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

National clinical guideline for stroke
4.6.1 Recommendations
A Any patient, regardless of age or stroke severity, where treatment can be started within
3 hours of known symptom onset and who has been shown not to have an
intracerebral haemorrhage or other contraindications should be considered for
treatment using alteplase.
B Between 3 and 4.5 hours of known stroke symptom onset, patients under 80 years
who have been shown not to have an intracerebral haemorrhage or other
contraindication, should be considered for treatment with alteplase.
C Between 3 and 6 hours of known stroke symptom onset, patients should be
considered for treatment with alteplase on an individual basis, recognising that the
benefits of treatment are likely to be smaller than those treated earlier, but that the
risks of a worse outcome, including death, will on average not be increased.
D Alteplase should only be administered within a well-organised stroke service with:
● staff trained in the delivery of thrombolysis and monitoring for post-thrombolysis
complications
● nurse staffing levels equivalent to those required in level 1 or level 2 nursing care
with staff trained in acute stroke and thrombolysis
● immediate access to imaging and re-imaging, and staff appropriately trained to
interpret the images
● processes throughout the emergency care pathway for the minimisation of inhospital
delays to treatment, to ensure that thrombolysis is administered as soon as
possible after stroke onset
● protocols in place for the management of post-thrombolysis complications.
E Emergency medical staff, if appropriately trained and supported, can administer
alteplase for the treatment of acute ischaemic stroke provided that patients can be
managed within an acute service with appropriate neuroradiological and stroke
physician support.
F Intra-arterial interventions should only be used in the context of a clinical trial.
G Perfusion scanning, eg to determine suitability for thrombolysis in patients where
time of onset is unknown or where the patient presents beyond 4.5 hours, should
only be used in the context of research trials.
H Every patient treated with thrombolysis should be started on an antiplatelet after 24
hours, unless contraindicated (eg after significant haemorrhage has been excluded).
I All people presenting with acute stroke who have had the diagnosis of primary
intracerebral haemorrhage excluded by brain imaging should, as soon as possible but
certainly within 24 hours, be given:
● an antiplatelet orally if they are not dysphagic
● an antiplatelet rectally or by enteral tube if they are dysphagic.
● Thereafter aspirin 300 mg should be continued until 2 weeks after the onset of
stroke, at which time definitive long-term antithrombotic treatment should be
initiated. People being discharged before 2 weeks can be started on long-term
treatments earlier.
J Any person with acute ischaemic stroke for whom previous dyspepsia associated
with an antiplatelet is reported should be given a proton pump inhibitor in addition
to aspirin.
46 © Royal College of Physicians 2012