This site is intended for health professionals only

Eight ways to enhance a stroke/TIA pathway

Map of Medicine gives evidence-based suggestions on achieving better efficiency without compromising quality in a stroke/TIA pathway.

1) Immediately scan all patients with suspected stroke1,2 and admit directly to a specialist acute stroke unit.3

A 2004 National Institute for Health Research (NIHR) health technology assessment (HTA) found the most effective strategy was to scan all patients immediately.1,2 This provided the greatest benefits in terms of most quality-adjusted life years (QALYs) achieved and least overall costs.1,2 NICE stroke quality standards state patients with acute stroke should receive brain imaging within one hour of arrival.4 Health economic evaluations have shown immediate specialist care reduces inpatient length of stay, six-month disability and 90-day recurrent strokes.5,6

2) Ensure patients with TIA, who are at high risk of recurrence, undergo specialist assessment within 24 hours of presentation.7

The 2008 SIGN stroke/TIA guideline recommends prompt specialist assessment for all TIA patients at high risk of recurrence.7 This recommendation is based on health economic evidence, which associated early active management at a daily non-appointment TIA clinic with an 80% drop in the risk of stroke recurrence.6

3) Give intravenous tissue plasminogen activator (alteplase) to patients with confirmed acute ischaemic stroke within three hours of onset of stroke symptoms.8

The NICE 2007 technology appraisal of alteplase in the treatment of acute ischaemic stroke concluded that alteplase plus best supportive care is clinically and cost--effective when compared with best supportive care alone.8 A 2005 decision analysis showed that in patients with acute stroke, thrombolytic treatment is associated with an incremental cost-effectiveness ratio (ICER) of £16,623 per QALY when compared with standard care.9

4) Use thrombolysis botulinum toxin type A (BTX-A) alongside physiotherapy to treat post-stroke muscle spasticity.10

BTX-A offers greater clinical benefit when compared with oral anti-spasmodic medications where both are used in a regimen including physiotherapy.10 A 2005 health economic evaluation found patients with post-stroke wrist or clenched-fist spasticity had more successfully treated months when receiving BTX-A as first-line or second-line therapy when compared with those on a regimen based on oral anti-spasmodic medications.10

5) Place all patients with atrial fibrillation at risk of ischaemic stroke on anticoagulation therapy.11

NHS Improvement estimates there are 12,500 people who suffer strokes directly attributable to atrial fibrillation annually, with up to 40% of patients who could benefit from anticoagulation not receiving it.12 Identifying and treating these patients appropriately would prevent around 6,000 strokes annually and save 4,000 lives.12

6) Use aspirin combination therapy in the secondary prevention of ischaemic stroke.3,7

NICE and SIGN guidance recommend aspirin plus modified-release dipyridamole over aspirin monotherapy as it delivers better clinical results in terms of stroke-free life years, disability-free life years and recurrent strokes averted.3,7 Health economic modelling results have shown the cost-effective value of combination therapy, as patients on aspirin gained an average of 10.8 QALYs at a lifetime cost of treatment per patient of $44,396 (approx. £24,000 as of January 2004), while patients on combination therapy gained an average of 11.1 QALYs at a lifetime cost of treatment per patient of $41,425 (approx. £23,000 as of January 2004).13,14

7) Use a combination of an ACE inhibitor and thiazide diuretic for all stroke/TIA patients to prevent further vascular events.4,7

The 2008 SIGN Stroke/TIA guideline recommends placing all patients with previous stroke or TIA regardless of blood pressure on daily combination therapy of an ACE inhibitor (perindopril 4mg/day) and a diuretic (indapamide 2.5mg/day).4,7 A 2009 health economic evaluation, comparing this regimen with standard care, found patients had fewer recurrent strokes and improved QALYs over a four-year monitoring period with a cost per QALY below £25,000.15

8) Place all patients who have had an ischaemic stroke or TIA on generic lipid-lowering medications.7,16,17

In patients with previous cerebrovascular disease, treatment with a lipid-lowering drug reduces the risk of non-fatal stroke, total stroke, coronary events, cardiovascular disease mortality, and all-cause death.7,16,17

For further information go to

Eight ways to enhance a stroke/TIA pathway Methodology

The productivity considerations presented in this document are relevant to the UK. They were identified by systematically searching for and appraising productivity evidence from multiple sources, including NICE guidance, health economic databases and Zynx Health (a sister company of Map of Medicine).

A productivity message explicitly states interventions that can reduce the cost of care, while maintaining or improving patient outcomes.

Actions that are believed to lead to improved productivity, but lack unequivocal clinical or economic evidence, are not included.

Some productivity considerations are informed by more recent evidence than that included in relevant national guidelines.

The document has been peer reviewed by an independent group of experts.

This document is not to be substituted for a healthcare professional's diagnosis or clinical decisions.
© 2011 Map of Medicine Ltd Stroke and transient ischaemic attack (TIA) 3/3