Clinical Guidelines for Acute Stroke Management - Living on the EDge

A notification system between emergency medical
services staff, emergency department staff and the
stroke team has also been found to reduce
intrahospital delays and improve patient related
outcomes (those benefiting from receiving
thrombolysis).
39, 83-85
> One non-randomised study reported benefits from
a process of reorganisation of services that included
establishing a nurse led triage team specifically <strong>for</strong>
neurological patients, improved prenotification by
ambulance staff of patients eligible <strong>for</strong> rt-PA, and
introducing a small CT unit within the emergency
department <strong>for</strong> priority imaging. 85 While the
proximity of the CT unit was seen as a key
component in this study it is optimistic to consider
this a feasible strategy <strong>for</strong> most departments.
> Education of emergency department staff has
also been undertaken as part of a multidimensional
strategy with improvements noted in processes
of care (<strong>for</strong> example, reduced delays to CT and
increased numbers receiving thrombolysis). 39, 81, 82 19
3.2 TRIAGE IN EMERGENCY DEPARTMENT GRADE LEVEL
a) Diagnosis should be reviewed by a clinician experienced in the valuation C Level III-3
of stroke.
108, 111
b) Emergency department staff should use a validated stroke screen tool to C Level II 112
assist in rapid accurate assessment <strong>for</strong> all people with stroke.
c) Local protocols developed jointly by staff from pre hospital emergency D Level III-3 &
services, the hospital emergency department and the stroke unit should be IV
39, 83, 85
used <strong>for</strong> all people with suspected stroke. Such protocols should include
early notification by paramedic staff, high priority transportation and triage,
rapid referrals from ED staff to stroke specialists and rapid access to
imaging.
3.3 Imaging
A. Brain imaging
<strong>Stroke</strong> and TIA are clinical diagnoses with brain
imaging available to confirm cerebral ischaemia or
haemorrhage and exclude stroke mimics. One robust
systematic review reported the most cost effective
strategy in acute stroke is <strong>for</strong> all patients to undergo
immediate imaging. 100 Recent studies have found that
MRI is more sensitive than CT <strong>for</strong> ischaemic changes
and is as sensitive as CT in identifying acute
haemorrhagic change. 114, 115 CT is sensitive to ICH in
the acute phase but not after 8-10 days when MRI
should be used to differentiate ICH and ischaemic
stroke. 100 Thus to confirm diagnosis and differentiate
ICH from ischaemic stroke, MRI is now considered the
imaging strategy of choice. Consideration of several
factors including longer imaging time and limited
availability of MRI scanners in many centres compared
to CT, however, limits the application of MRI as a
routine strategy and it is likely that CT will remain
the imaging modality of first choice <strong>for</strong> the
<strong>for</strong>eseeable future.
B. Carotid Imaging
In patients with carotid territory symptoms and where
a large artery disease is suspected, carotid imaging
studies should be per<strong>for</strong>med. A recent robust
systematic review comparing non invasive tests to
conventional intra arterial angiography found that non
invasive methods provide good accuracy, in particular
contrast enhanced magnetic resonance angiography
(CEMRA), in patients with 70-99% stenosis. Other
methods (Doppler ultrasound, Magnetic Resonance
angiography, Computed Tomography Angiography)
were found to be less accurate than CEMRA but still
reasonably good with CTA found to have the lowest
accuracy. 102 It was noted that CEMRA is a relatively
new test and not all patients would have access to
Section 3 Early Assessment and Diagnosis