis
  • nursing staff trained in acute stroke and thrombolysis to provide level 1 and level 2 care (see the NHS Data Model and Dictionary on critical care level)
  • immediate access to imaging and re‑imaging, and staff trained to interpret the images 
• Staff in emergency departments, if appropriately trained and supported, can administer alteplase for the treatment of ischaemic stroke provided that patients can be managed within an acute stroke service with appropriate neuroradiological and stroke physician support 
• Ensure that protocols are in place for delivering and managing intravenous thrombolysis, including post-thrombolysis complications. 

Thrombectomy for People with Acute Ischaemic Stroke

• Offer thrombectomy as soon as possible and within 6 hours of symptom onset, together with intravenous thrombolysis (if not contraindicated and within the licensed time window), to people who have:
  • acute ischaemic stroke and
  • confirmed occlusion of the proximal anterior circulation demonstrated by computed tomographic angiography (CTA) or magnetic resonance angiography (MRA) taking into account the factors below
• Offer thrombectomy as soon as possible to people who were last known to be well between 6 hours and 24 hours previously (including wake‑up strokes):
  • who have acute ischaemic stroke and confirmed occlusion of the proximal anterior circulation demonstrated by CTA or MRA and
  • if there is the potential to salvage brain tissue, as shown by imaging such as CT perfusion or diffusion-weighted MRI sequences showing limited infarct core volume taking into account the factors below
• Consider thrombectomy together with intravenous thrombolysis (where not contraindicated and within the licensed time window) as soon as possible for people last known to be well up to 24 hours previously (including wake‑up strokes):
  • who have acute ischaemic stroke and confirmed occlusion of the proximal posterior circulation (that is, basilar or posterior cerebral artery) demonstrated by CTA or MRA and
  • if there is the potential to salvage brain tissue, as shown by imaging such as CT perfusion or diffusion-weighted MRI sequences showing limited infarct core volume taking into account the factors below
• Take into account the person's overall clinical status and the extent of established infarction on initial brain imaging to inform decisions about thrombectomy. Select people who have (in addition to the factors above)
  • a pre-stroke functional status of less than 3 on the modified Rankin scale and
  • a score of more than 5 on the National Institutes of Health Stroke Scale (NIHSS). 

Aspirin and Anticoagulant Treatment

People with Acute Ischaemic Stroke

• Offer the following as soon as possible, but certainly within 24 hours, to everyone presenting with acute stroke who has had a diagnosis of intracerebral haemorrhage excluded by brain imaging:
  • aspirin 300 mg orally if they do not have dysphagia or
  • aspirin 300 mg rectally or by enteral tube if they do have dysphagia.

Continue aspirin daily 300 mg until 2 weeks after the onset of stroke symptoms, at which time start definitive long-term antithrombotic treatment. Start people on long-term treatment earlier if they are being discharged before 2 weeks. 

• Offer a proton pump inhibitor, in addition to aspirin, to anyone with acute ischaemic stroke for whom previous dyspepsia associated with aspirin is reported 
• Offer an alternative antiplatelet agent to anyone with acute ischaemic stroke who is allergic to or genuinely intolerant of aspirin. (Aspirin intolerance is defined as either of the following: proven hypersensitivity to aspirin-containing medicines, or history of severe dyspepsia induced by low-dose aspirin) 
• Do not use anticoagulation treatment routinely for the treatment of acute stroke.^[A]

People with Acute Venous Stroke

• Offer people diagnosed with cerebral venous sinus thrombosis (including those with secondary cerebral haemorrhage) full-dose anticoagulation treatment (initially full-dose heparin and then warfarin [international normalised ratio 2 to 3]) unless there are comorbidities that preclude its use. 

People with Stroke Associated with Arterial Dissection

• Offer either anticoagulants or antiplatelet agents to people who have stroke secondary to acute arterial dissection. 

People with Acute Ischaemic Stroke Associated with Antiphospholipid Syndrome

• Manage acute ischaemic stroke associated with antiphospholipid syndrome in the same way as acute ischaemic stroke without antiphospholipid syndrome.

Reversal of Anticoagulation Treatment in People with Haemorrhagic Stroke

• Return clotting levels to normal as soon as possible in people with a primary intracerebral haemorrhage who were receiving warfarin before their stroke (and have elevated international normalised ratio). Do this by reversing the effects of the warfarin using a combination of prothrombin complex concentrate and intravenous vitamin K. 

Anticoagulation Treatment for Other Comorbidities

• Ensure that people with disabling ischaemic stroke who are in atrial fibrillation are treated with aspirin 300 mg for the first 2 weeks before anticoagulation treatment is considered 
• For people with prosthetic valves who have disabling cerebral infarction and who are at significant risk of haemorrhagic transformation, stop anticoagulation treatment for 1 week and substitute aspirin 300 mg 
• Ensure that people with ischaemic stroke and symptomatic proximal deep vein thrombosis or pulmonary embolism receive anticoagulation treatment in preference to treatment with aspirin unless there are other contraindications to anticoagulation 
• Treat people who have haemorrhagic stroke and symptomatic deep vein thrombosis or pulmonary embolism to prevent the development of further pulmonary emboli using either anticoagulation or a caval filter. 

Statin Treatment

• Immediate initiation of statin treatment is not recommended in people with acute stroke  
• Continue statin treatment in people with acute stroke who are already receiving statins. 

Maintenance or Restoration of Homeostasis

Supplemental Oxygen Therapy

• Give supplemental oxygen to people who have had a stroke only if their oxygen saturation drops below 95%. The routine use of supplemental oxygen is not recommended in people with acute stroke who are not hypoxic
• Be aware that some pulse oximeters can underestimate or overestimate oxygen saturation levels, especially if the saturation level is borderline. Overestimation has been reported in people with dark skin. See also the NHS England Patient Safety Alert on the risk of harm from inappropriate placement of pulse oximeter probes.

Blood Sugar Control

• Maintain a blood glucose concentration between 4 and 11 mmol/litre in people with acute stroke 
• Provide optimal insulin therapy, which can be achieved by the use of intravenous insulin and glucose, to all adults with type 1 diabetes with threatened or actual stroke. Critical care and emergency departments should have a protocol for such management. 

Blood Pressure Control for People with Acute Intracerebral Haemorrhage

• Consider rapid blood pressure lowering for people with acute intracerebral haemorrhage who do not have any of the exclusions listed below and who:
  • present within 6 hours of symptom onset and
  • have a systolic blood pressure of between 150 and 220 mmHg 
• Taking into account the risk of harm, consider rapid blood pressure lowering on a case-by-case basis for people with acute intracerebral haemorrhage who do not have any of the exclusions listed below and who:
  • present beyond 6 hours of symptom onset or
  • have a systolic blood pressure greater than 220 mmHg
• When rapidly lowering blood pressure in people with acute intracerebral haemorrhage, aim to reach a systolic blood pressure of 140 mmHg or lower while ensuring that the magnitude drop does not exceed 60 mmHg within 1 hour of starting treatment 
• Do not offer rapid blood pressure lowering to people who:
  • have an underlying structural cause (for example, tumour, arteriovenous malformation or aneurysm)
  • have a score on the Glasgow Coma Scale of below 6
  • are going to have early neurosurgery to evacuate the haematoma
  • have a massive haematoma with a poor expected prognosis 
• When considering blood pressure lowering in young people aged 16 or 17 with acute intracerebral haemorrhage who do not have any of the exclusions listed above, seek advice from a paediatric specialist. 

Blood Pressure Control for People with Acute Ischaemic Stroke

• Anti-hypertensive treatment in people with acute ischaemic stroke is recommended only if there is a hypertensive emergency with one or more of the following serious concomitant medical issues:
  • hypertensive encephalopathy
  • hypertensive nephropathy
  • hypertensive cardiac failure/myocardial infarction
  • aortic dissection
  • pre-eclampsia/eclampsia 
• Blood pressure reduction to 185/110 mmHg or lower should be considered in people who are candidates for intravenous thrombolysis. 

Nutrition and Hydration

Assessment of Swallowing Function

• On admission, ensure that people with acute stroke have their swallowing screened by an appropriately trained healthcare professional before being given any oral food, fluid or medication 
• If the admission screen indicates problems with swallowing, ensure that the person has a specialist assessment of swallowing, preferably within 24 hours of admission and not more than 72 hours afterwards 
• People with suspected aspiration on specialist assessment, or who require tube feeding or dietary modification for 3 days, should be:
  • re-assessed and considered for instrumental examination
  • referred for dietary advice 
• People with acute stroke who are unable to take adequate nutrition, fluids and medication orally should:
  • receive tube feeding with a nasogastric tube within 24 hours of admission unless they have had thrombolysis
  • be considered for a nasal bridle tube or gastrostomy if they are unable to tolerate a nasogastric tube
  • be referred to an appropriately trained healthcare professional for detailed nutritional assessment, individualised advice and monitoring
  • have their oral medication reviewed to amend either the formulation or the route of administration. 

Oral Nutritional Supplementation

• Screen all hospital inpatients on admission for malnutrition and the risk of malnutrition. Repeat screening weekly for inpatients 
• Screening should assess body mass index (BMI) and percentage unintentional weight loss. It should also consider the time over which a nutrient intake has been unintentionally reduced and/or the likelihood of future impaired nutrient intake. The Malnutrition Universal Screening Tool (MUST), for example, may be used to do this 
• When screening for malnutrition and the risk of malnutrition, be aware that dysphagia, poor oral health and reduced ability to self-feed will affect nutrition in people with stroke 
• Screening for malnutrition and the risk of malnutrition should be carried out by healthcare professionals with appropriate skills and training 
• Routine nutritional supplementation is not recommended for people with acute stroke who are adequately nourished on admission 
• Start nutrition support for people with stroke who are at risk of malnutrition. This may include oral nutritional supplements, specialist dietary advice and/or tube feeding. 

Hydration

• Assess, on admission, the hydration of everyone with acute stroke. Review hydration regularly and manage it so that normal hydration is maintained. 

Optimal Positioning and Early Mobilisation for People with Acute Stroke

Optimal Positioning

• Assess the individual clinical needs and personal preferences of people with acute stroke to determine their optimal head position. Take into account factors such as their comfort, physical and cognitive abilities and postural control. 

Early Mobilisation

• Help people with acute stroke to sit out of bed, stand or walk as soon as their clinical condition permits as part of an active management programme in a specialist stroke unit 
• If people need help to sit out of bed, stand or walk, do not offer high-intensity mobilisation in the first 24 hours after symptom onset. 

Avoiding Aspiration Pneumonia

• To avoid aspiration pneumonia, give food, fluids and medication to people with dysphagia in a form that can be swallowed without aspiration, after specialist assessment of swallowing (see the second recommendation in Assessment of swallowing function).

Surgery for People with Acute Stroke

Acute Intracerebral Haemorrhage

• Stroke services should agree protocols for monitoring, referring and transferring people to regional neurosurgical centres for the management of symptomatic hydrocephalus
• People with intracerebral haemorrhage should be monitored by specialists in neurosurgical or stroke care for deterioration in function and referred immediately for brain imaging when necessary 
• Previously fit people should be considered for surgical intervention following primary intracerebral haemorrhage if they have hydrocephalus 
• People with any of the following rarely require surgical intervention and should receive medical treatment initially:
  • small deep haemorrhages
  • lobar haemorrhage without either hydrocephalus or rapid neurological deterioration
  • a large haemorrhage and significant comorbidities before the stroke
  • a score on the Glasgow Coma Scale of below 8 unless this is because of hydrocephalus
  • posterior fossa haemorrhage. 

Decompressive Hemicraniectomy

• Consider decompressive hemicraniectomy (which should be performed within 48 hours of symptom onset) for people with acute stroke who meet all of the following criteria:
  • clinical deficits that suggest infarction in the territory of the middle cerebral artery, with a score above 15 on the NIHSS
  • decreased level of consciousness, with a score of 1 or more on item 1a of the NIHSS
  • signs on CT of an infarct of at least 50% of the middle cerebral artery territory:
    • with or without additional infarction in the territory of the anterior or posterior cerebral artery on the same side or
    • with infarct volume greater than 145 cm³, as shown on diffusion-weighted MRI scan 
• Discuss the risks and benefits of decompressive hemicraniectomy with people or their family members or carers (as appropriate), taking into account their functional status before the stroke, and their wishes and preferences. 

NICE has produced patient decision aids to support discussions about decompressive hemicraniectomy.

• People who are referred for decompressive hemicraniectomy should be monitored by appropriately trained professionals skilled in neurological assessment. 

Footnotes

[A] There may be a subgroup of people for whom the risk of venous thromboembolism outweighs the risk of haemorrhagic transformation. People considered to be at particularly high risk of venous thromboembolism include anyone with complete paralysis of the leg, a previous history of venous thromboembolism, dehydration or comorbidities (such as malignant disease), or who is a current or recent smoker. Such people should be kept under regular review if they are given prophylactic anticoagulation.