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At the heart of general practice since 1960

Rapid assessment vital in stroke and TIA

How should GPs manage TIA?

What is the role of thrombolysis in stroke?

Which patients should undergo brain imaging?

How should GPs manage TIA?

What is the role of thrombolysis in stroke?

Which patients should undergo brain imaging?

Each year, around 110,000 people in england have a stroke and a further 20,000 a transient ischaemic attack (TIA). In England, stroke is estimated to cost the economy around £7 billion per year.1

In the 1990s, patients in the UK had a greater risk of stroke-related mortality and disability than elsewhere in Europe.2

Overall standards have risen over the past ten years, with the QOF, see table 1, attached, clearly having improved the delivery of secondary prevention for vascular disease and the vast majority of hospitals now offering stroke unit care.

The 2007 DH National Stroke Strategy3 has also had a significant impact, with most strategic health authorities putting stroke near the top of the agenda for service development.

However, regular National Sentinel Stroke Audits4 have shown great variation in the quality of care for stroke patients in hospitals, with some centres finding it difficult to provide even basic specialist care.

In July 2008 NICE published guidelines for the management of acute stroke and TIA.5 At the same time, the Intercollegiate Stroke Working Party at the RCP produced guidance covering the rest of the stroke pathway, including secondary prevention, rehabilitation and the management of long-term stroke-related disability.6

These guidelines provide a valuable framework for raising standards of care at both a local and national level.

Transient Ischaemic Attack

The risk of stroke within the first month after a TIA can be as high as 30% in some patients7 and therefore symptoms should never be ignored.

The correct diagnosis of TIA and the identification and treatment of risk factors will reduce the subsequent risk of stroke.8 Around 10% of patients will also benefit from a carotid endarterectomy. Therefore, a responsive specialist service that can deliver appropriate treatment as quickly as possible needs to be available to all patients.

When assessing a patient who may have had a TIA, GPs should consider four questions before referral:

• Are the neurological symptoms focal?
• Are the neurological symptoms negative rather than positive? For example numbness rather than parasthaesiae, muscle weakness rather than muscle twitching, or loss of visual acuity versus flashing lights or other visual fortification spectra
• Was the onset of the focal neurological symptoms sudden?
• Were the focal neurological symptoms maximal at onset rather than progressing over a period?

If the answer to all four questions is yes, the symptoms are almost certainly caused by vascular pathology. If even one of the answers is no, cerebrovascular disease is much less likely and alternative diagnoses should be considered.

Non-focal symptoms, such as faintness, dizziness, light-headedness, confusion, mental disorientation, incontinence and syncope are all very unlikely to be caused by a TIA. Patients with these symptoms should therefore be referred to a falls, cardiology or ENT clinic as appropriate.

The NICE guideline5 recommends that patients who have had a suspected TIA and have no neurological symptoms at the time of assessment (within 24 hours of the onset of symptoms) should have their risk of subsequent stroke assessed as soon as possible using a validated scoring system such as the ABCD2 score (see figure 1, attached).

These scoring systems exclude certain populations who may be at particularly high risk of stroke, such as those with recurrent events and those on anticoagulation who also need urgent evaluation. The scores may also not be relevant for patients who present late.

If the patient is at high risk of stroke (ABCD2 ? 4), they should start aspirin 300mg immediately and be referred to a specialist for assessment and investigation within 24 hours of the onset of symptoms. As soon as the diagnosis is confirmed, secondary prevention measures should be introduced and individual risk factors addressed.

Patients with crescendo TIA (two or more TIAs in a week) should be considered as being at high risk of stroke, even though they may have an ABCD2 score of <4.

Patients with an ABCD2 ? 3 or who have had a TIA but present late (more than one week after their last symptom has resolved) should be considered at lower risk of stroke and see a specialist within one week of symptom onset.

Acute Stroke

Stroke usually occurs without warning. Occasionally there may be a preceding headache, especially in patients with an intracerebral or subarachnoid haemorrhage. Neurological symptoms usually develop within a few minutes, although they can develop in a stuttering fashion over several hours.

Classically, haemorrhage develops rapidly and is associated with headache, vomiting and sometimes clouding of consciousness.

The increasing use of brain imaging in the early stages of stroke has shown that haemorrhage frequently presents in ways that are indistinguishable from infarction.

A stroke or TIA should be managed as a medical emergency. There is now good evidence that thrombolysis for acute ischaemic stroke is an effective treatment for selected patients and significantly reduces the risk of long-term disability.9

Thrombolysis needs to be given within a maximum of three hours of the onset of symptoms, with the benefit increasing sharply the earlier it is given. However, it should only be prescribed after a specialist has assessed the patient to determine if it is appropriate and if the patient requires brain imaging to exclude haemorrhage.

GPs should ensure that everyone in the practice knows that patients with symptoms that might indicate stroke should be advised to call an ambulance immediately and go straight to hospital.

The NICE guideline recommends that, outside hospital, patients with a sudden onset of neurological symptoms should be screened for a diagnosis of stroke or TIA using a validated tool, such as FAST (Face Arm Speech Test), see figure 2, attached. Hypoglycaemia should be excluded as a cause.

Brain imaging should be performed immediately in patients with acute stroke and any of the following:

• Indications for thrombolysis or early anticoagulation treatment, such as stroke with a known time of onset less than three hours ago (although a recently reported trial reported benefits up to 4.5 hours, the earlier it is given the more likely it is to be successful), proven by scanning that there is no haemorrhage; ? 80 years; systolic blood pressure <180mmHg at time of dose. Thrombolysis should not be administered if the patient is rapidly improving spontaneously
• On anticoagulant treatment
• Known bleeding tendency
• A depressed level of consciousness (Glasgow Coma Scale <13)
• Unexplained progressive or fluctuating symptoms
• Papilloedema, neck stiffness or fever
• Severe headache at onset of stroke symptoms.

Brain imaging should be performed as soon as possible for all patients with an acute stroke who do not have the above indications.

Patients with an acute stroke who have had a diagnosis of primary intracerebral haemorrhage excluded by brain imaging should be given aspirin 300mg orally or rectally or by enteral tube if they are dysphagic, as soon as possible (certainly within 24 hours). This therapy should be continued for two weeks after the onset of stroke symptoms. The patient should then start definitive long-term antithrombotic treatment. Patients discharged before two weeks can start long-term therapy earlier.

Those with an acute ischaemic stroke who have a history of aspirin-associated dyspepsia should be prescribed a proton pump inhibitor as well as aspirin. Alternative antiplatelet agents can be used if the patient is allergic to, or intolerant of, aspirin.

Alteplase should be reserved for use within a stroke service, by staff trained in delivering thrombolysis and monitoring for complications.

Community Care

All patients require careful follow-up and support by the primary care team after discharge from specialist services.

The RCP guideline includes information on the use of antiplatelet treatment (aspirin and dipyridamole for most patients), anticoagulation for patients with atrial fibrillation, lipid-lowering treatment (simvastatin for most patients) and the management of blood pressure, diet and exercise.

At least half of patients who survive a stroke will have some degree of persistent physical and/or cognitive impairment. These patients are likely to require ongoing rehabilitation from a coordinated multidisciplinary team and lifestyle advice.

One of the most common complaints from stroke patients and their carers after discharge is that they feel abandoned and find it very difficult to navigate their way through the complex systems that may exist to support them. It is hoped that these guidelines will enable healthcare professionals to deliver the right interventions, at the right time and in the right place, to minimise the impact of this devastating condition.

Authors

Dr Anthony Rudd
FRCP
consultant stroke physician , Guy's and
St Thomas' NHS Foundation Trust

Dr Pippa Tyrrell
MD FRCP (London)
senior lecturer, honorary consultant in stroke medicine, Royal Salford NHS Foundation Trust
on behalf of the Guideline Development Group and the Intercollegiate Stroke Working Party

Acknowledgments

The authors would like to thank Dr Sharon Swain, health services research fellow in guideline development, NCCC, Claire Turner, senior project manager in guideline development, NCCC, and Alex Hoffman, Stroke Programme Manager, Clinical Standards Unit, RCP London for their help with the preparation of this article.

Key points Table 1: QOF stroke and TIA indicators Figure 1: ABCD2 score Figure 2: The FAST score

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