AuthorROYAL COLLEGE OF PHYSICIANS. Clinical Effectivenetss and Evaluation Unit. Intercollegiate Stroke Working Party
Title National clinical guidelines for stroke
Publisher
Royal College of Physicians, 2004
Summary
These guidelines cover the management of patients with acute stroke from onset, through rehabilitation, to the longer term.
Context
It is now proven beyond doubt that patients managed by a specialist co-ordinated stroke team in a stroke unit have lower mortality and morbidity. One major stimulus to develop these guidelines was the burden of stroke on the NHS, constituting over 4% of expenditure, the third highest cause of death in the UK and the biggest single cause of major disability. There was also concern that standards of service varied widely around the country, and that practice was often poor. This was confirmed by the Clinical Standards Advisory Group report (1998) and by the National Sentinel Audit of Stroke, which showed that less than half of all trusts have stroke units and that patients are managed better within stroke units. The challenge facing the NHS, social services and housing authorities is to translate known best practice into actual practice.
Contents
The publication consists of a folder containing four items: the detailed guidelines, a supplement containing tables of evidence, an information booklet for patients and carers on care after stroke and transient ischaemic attack (TIA), and a concise guide. The detailed guidelines have a foreword, notes on how to use them and on the patient and carer perspective, and a list of acronyms and abbreviations used in the guidelines and evidence tables.
Three major sections follow. An introduction consists of an introduction to the section and discussion of the scope of the guidelines; information on s troke, TIA and subarachnoid haemorrhage; the aims of the guidelines; context and use; the methodology of guidelines development (the Intercollegiate Stroke Working Party, searching the scientific literature, assessing the quality of research and writing the guidelines, evidence and lack of evidence, and peer review); format; terminology and theoretical framework; participation in clinical research; cost of stroke care; licensing of drugs; updating the guidelines; and funding and conflicts of interest.
The second section is on service provision, and covers s ervice organisation, spe cialist stroke services (provision, the specialist team, and services for management of patients with acute stroke: hospital or home?); stroke services for younger people; patients and carers (patient and carer education, and carers and families); organisation of and approaches to rehabilitation (use of assessments/measures, goal-setting, the underlying approach to rehabilitation, and contact with therapists); palliative care; and service evaluation (organisational and clinical audit, and patient and carer opinions).
The third section is about clinical care and is sub-divided into three parts . The first, on acute management, considers d iagnosis and investigations (investigation and management of patients with TIA, and investigation of acute stroke); immediate (medical/surgical/nursing/therapy) interventions for stroke (initial screening and monitoring, and general interventions); management of acute ischaemic stroke (thrombolysis, anti-thrombotic treatment, and other drug treatment); management of specific diagnoses (primary intracerebral haemorrhage, hydrocephalus and cerebral oedema, cerebral venous thrombosis, cervical arterial dissection, and subarachnoid haemorrhage); secondary prevention (lifestyle, blood pressure, anti-thrombotic treatment, antilipid agents, hormone replacement therapy, carotoid stenosis, and concordance with secondary prevention strategies); multidisciplinary assessment: rehabilitation referral; swallowing, feeding and nutrition: assessment and management of dysphagia and nutrition; p revention of complications (positioning and support interventions, and venous thromboembolism); and bladder and bowel management. The second part, about r ehabilitation, discusses p sychological impairment (mood disturbance: depression, emotionalism, anxiety); cognitive impairment (general guidelines for all cognitive impairments, spatial awareness (neglect/inattention), memory, attention, praxis, and executive function); communications (aphasia, dysarthria and articulatory dyspraxia); motor impairment (improving motor control: conventional treatment, biofeedback, functional electrical stimulation, treadmill training, strength and aerobic training, robot-assisted therapy, orthotics including splinting and casting, management of spasticity, and constraint-induced movement therapy); sensory impairment and pain (sensory disturbance: controlling pain after stroke, shoulder pain, sensory stimulation: acupuncture and transcutaneous electrical nerve stimulation); drugs reducing impairment; and functional rehabilitation interventions (activities of daily living, and equipment and adaptions); and personal aids and environment.
The third and final part is on transfer to the community and covers d ischarge planning and long-term management (further rehabilitation, prevention of further stroke, and social function). Appendices list peer reviewers, recommended indicators for audit of stroke, and useful addresses. The guidelines end with references and an index. The tables of evidence in the supplement list most of the evidence collected and collated to inform the g uidelines . Each table is set out in a consistent order: the meta-analyses and systematic reviews are placed first followed by the single trials and observational studies in date order. Each table gives a reference, a brief description of the sample and the design, a brief description of the intervention, the outcome measures used and a brief conclusion. They include o rganisation of stroke care: specialised services and early discharge to community services; use of day hospitals/domiciliary rehabilitation; organisation of stroke care: other relevant studies; use of protocols; staff training; acute home care; effects of stroke on younger people (under 65); information giving and patient education; stress on carers; social support interventions for patients and carers; assessment; goal-setting in rehabilitation; therapeutic approaches; intensity of therapy input; accuracy of diagnosis and classification; outcome measures; service audit/evaluation/comparison; patients' opinion surveys; TIA; diagnosis of stroke; screening for dysphagia after stroke; general interventions in the acute phase; thrombolysis; antiplatelets and anticoagulants in the acute phase; neuroprotectors; centrally acting drugs; surgery for intracerebral haemorrhage; treatment of cerebral oedema; management of cerebral venous thrombosis and of extracranial arterial dissection; subarachnoid haemorrhage: drug treatments and surgical management; secondary prevention after stroke: lifestyle, antihypertensive therapy, antiplatelet agents and anticoagulants, antilipid agents, and hormone replacement therapy; carotid artery surgery; concordance with medication; multidisciplinary assessment: rehabilitation referral; assessment of swallowing after stroke; dysphagia natural history and management; nutrition after stroke; prevention of complications: positioning and support interventions, and venous thromboembolism; bladder and bowel management; epidemiology and treatment of depression after stroke; treating emotionalism; cognitive rehabilitation for neglect, memory, impaired attention, apraxia, and executive functioning; management of aphasia; improving motor control: conventional treatments - arm movement/function and walking ability, walking aids - and biofeedback, functional electrical stimulation, treadmill training, strength and aerobic training, robotic-assisted therapy, and orthotics; spasticity; botulinum toxin and spasticity; constraint-induced movement therapy; sensory impairment, post-stroke pain, and neuropathic/post-stroke pain; shoulder pain; studies on TENS and acupuncture; drugs directly reducing impairment/disability; activities of daily living; equipment and adaptations (personal aids and environment); discharge planning; late rehabilitation after stroke; and social function, ending with late additions. R eaders are recommended to read the original references for more detail. The booklet explains who it is for and what it covers; what a stroke or a TIA is; how stroke care is organised, including services for younger people with stroke; ho w to recognise a TIA or stroke; and what treatment one should have after a TIA or a stroke. It includes information on a lertness and ability to think, swallowing and eating, preventing complications, w hat to expect from rehabilitation, m oving and walking, speaking, writing and understanding, bladder and bowel control, the senses, getting back to a normal life, emotional and psychological effects of stroke, h ow to prevent further stroke or TIA, the long term, help for friends and family have when one goes home, useful organisations (l ocal health services, social services, and financial help and advice), and voluntary and support groups including t he Stroke Association, Different Strokes (an organisation for younger people who have had strokes), Connect - the Communication Disability Network, Speakability (a national charity supporting aphasia sufferers and their carers), local stroke clubs and carer groups, ending with addresses and telephone numbers.
Conclusion
The concise guide summarises the recommendations, graded according to the evidence. Services should be organised so that patients are admitted under the care of a specialist team for acute care and rehabilitation; services should have a geographically identified unit as part of the in-patient service, a coordinated multidisciplinary team that meets at least once a week, staff with specialist expertise in stroke and rehabilitation, educational programmes for staff, patients and carers, agreed protocols for common problems, and access to brain and vascular imaging services; any patient with persistent symptoms should be rapidly referred to hospital with the expectation of admission to a stroke unit; hospitals offering thrombolysis to patients after ischaemic stroke, outside a trial, should only do so after specialist staff training and registration with the UK Safe Implementation of Thrombolysis in Stroke Monitoring Study (SITS-MOST) programme; specialist stroke services should be available in the community as part of an integrated system of care to facilitate early supported discharge; services must recognise the particular physical, psychological and social needs of younger patients with stroke; all staff providing palliative care for patients after stroke should be trained in palliative care; information should be freely available to patients and their families in a variety of languages and formats appropriate to patient needs and impairments; stroke services must be alert to the likely strain on carers, specifically recognising the stress associated with 'hidden' impairments such as cognitive loss, incontinence, and irritability; and plans for service developments should take account of the opinions of patients and carers.
Patients with TIA, or those with stroke who have made a good immediate recovery, should be assessed and investigated in a specialist service (e.g. a neurovascular clinic) as soon as possible within seven days of the incident; patients likely to have a diagnosis of TIA should be prescribed aspirin (300 mg daily), or alternative antiplatelet regime, immediately; patients with more than one TIA in a week should be investigated in hospital immediately; and risk factors for cerebrovascular disease such as severe hypertension should be treated appropriately or the patient referred for specialist management. Under assessment of acute stroke come the recommendations: brain imaging should be undertaken as soon as possible in all patients, at least within 24 hours of onset, and as a matter of urgency if the patient has been having anticoagulant treatment, a known bleeding tendency, a depressed level of consciousness, unexplained progressive or fluctuating symptoms, papilloedema, neck stiffness or fever, severe headache at onset, or indications for thrombolysis or early anticoagulation; the diagnosis should always be reviewed by an experienced clinician with expertise in stroke; if the underlying pathology is uncertain, or the diagnosis of stroke is in doubt after computed tomography scan, magnetic resonance imaging should be considered; and the patient should be assessed on admission for risk of aspiration, using a validated 50 ml water swallow screening tool, administered by an appropriately trained professional; and needs in relation to moving and handling, and their risk of developing pressure sores should be assessed. Subarachnoid haemorrhage should be considered in any patient presenting with sudden onset, or severe and unusual headache, with or without any associated alteration in consciousness. All patients with suspected subarachnoid haemorrhage, irrespective of age or clinical grade, should be discussed with a neurosurgeon immediately.
Recommendations on acute interventions are: blood glucose, arterial oxygen concentration, hydration and temperature should be maintained within normal limits; blood pressure should only be lowered in the acute phase where there are likely to be complications from hypertension, e.g. hypertensive encephalopathy, or aortic aneurysm with renal involvement; patients should be mobilised as soon as possible; and aspirin (300 mg) orally or rectally should be given as soon as possible after the onset of stroke symptoms if a diagnosis of primary haemorrhage has been excluded. Rehabilitation recommendations begin with the c ore principles: a ll patients should be referred to a specialist rehabilitation team as soon as possible after admission; all members of the healthcare team should work together with the patient, carer and family, using a shared philosophy and common goals; patients should undergo as much therapy appropriate to their needs as they are willing and able to tolerate; and the team should promote integrating the practice of skills gained in therapy into the patient's daily routine in a consistent manner.
Regarding assessment: patients should be screened for depression and anxiety within the first month of stroke, and their mood kept under review; all patients should be screened for the presence of cognitive impairments as soon as practicable; patients with aphasia should be assessed by a speech and language therapist as to their suitability for intensive speech and language therapy; a physiotherapist with expertise in neuro-disability should coordinate therapy to improve movement performance; all patients with difficulties in activities of daily living should be assessed by an occupational therapist with specialist knowledge in neurological rehabilitation; every patient, at home or leaving hospital, should be assessed fully to determine whether equipment or adaptations could increase safety or independence; and all patients with stroke should be routinely assessed as to whether pain is a significant problem and be referred to a specialist service if necessary.
General management recommendations are: patients with dysphagia should be managed by a trained specialist and receive advice on safe swallowing techniques; nutritional and hydration support should be considered for any patient with malnutrition or difficulties feeding; bowel and bladder function should be monitored and actively managed from admission; the patient's cognitive status should be considered when planning and delivering treatment; and early hospital discharge (before the end of acute rehabilitation) should only be undertaken if there is a specialist stroke rehabilitation team in the community. Under secondary prevention: an individualised strategy for prevention should be implemented within a maximum of seven days of acute stroke or TIA; all patients should be given appropriate advice on lifestyle factors; high blood pressure persisting for over two weeks should be treated; further reduction of blood pressure should be undertaken using a thiazide diuretic or an angiotensin-converting enzyme inhibitor or preferably a combination of both, unless there are contraindications; all patients with ischaemic stroke or TIA who are not on anticoagulation should be taking an antiplatelet agent, i.e. aspirin (50-300 mg) daily, or clopidogrel, or a combination of lowdose aspirin and dipyridamole modified release (MR).
Where patients are aspirin intolerant, an alternative antiplatelet agent (e.g. clopidogrel 75 mg daily or dipyridamole MR 200 mg twice daily) should be used; anticoagulation should be started in every patient with persistent or paroxysmal atrial fibrillation (valvular or non-valvular) unless contraindicated; anticoagulants should not be started until brain imaging has excluded haemorrhage, and usually not until 14 days have passed from the onset of an ischaemic stroke; treatment with a statin should be given to patients with ischaemic stroke or TIA, and total cholesterol of >3.5 mmol/L unless contraindicated; any patient with a carotid artery territory stroke, without severe disability, should be considered for carotid endarterectomy; and carotid endarterectomy should be performed as soon as the patient is fit for surgery, preferably within two weeks of TIA.
Longer-term management recommendations are: hospital services should have a protocol to ensure that: patients and families are involved in plans for transfer to the community; all necessary equipment and support services are in place; any continuing treatment starts without delay; and patients are given information about local services; patients should continue to have access to specialist stroke care and rehabilitation after leaving hospital; patients and their carers should have their individual psychosocial and support needs reviewed on a regular basis; any patient with reduced activity at six months or later after stroke should be assessed for a further period of targeted rehabilitation; and independence should be encouraged and, as patients become more active, consideration should be given to withdrawal of physical and psychological support, enteral tubes, cessation of therapy, and withdrawal of personal care support. A section on participation in clinical research states that there are many areas of stroke care where the evidence base is weak and that even where recommendations are given top grade there may well be justification for further research. Stroke teams should participate in well-conducted multi-centre trials in order to advance scientific knowledge and help lay the foundations for future improvements in the quality of stroke care. The concise guide ends with notes on gu ideline strength: level of evidence and grade of recommendation.
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