national-clinical-guidelines-for-stroke-fourth-edition

National clinical guideline for stroke
4.5 Diagnosis of acute stroke
Stroke is a medical emergency and if outcomes are to be optimised there should be no
time delays in accessing treatment. Any person who arrives at hospital with an acute
onset neurological syndrome with persisting symptoms and signs (ie potential stroke)
needs full diagnosis to differentiate between acute cerebrovascular causes and others,
especially those such as hypoglycaemia or head injury needing other specific
treatments. Major reorganisation of stroke care has taken place over recent years in
some parts of the UK to improve access to acute stroke care. This should be for all
stroke patients and not just those who might be suitable for thrombolysis. There are
clear indications for immediate scanning. Even for those patients without these specific
indications, it has been shown that immediate scanning is the most cost-effective
strategy (Wardlaw et al 2004). It is also necessary to delineate the type of vascular event
as soon as is practicable because management and prognosis are determined by
aetiology (eg thrombosis, embolism and haemorrhage). The working party has reduced
the maximum time between admission and scanning to 12 hours to ensure that all
patients admitted out of hours are scanned at the latest during the following day.
Finally, any underlying causes such as heart disease, diabetes and hypertension need
diagnosis and management in their own right (these are not discussed further within
this guideline).
4.5.1 Recommendations
A Brain imaging should be performed immediately (ideally the next imaging slot and
definitely within 1 hour of admission, whichever is sooner) for people with acute
stroke if any of the following apply:
● indications for thrombolysis or early anticoagulation treatment
● 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.
B For all people with acute stroke without indications for immediate brain imaging,
scanning should be performed as soon as possible (at most within 12 hours of
admission).
C Patients with suspected stroke should be assessed for thrombolysis, receiving it if
clinically indicated and be admitted directly to a specialist acute stroke unit.
D All patients should have immediate access to a stroke physician to ensure patients get
access to appropriate medical interventions.
4.5.2 Sources
A National Institute for Health and Clinical Excellence 2008b, consistent with National
Institute for Health and Clinical Excellence 2010d
B National Institute for Health and Clinical Excellence 2008b; consensus
C National Institute for Health and Clinical Excellence 2010d; consensus
44 © Royal College of Physicians 2012