Assessment and care of stroke

Dr Helen Hosker reviews the latest guidelines on early and continuing care of stroke patients.

Two important guidelines for stroke and TIA, which underpin the National Stroke Strategy, were published in July 2008. The NICE clinical guideline 68 Diagnosis and Initial Management of Acute Stroke and Transient Ischaemic Attack,1 covers the first 48 hours after onset of symptoms. The third edition of National Clinical Guidelines for Stroke2 covers all other aspects of stroke care.

One of the key messages is that stroke is a medical emergency. There is a need for both the public and healthcare professionals to be able to recognise the symptoms and access specialist stroke care urgently.

The FAST (Face Arm Speech Test) tool is a validated tool used to identify a stroke or TIA outside of hospital (see box).

The tool is easy to remember and should lead to an improvement in recognition of stroke by the public. There are plans for a major public awareness campaign, funded by the DoH.

FAST is not a diagnostic tool, but will probably positively screen about 80-90 per cent of stroke symptoms.

The ROSIER (Risk Of Stroke In the Emergency Room)3 scale is validated for use within A&E. Patients contacting the surgery with a possible diagnosis of stroke should be advised to call an ambulance. Ambulance services now treat stroke as a medical emergency that should be transferred to hospital and ideally admitted to an acute stroke unit.

Stroke assessment
Patients presenting within three hours of the onset of symptoms who may be eligible for thrombolysis should be assessed for a scan immediately. The scan is key in establishing the diagnosis and underlying nature of stroke: ischaemic (80 per cent) or haemorrhagic (20 per cent).

Those eligible for thrombolysis should be treated with alteplase.4 Thrombolysis should only be given in a specialist stroke unit by trained staff.

All patients should be screened for problems swallowing before being given anything by mouth. Assessment of impairments should begin within a few hours of admission, with a full multidisciplinary assessment, if required, taking place within five working days.

Those unlikely to survive their stroke should, in agreement with relatives, receive high-quality end-of-life care.

TIA
TIA is a retrospective diagnosis and continuing symptoms at the time of presentation should be classed as a stroke. TIAs should no longer be regarded as 'just a mini stroke'.

Anyone who is thought to have had a stroke must have their risk of a future stroke assessed using the ABCD2 tool to assess for risk of subsequent stroke (see box right).5

A score of four or more or anyone with crescendo TIA - defined as two or more TIAs in one week - should be assessed by a specialist within 24 hours. Those with a score of three or less should be assessed by a specialist within a week. Hypoglycaemia should be excluded in the differential diagnosis.

If TIA is thought to be the diagnosis patients should be given aspirin 300mg immediately, unless contraindicated. A landmark study showed that delaying aspirin resulted in some high-risk patients having a stroke that could have been prevented.6

Rehabilitation
After a stroke, patients should receive a thorough specialist assessment. Patients and their families should be fully involved in discharge planning, be provided with information and be offered contact with statutory and voluntary agencies. GPs, community teams and social services should all be informed in advance.

Rehabilitation should be offered until the patient's functioning level has returned to pre-stroke levels, or is stable, or until six months. Most improvement occurs within six months but some may benefit from rehabilitation beyond this time.

To deliver these requirements for stroke rehabilitation there will need to be an expansion in community stroke services.

The National Stroke Strategy requires that all patients are seen at six weeks and six months after discharge, and annually thereafter. To develop services that can meet these requirements, and for patients to have access to further rehabilitation if required, is a big challenge for practice-based commissioners.

Secondary prevention
Secondary prevention to reduce the risk of recurrent stroke and other acute vascular events is a key role for general practice. Each patient should be assessed for modifiable risk factors for vascular disease.

The management of obesity in stroke patients is important. Preventing or treating obesity will help to improve a patient's mobility and/or manual handling requirements.

Aspirin 50-300mg daily and dipyridamole MR 200mg twice daily should be given as standard treatment following ischaemic stroke. Aspirin alone is suitable for those unable to tolerate dipyridamole. Clopidogrel is a suitable alternative for those with aspirin intolerance. A PPI can be given if there is risk of GI bleeding or side-effects.

Persistent or paroxysmal AF should be treated with anti-coagulation, if cerebral haemorrhage has been excluded, and started 14 days after ischaemic stroke. Antiplatelet treatment is not indicated for secondary prevention following haemorrhagic stroke.

Management of BP is essential and targets are largely borrowed from CHD guidelines. There are some who would advocate a 'the lower the better' BP, unless there is bilateral carotid artery stenosis. BP lowering should not be determined by quality framework audit thresholds of 150/90mmHg and treatment should try to seek to achieve lower levels. Beta-blockers should not be initiated for stroke prevention, but otherwise the choice of BP lowering agent is in line with the current guidelines.7

The use of statins in preventing further ischaemic strokes has been proven.8 There are concerns that lowering cholesterol too much is associated with a risk of haemorrhagic stroke. The guidelines for CHD for cholesterol reduction and statins apply.9


Fast tool
  • Facial weakness - can the person smile? Has their mouth or eye drooped?
  • Arm weakness - can the person raise both arms?
  • Speech disturbance - can the person speak clearly and can they understand what you say?
  • Test all three.

 

ABCD2 tool5
Symptom Score
Age >60 years1 point
BP >140/80mmHg1 point

Clinical (neurological deficit)
Hemiparesis
Speech problem without weakness


2 points
1 point
Duration
>60 minutes
10-60 minutes

2 points
1 point
Diabetes1 point
Maximal score is 7

- Dr Hosker is a GP in Manchester, clinical commissioning lead for falls and stroke, Manchester PCT and executive council member of the Primary Care Neurology Society and member of the Intercollegiate Stroke Working Party

References

1. NICE clinical guideline 68. Diagnosis and Initial Management of Acute Stroke and Transient Ischaemic Attack. London July 2008.

2. RCP. National Clinical Guideline for Stroke 3rd Edition. 2008.

3. Nor A, Davis J et al The recognition of stroke in the emergency room (ROSIER) scale. Lancet 2005; 4: 727-34.

4. NICE technical appraisal guidance 122. Alteplase for the treatment of acute ischaemic stroke. London June 2007.

5. Claiborne Johnston S, Rothwell P et al. Validation and refinement of scores to predict very early stroke risk after transient ischaemic attack. Lancet 2007; 369: 283-92.

6. Rothwell P, Giles M et al. Effect of urgent treatment of transient ischaemic attack and minor stroke on early recurrent stroke (EXPRESS study). Lancet 2007; 370: 1,432-42.

7. British Hypertension Society. Guidelines for Hypertension Management 2004

8. Amarenco P, Bogousslavsky J et al. The stroke prevention by aggressive reduction in cholesterol levels (SPARCL) trial. N Engl J Med 2006; 355: 549-59.

9. NICE Clinical Guideline 67. Lipid modification. London May 2008.

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