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

D Consensus; quality marker eight of National Stroke Strategy: ‘Patients with suspected
acute stroke receive an immediate structured clinical assessment from the right
people’.
4.5.3 Implications
Virtually all stroke patients now have a brain scan during their admission. However, often
this is not done as quickly as the recommendations suggest. There should not be an
increase in total scans performed but there may need to be a reorganisation of services to
allow for scanning to be performed urgently when indicated and ensure that all hospitals
admitting acute stroke patients have access to brain scanning 24 hours a day and 7 days a
week. All acute stroke patients should have their scan completed by the next day even
during weekends. There should be sufficient CT and MRI capacity to satisfy these
requirements, and it is primarily a matter of scheduling scans and running a service out
of hours for emergencies.
4.6 Immediate management of non-haemorrhagic stroke
4 Acute phase care
Thrombolysis for ischaemic stroke is becoming universally available in the UK. Treatment
with alteplase should only be given in units where staff are trained and experienced in the
provision of stroke thrombolysis, with a thorough knowledge of the contraindications to
treatment (which includes the prior use of all anticoagulants including the new oral
anticoagulants) and the management of complications such as neurological deterioration
and anaphylaxis.
Research has recently established that the existing licensed indications for alteplase
treatment should be widened. The IST3 trial and the linked Cochrane review have added
significantly to the understanding of when and to whom thrombolysis should be offered.
The results emphasise how critical it is that treatment is given as quickly as possible after
the onset of stroke. The benefits of treatment rapidly diminish with time and beyond 4.5
hours the benefits are unproven. Despite the higher risk of early (within 7 days) fatal and
non-fatal intracerebral haemorrhage with thrombolysis, mortality at 6 months is not
increased compared to patients who do not receive thrombolysis. The Cochrane review
shows that older patients benefit at least as much as those below the age of 80 years, so
there is no upper-age limit for treatment, particularly within the first 3 hours. Patients
with severe stroke and those with early signs of infarction on the initial scan also benefit
from treatment (as long as these early radiological signs are subtle and consistent with
the stated time of onset and do not suggest a lesion older than 6 hours). However, IST3
only recruited patients with a prestroke Oxford Handicap Score of less than 3, ie not
having a level of disability that significantly restricted activities of daily living. Great care
should therefore be taken in making the decision to thrombolyse a patient who has
significant prestroke comorbidity. Ongoing research may clarify the remaining
uncertainties regarding the ‘latest time for treatment benefit’ between 4.5 and 6 hours
after onset, and the role of advanced imaging to select patients up to 9 hours after onset.
A planned updated individual patient meta-analysis may also provide future additional
guidance.
© Royal College of Physicians 2012 45