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NHS FORTH VALLEY

Acute Stroke Guideline

Date of First Issue


26/03/2012
Approved
01/11/2011
Current Issue Date
09/04/2014
Review Date
09/04/2016
Version
2.10
EQIA
Yes
26/03/2012
Author / Contact
Dr Anthony Byrne
Group Committee Drug & Therapeutics Committee
Final Approval
This document can, on request, be made available in alternative formats

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Consultation and Change Record


Contributing Authors:

Dr A. Byrne, Dr A. Grant, Dr A. McKenzie, Dr L. Fielden,


Claire Fraser (Speech & Language Therapist)

Consultation Process:

Prof Malcolm MacLeod (Clinical Lead Neurological Conditions MCN)


Isabel Devoy (Charge Nurse, Stroke Unit)
Amanda Smart (Stroke Nurse)
Caroline Mcghee (Stroke Research Nurse)
Anne Marie Irving (Speech & Language Therapy Co-ordinator)
Morag Ogilvie (Dietician)
Vicky Hough (Senior Pharmacist)
Acute Drugs and Therapeutics Committee
Quality Improvement Website

Distribution:

Clinical Leads Emergency Department, Clinical Assessment Unit, Acute


Admissions Unit
Senior Charge Nurses
Patient Flow Co-ordinators

Change Record

Date

Author

Change

Version

Feb 2014

AWB

Update - Brain Imaging

2.10

Feb 2014

AWB

Update - DVT Prophylaxis IPC Stockings

2.10

Feb 2014

AWB

Update - Addition of novel anticoagulant drugs

2.10

Feb 2014

CF/AWB

Update Swallow screening

2.10

Feb 2014

AWB

Addition - Scottish Stroke Care Audit

2.10

Feb 2014

AWB

Addition Stroke Bundle Sticker

2.10

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FOREWORD
This guideline is intended to summarize treatment of acute stroke during the initial phases of
diagnosis, investigation and management (i.e. the first few hours to days). They are to support
non-specialist staff prior to the patient being admitted to the Stroke Unit.
More comprehensive guidelines exist and can be accessed online e.g. SIGN guideline 108, NICE.
This guidance is not intended to serve as a standard of medical care or be applicable in every
situation. Decisions regarding the treatment of individual patients must be made by the clinician in
light of that patients presenting clinical condition and with reference to current good medical
practice.
Subarachnoid haemorrhage, subdural and extradural haemorrhage are not dealt with in this
document as they do not fall under the remit of stroke disease.

National Guidelines for further reference.


Scottish Intercollegiate Guidelines Network (SIGN)
SIGN 108: Management of patients with stroke or TIA: assessment, investigation,
immediate management and secondary prevention. December 2008.
URL - http://www.sign.ac.uk/pdf/sign108.pdf
National Institute for Clinical Excellence (NICE)
Stroke: National clinical guideline for diagnosis and initial management of acute stroke and
transient ischaemic attack (TIA). July 2008.
URL - http://guidance.nice.org.uk/nicemedia/live/12018/41363/41363.pdf
Where reference is made to drug therapy, further information on indications, cautions, contraindications, side-effects and dosing can be obtained from the British National Formulary (BNF).
Website links are current at time of publication. These may change over time. Appropriate search
on the FV intranet should find updated internal guidelines and internet search for external
websites.

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Section 1: Acute Management of suspected Stroke


1.1

Acute Assessment

Airway

Maintain airway. Airway obstruction is usually due to reduced conscious level or


aspiration in this setting. Consider simple airway opening manoeuvres, airways
suction and insertion of an oropharyngeal or nasopharyngeal airway. Tracheal
intubation if clinically appropriate.

Breathing

Assess oxygen saturation and respiratory rate. Maintain oxygen saturations


94%-98%. In patients at risk of hypercapnic respiratory failure the target is 8892%. In such patients obtain an arterial blood gas on oxygen therapy (NB: Do not
perform arterial puncture if considering thrombolysis).

Circulation

Assess blood pressure and pulse. Avoid wide fluctuations in blood pressure.
Commence IV fluids in hypovolaemic or drowsy patients and in those nil by mouth.
If IV access cannot be obtained and central venous access is inappropriate, then
subcutaneous fluids can be used to maintain plasma osmolality.
Avoid dextrose in the early post-stroke phase to avoid iatrogenic hyperglycaemia.

Disability

Assess Glasgow Coma Scale.


If GCS <13 consider emergency CT brain scan (see 1.4).

D (Dextrose)

EXCLUDE HYPOGLYCAEMIA AS THE CAUSE OF NEUROLOGICAL DEFICIT


Check rapid blood glucose with finger-prick testing.
If below 4.0 mmol-1 give repeated doses of 50ml 10% glucose solution until
corrected. Reassess the neurological deficit once blood glucose is corrected. If the
neurological deficit resolves rapidly, the neurological deficit is more likely
hypoglycaemia induced rather than due to stroke.
If nil by mouth and type I diabetic, commence insulin sliding scale
(See section 2.1.6).

Monitor temperature. If temperature exceeds >37.5oC commence regular paracetamol.


Intracerebral events may induce pyrexia, however, a possible infective source
should be considered. Take cultures, identify source and commence antibiotics as
appropriate (adapted from SIGN)

Exposure

Full clinical assessment: History & Examination.

Cognitive
Function

Calculate an Abbreviated Mental Test (AMT)


Note the presence or absence of delirium if possible (e.g. CAM score or 4AT).

1.2

Immediate investigations

Obtain blood for FBC, U&E, LFT, CRP, glucose, cholesterol, ESR & clotting screen.
Perform 12 lead ECG, in particular looking for the presence or absence of atrial fibrillation.
Request Chest X-ray
Request a CT brain scan (see section 1.4)

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1.3

Swallow Screen

All patients with suspected stroke should be screened to identify any difficulty in
swallowing. This will be carried out before giving any food, drink or oral
medication and within 6 hours of admission (NICE).

Results will be clearly documented in the unified case notes using the stroke
bundle sticker or water swallow test paperwork. If a patient is not sufficiently alert to
cooperate with screening note this as a Fail and document clearly that screening has
been commenced.

If the patient fails, the screening will be repeated on a 12-hourly basis until 48 hours
post-stroke. If the patient is kept nil-by-mouth
o Commence full oral hygiene
o IV fluids to maintain hydration
o Identify clinically essential medicines and consider alternative routes for
administration (e.g. rectal aspirin, intravenous digoxin).

Patients who fail the water swallow test should be discussed with the Speech and
Language therapist and a dietician.

Refer to full guidance for swallow screening

http://www.nhsforthvalley.com/__documents/qi/ce_guideline_nursing/swallow-screening-foradults-with-suspected-dysphagia-clinical-care-standards.pdf

1.4

CT Brain Imaging

Antiplatelet agents/Anticoagulants should be withheld while awaiting brain imaging.


Indications for Immediate Scanning:

Potential candidate for thrombolytic therapy (refer immediately to thrombolysis protocol)


On anticoagulant therapy (e.g. warfarin, heparin or novel oral anticoagulant agents e.g.
rivaroxaban, dabigatran, apixaban)
Known bleeding tendency
Reduced level of consciousness (GCS <13, where level of consciousness diminished
rather than lone dysphasia)
Unexplained progressive or fluctuating symptoms
Papilloedema, neck stiffness or fever
Severe headache at onset of stroke symptoms

For all other patients with suspected stroke or TIA:

Efforts should be made to scan the patient on the day of the admission if this can be done.
If presenting out-of-hours and no immediate indication (as above), a CT brain should be
requested for the following morning by the admitting doctor.
CT brain scan should be performed within 24 hours of hospital admission.
Confirm in the patients case-notes that a CT scan has been requested. This should help to
avoid duplicate requests and risk of unnecessary ionising radiation exposure.
The result of the scan should be reviewed at the earliest opportunity and recorded in the
patients case notes.
Appropriate action should then be taken as soon as possible (e.g. administering aspirin if
ischaemic stroke, discussion with neurosurgery if appropriate etc.).

It is the responsibility of the person requesting the CT brain scan to ensure the report is
reviewed or that appropriate handover of this responsibility is made to the next shift or
ward to which the patients is transferred in order that the above actions be carried out.
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1.5

Immediate Management Post-Imaging

If brain imaging has excluded an intracerebral haemorrhage or complicating structural CNS lesion
(e.g. tumour, abscess);

1.6

Prescribe aspirin 300mg stat immediately.


If unable to swallow, prescribe rectally or by enteral tube. (SIGN)
Aspirin 300mg should be prescribed for 14 days on the drug prescription sheet.
If aspirin allergic/intolerant:
Give a loading dose of clopidogrel 300mg then continue clopidogrel 75mg daily.

Admission to the Stroke Unit

Organised Stroke Unit care has been shown to improve functional outcome and reduce
mortality in patients with stroke.

SIGN Grade A recommendation


o Stroke patients requiring admission to hospital should be admitted to a
stroke unit staffed by a coordinated multidisciplinary team with a special
interest in stroke care.

The importance of this is recognised by the Scottish Government who set a HEAT
target regarding patients with stroke being treated promptly in a Stroke Unit.

After initial work-up in the Emergency Department, Clinical Assessment Unit or Acute
Admissions Unit, patients with stroke or TIA should be transferred to the Stroke Unit.

This should be facilitated early through the Patient Flow Co-ordinators, Stroke Unit and
Stroke Team.

Referral to the Stroke Team should be made. The preferred method of referral may be
updated more frequently than these guidelines. The most up-to-date advice on referral
will be available in CAU/AAU/ED.

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1.7

Stroke Bundle Sticker

STROKE BUNDLE

For all patients admitted with suspected stroke

SWALLOW SCREENING

Date:

Time:

:
Initials

Please refer to NHS FV Swallow Screening Procedure and record detailed result on form

Pass

Fail

BRAIN IMAGING
/

Time:

/
:

CT
Scan Performed

Request to Radiology
Date:

Too drowsy to test

Date:
h

Time:

/
h

MRI
Report reviewed
/

Time:

Initials

ASPIRIN

Date:

/
:

Initials
(record time aspirin given)

Date:

Time:

If no haemorrhage on imaging and no other contra-indication, prescribe & administer ASPIRIN 300mg stat
and regular ASPIRIN 300mg daily. DO NOT routinely prescribe prophylactic LMWH.

ACCESS TO STROKE UNIT

HEAT Target

Liaise with Flow Co-ordinator and Stroke Nurse or Unit to arrange transfer if clinically stable and appropriate to do so

Admitted to
Stroke Unit

Date:

Time:

Initials

The Stroke Bundle Sticker is available in the acute front door areas the Emergency
Department, the Clinical Assessment Unit and the Acute Admissions Unit in addition to the
Stroke Unit. If a patient is suspected of having a stroke or TIA then place a sticker in their notes
to prompt actions and record times. If the subsequent diagnosis is not stroke or TIA then simply
document this in the notes rather than remove the sticker.
The information above is used for the Scottish Stroke Care Audit to monitor services and
improve patient care (see Section 7).

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Section 2: Ischaemic Stroke Management


2.1

Pharmacological Therapy

2.1.1 Antiplatelet therapy

Patients prescribed aspirin 300mg should continue on this for 14 days then change to
clopidogrel 75mg for long term secondary prevention. (NICE update 2010).

Patients initially prescribed clopidogrel (300mg loading dose then 75mg daily) should
continue on the clopidogrel.

Review any proton pump inhibitor (PPI) therapy. There


omeprazole/esomeprazole may reduce the efficacy of clopidogrel:
-

is

evidence

that

stop PPI if no longer indicated and no ongoing gastric protection required.


or

change to lansoprazole if a PPI is specifically required or use an H2-antagonist


(e.g. ranitidine).

If unable to take clopidogrel for long term therapy, aspirin 75mg PLUS dipyridamole
retard 200mg BD is the preferred option.

If both aspirin and clopidogrel intolerant, dipyridamole retard 200mg BD as a single


agent can be prescribed.

2.1.2 Anticoagulant therapy (warfarin, heparin or novel oral anticoagulants)

Anticoagulant therapy should not be used routinely in the acute ischaemic stroke
setting (SIGN, NICE).

The administration of anticoagulants is contraindicated during the first 24 hours after


thrombolytic therapy.

Patients with non-valvular atrial fibrillation or paroxysmal atrial fibrillation should be


considered for anticoagulant therapy. Assessment should be made of the potential
benefits and risks of anticoagulant therapy on an individual patient basis. Tools such as
the CHA 2 DS 2 -VASc score and HAS-BLED score may be used to assist this process.

Anticoagulation with warfarin can be introduced early in patients with minor stroke or TIA
(SIGN), but should be deferred for two weeks after onset in those with major stroke
(SIGN, NICE). Target INR is 2.0-3.0. Antiplatelet therapy (as in section 2.1.1) should be
used in the interim.

Novel oral anticoagulant agents (rivaroxaban, dabigatran, apixaban) can be


considered for use as an alternative to warfarin. Refer to the specific guidance in the
Haematology section of Acute Clinical Guidelines on the NHS Forth Valley intranet for
information appropriate use and patient selection.
http://www.qifv.scot.nhs.uk/CE_Guidance.asp?topic=Acute%20Clinical

Anticoagulation is not recommended for preventing recurrent stroke in patients with


non-cardioembolic ischaemic stroke.

In people with prosthetic heart valves who have disabling cerebral infarction and who
are at significant risk of haemorrhagic transformation, anticoagulation treatment should
be stopped for 1 week and aspirin 300 mg substituted (NICE). Such patients should be
discussed with the cardiologist at the earliest opportunity.

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2.1.2 Anticoagulant therapy

(continued)

Patients with ischaemic stroke and symptomatic proximal deep vein thrombosis or
pulmonary embolism should receive anticoagulation treatment in preference to
treatment with aspirin unless there are other contraindications to anticoagulation (NICE).

People with haemorrhagic stroke and symptomatic deep vein thrombosis or pulmonary
embolism should have treatment to prevent the development of further pulmonary
emboli. Each patient should be considered on an individual basis. Treatment options
include an inferior vena caval filter or anticoagulation.

2.1.3 DVT/PE Thromboprophylaxis

The administration of anticoagulants is contraindicated during the first 24 hours after


thrombolytic therapy.

Anti-embolic (TED) stockings are not recommended for thromboprophylaxis after stroke
(CLOTS-1 and CLOTS-2 trials).

Intermittent Pneumatic Compression (IPC) has been shown to significantly reduce the
risk of DVT and improve overall survival to 6 months (CLOTS-3 trial). IPC can be used in
patients with ischaemic or haemorrhagic stroke and should be used as soon as is
feasible after admission and definitely within the first three days.
o

Which patients should be treated with IPC?


Patients for active treatment (e.g. not simply for palliation)
Immobile patients (unable to walk independently to the toilet)
Willing to wear the compression sleeves
Those not suffering from contra-indications to IPC
Severe congestive heart failure
Severe skin problems on their legs
Severe peripheral vascular disease

How long should treatment continue?


IPC should be taken off (whichever comes first)
When the patient becomes independently mobile
At discharge from hospital
If the patient develops any adverse effects
After 30 days of use
Sending patients home or to nursing home with the equipment is not
recommended.
This follows the CLOTS-3 trial protocol.

After 30 days the responsible clinical team should assess the patient for appropriate DVT
prophylaxis.

Regularly review the need for thromboprophylaxis (both the need to commence therapy
or to discontinue therapy when no longer appropriate).

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2.1.4 Antihypertensive therapy (acute phase)


Do not lower blood pressure routinely in acute stroke (SIGN and NICE)

There is no evidence of benefit in treating hypertension in ischaemic stroke acutely and


there is some evidence suggesting potential harm.

Avoid fluctuations in blood pressure


If able to swallow and no other contra-indication, continue any usual blood pressure
medication, unless there is good evidence that the patient has not been complying with
anti-hypertensive medication pre-admission.
Consider lowering blood pressure acutely only with the following serious concomitant
medical issues (NICE)

Hypertensive encephalopathy
Hypertensive nephropathy
Hypertensive cardiac failure/myocardial infarction
Aortic dissection
Pre-eclampsia or eclampsia
Intracerebral haemorrhage with systolic blood pressure 200 mmHg
or
The patient may be considered for blood pressure lowering medication if a potential
candidate for thrombolysis and BP is >185/110, however, this is at the discretion of the oncall stroke specialist.

2.1.5 Statins

A statin should be prescribed to patients who have had an ischaemic stroke,


irrespective
of cholesterol level (SIGN). Cholesterol level should still be checked on admission and
caution exercised if the cholesterol level is low.

Patients with ischaemic stroke on prior statin therapy should continue treatment, via a
nasogastric tube, if necessary.

SIGN recommends using simvastatin 40mg or atorvastatin 80mg based on the Heart
Protection Study (HPS) and SPARCL trial respectively.

Patients not currently prescribed a statin would usually receive simvastatin 40mg.
Following clinical risk assessment by a stroke consultant atorvastatin 80mg may be
recommended.

Statin therapy following haemorrhagic stroke is not recommended routinely unless


the risk of further ischaemic vascular events outweighs the risk of further haemorrhage.

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2.1.6 Hyperglycaemia/Diabetes treatment


Hyperglycaemia in stroke

Diabetic patients on insulin who are unable to swallow (or in whom there is concern about
ability to maintain adequate oral intake) should be commenced on an IV sliding scale
insulin regimen.

Care should be taken not to cause hypoglycaemia with such regimes and a glucose
of 7mmol/l is acceptable as the minimum level. The insulin dosing for the sliding
scale may have to be adjusted to avoid glucose levels below this.

Routine use of intravenous insulin regimens to lower blood glucose in patients with
moderate hyperglycaemia after acute stroke is not recommended as there is no trial
evidence yet of benefit and a significant demonstrated risk of inducing hypoglycaemia.

Advice should be sought from the diabetic specialist team if there is continued concern
about glycaemic control.

A random glucose >6.0mmol/l should be further assessed to exclude or confirm a diagnosis


of impaired glucose tolerance or diabetes.

Hypoglycaemia in stroke

2.2

Hypoglycaemia should be avoided and a blood glucose minimum of 7mmol/l is acceptable.


Hypoglycaemia should be managed as per the usual local protocol.

Further investigation

2.2.1 Further brain imaging

Consider if there is an otherwise UNEXPLAINED DETERIORATION in the patients


condition (to exclude complications such as hydrocephalus or haemorrhagic transformation
of infarct) and when repeat imaging will influence further management.

Clinical deterioration following stroke may be related to intercurrent infection so this must
also be considered.

Routine follow up scanning is required after THROMBOLYTIC THERAPY for acute


ischaemic stroke. This should usually be performed around 24 hours from treatment but
can be done at an appropriate time earlier or later if treated out-of-hours. Emergency
scanning following thrombolysis should be done if there is a neurological deterioration
raising suspicion of intracerebral haemorrhage. See thrombolysis protocols.

Further imaging with CT angiogram, MRI brain or MR angiogram may be required and
should be discussed with a consultant.

2.2.2 Carotid artery imaging

Request urgent carotid duplex scan for all patients with non-disabling ischaemic stroke
syndrome or TIA in the carotid territory who are potential candidates for carotid surgery
(SIGN).

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2.2.3 Echocardiogram

Echocardiography is not recommended for all patients with ischaemic stroke or TIA (SIGN).

Echocardiogram should be considered for patients


o where clinical findings or baseline investigations (e.g. abnormal ECG) suggest
cardiac disease.
o with cryptogenic stroke.

Hypertension without ECG abnormality is not an indication for echocardiogram.

Enter as much information on the request card as possible to allow appropriate vetting of
the request (e.g. ECG findings, presence of murmurs etc).

If a patient has had a recent echocardiogram prior to their stroke, a repeat echo may not be
appropriate.

The routine use of echocardiography with contrast media for further evaluation of patients
following stroke or TIA is not recommended. This should only be requested after discussion
with a cardiologist.

2.2.4 Cardiac Rhythm Monitoring

Cardiac rhythm monitoring (24/48/72 hour ECG tapes) may be appropriate to investigate for
paroxysmal atrial fibrillation in patients with sinus rhythm on admission ECG.
This should be requested on discussion with a consultant.

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Section 3: Primary Intracerebral Haemorrhage


3.1

Initial Management

Following brain imaging confirming intracerebral haemorrhage

All antiplatelets/anticoagulants should be discontinued.

A baseline full blood count and clotting screen is required (if not already done).

Clotting levels in those receiving anticoagulation treatment (and have an elevated INR)
should be returned to normal as soon as possible. The haematoma seen on the CT is a
snapshot image and will often continue to expand following the CT scan. Discuss with the
on-call haematologist the appropriate treatment to give. This will usually be a combination
of prothrombin complex and intravenous vitamin K. (NICE).

The PT and APTT can be affected by novel oral anticoagulant drugs but these changes do
not reflect the degree of anticoagulant effect of these drugs. If a patient suffers an intracerebral haemorrhage while taking one of these drugs then discuss appropriate treatment
with the on-call haematologist.

While routine surgical evacuation by craniotomy is not recommended for supratentorial primary
intracerebral haematoma, early neurosurgical discussion may still be required in individual
circumstances. This may include younger patients with haemorrhage and subsequent pressure
effects or those with very superficial haemorrhage. If there is doubt about appropriateness, then
discussion should take place in order that patients do not miss out on appropriate intervention.
Blood Pressure Management
Consider acute management of hypertension in intracerebral haemorrhage if systolic blood
pressure >200mmHg. Lowering by no more than 20% in the first 24 hours may be
advisable. Intravenous labetolol or glyceryl tri-nitrate may be options. Clinical trial evidence
in this area is inconclusive.
Clinical Observation
Regular clinical observation should be made including neuro-obs and Glasgow Coma
Scale. This should be done at least hourly for the first 24-48 hours.

A deterioration may indicate haematoma expansion or a re-bleed. Further CT imaging may


be appropriate, particularly where neurosurgery has indicated they may accept the patient
in the event of a clinical deterioration.

Patients with Prosthetic Heart Valves


Patients with cerebral haemorrhage and a prosthetic heart valve should also be discussed
with cardiology, particularly those who need long term anticoagulation due to the valve.

Patients anticoagulated solely due to atrial fibrillation who have a cerebral haemorrhage
should usually have their anticoagulation fully reversed.

Statin Therapy
Statin therapy after haemorrhagic stroke is not recommended routinely unless the risk of
further ischaemic vascular events outweighs the risk of further haemorrhage (SIGN).
Subarachnoid haemorrhage and subdural and extradural haemorrhage are managed
differently from primary intracerebral haemorrhage and are not covered in this guidance.

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Section 4: Post-stroke Dysphagia


4.1

Swallowing Impairment

Dysphagia, defined as a difficulty in swallowing, is a frequent and often serious


complication of stroke and other neurological conditions. It is associated with increased
incidence of morbidity and mortality due to the risk of aspiration and associated chest
infections, dehydration and malnutrition, and missed medication.

Dysphagia can be a short-term problem that resolves or a slowly degenerating condition


that remains long term and has ongoing consequences for nutrition and hydration. It is
essential that this problem is detected early and managed appropriately by all members of
the multidisciplinary team (MDT).

Early placement of a nasogastric feeding tube should be considered in patients identified


as unable to take adequate food or medication due to a low conscious level and/or the
presence of dysphagia (SIGN). This would usually be a decision made once the patient is
in the Stroke Unit following MDT discussion.

The presence of dysphagia indicates an increased risk of lower respiratory tract infection.
o Aspiration is a risk of stroke and is associated with poor outcome.
o Risk reduction - sit up and mobilise as soon as possible (NICE, SIGN)
o Treat for aspiration pneumonia as per the local antibiotic guidelines.

The presence of a nasogastric tube does not prevent aspiration of saliva or reflux of NG feed and
aspiration. Attending staff should remain alert to the possibility of aspiration after placement.

4.2

Screening for Swallowing Difficulties and Referral to SLT.

In clinical practice, the screening process is used to identify those patients who should be
referred for full clinical assessment by a professional skilled in the management of
dysphagia (usually a speech and language therapist (SLT).

If the screening procedure does not identify any difficulties, the patient can be allowed to
eat and drink avoiding unnecessary restrictions on oral intake (SIGN 119).

4.3

Further Guidance for Swallow Screening and Nutrition

Full clinical care standard for swallow screening

http://www.nhsforthvalley.com/__documents/qi/ce_guideline_nursing/swallow-screening-foradults-with-suspected-dysphagia-clinical-care-standards.pdf

For patients who are assessed as needing nasogastric feeding

http://www.nhsforthvalley.com/__documents/qi/ce_guideline_nutrition/clinical-care-standar-forplacement-of-nasogastric-feeding-tubes-in-adults.pdf
http://www.nhsforthvalley.com/__documents/qi/ce_guideline_nutrition/nasogastric-feeding-carebundle.pdf

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Section 5:

Transient Ischaemic Attack (TIA)

The symptoms of a TIA usually resolve within minutes or a few hours at most, and anyone with
continuing neurological signs when first assessed should be assumed to have had a stroke.

1. Take History and Perform Examination


2. Is this likely to be a vascular event?

Was the event of sudden onset? Are the symptoms focal (attributable to a single vascular territory)?
Unilateral weakness and/or sensory disturbance of face, arm, leg or a contiguous combination
Dysphasia
Visual Field Defect Diplopia
Does the patient have vascular risk factors?

Stroke a clinical syndrome of rapidly developing symptoms and/or signs of focal neurological dysfunction lasting
more than 24 hours with no apparent cause other than of vascular origin
TIA - transient episodes of focal cerebral dysfunction or transient monocular dysfunction during which symptoms last
less than 24 hours and are presumed to be of vascular origin.

Patients with LOSS OF CONSCIOUSNESS should NOT be referred to this clinic


Blackouts, faints, seizures & dizziness should be admitted or referred to other clinics as appropriate

3. Are symptoms/signs still present?


YES Admit & treat as stroke
NO - Continue risk assessment
4. Risk Assessment
ABCD2 Score1 Age / Blood pressure / Clinical symptoms / Duration / Diabetes
Age
Clinical
Duration

60 years or over = 1, under 60 years = 0


BP
Systolic BP>140 or Diastolic BP>90=1, other values=0
Unilateral weakness (face/arm/leg) = 2 OR Speech disturbance only = 1 OR Other impairment = 0
>60 min = 2, 10 to 59 min =1, <10 min = 0
Diabetes
Yes = 1, No = 0

Score

Risk Group

0 to 3
4 to 5
6 to 7

Low
Medium
High

2 days

Risk of Recurrence at Interval


7 days

90 days

1.0%
4.1%
8.1%

1.2%
5.9%
11.7%

3.1%
9.8%
17.8%

Other Factors considered High Risk: More than 1 event in 7 days


Atrial Fibrillation
On anticoagulants
Prosthetic Heart Valve TIA plus neck pain suggesting arterial dissection

5. Action Plan
Office Hours - 0900h to 1600h Monday to Friday
2
Contact TIA MOBILE 01324 567691
Complete Referral Form
Bloods
Out of Hours - 1600h to 0900h AND all day Saturday & Sunday

ECG

CXR

ABCD2 score 4 or Other High Risk Factor

ABCD2 score < 4 and no High Risk Factors

ADMIT & arrange tests below


Complete referral & leave at A&E reception
2
3
Bloods ECG CXR
CT Brain scan next day
Carotid Doppler & Echo (if indicated per protocol) next day

Bloods
ECG CXR
Complete referral form & leave at ED reception
Start appropriate secondary prevention
Give Driving Advice (see below)
Advise call 999 if further symptoms pending review
If diagnostic doubt, significant abnormality found on basic tests,
or significant co-morbidity, then use clinical judgement &
admission may be appropriate

Start appropriate secondary prevention

6. Other Information
Immediate Secondary Prevention Drug Regime
Aspirin 300mg STAT followed by 75mg daily
(If true aspirin intolerance, Clopidogrel 300mg STAT followed by 75mg daily)
Drugs to be dispensed from the Emergency Department or Clinical Assessment Unit
Other drug therapy (other antiplatelets, statins, anti-hypertensives etc.) will be started after clinic review

TIA TRIAGE MOBILE 01324 567691 PAGE 1684


4

Patients with stroke, TIA or amaurosis fugax must not drive for at least one month
Document that advice given. If patient drives against advice, will not be covered by insurance company
1. Johnston SC et al. Validation and refinement of scores to predict very early stroke risk after transient ischaemic attack. Lancet 2007;369:283-92
2. SIGN 108.Section 4.5 U&Es, random glucose, random cholesterol, FBC, ESR. Other blood tests as clinically indicated.
3. CXR for all who are admitted, all smokers and all with another clear indication (unless a CXR has recently been performed).
Other patients will be assessed at clinic and a chest x-ray performed if necessary.
4. DVLA guidelines can be found online at https://www.gov.uk/government/publications/at-a-glance

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Section 6:
6.1

Special Circumstances

Malignant MCA syndrome

Following proximal middle cerebral artery (MCA) occlusion, subsequent massive oedema of
infarcted tissue can result in a progressive increase in intracranial pressure, coning and
death.

For individuals aged up to 60 years who suffer an acute MCA territory ischaemic stroke
complicated by massive cerebral oedema, surgical decompression by hemicraniectomy
can significantly reduce mortality if performed within 48 hours of stroke onset (SIGN).

Patients 60 yr showing neurological deterioration after major MCA infarction should be


discussed with the neurosurgical team at the Department of Surgical Neurosciences,
Edinburgh Western General Hospital.

Intravenous mannitol and/or corticosteroids have no effect on outcome and are not
recommended.

6.2

Posterior Circulation Infarct or Haemorrhage

Patients presenting with a significant posterior circulation stroke should be


discussed with a senior and may merit discussion with the Stroke team at Edinburgh
Western General Hospital regarding temporary transfer even if there is no immediate
neurosurgical issue at time of presentation.

Local oedema within the posterior fossa following significant cerebellar infarction with local
mass effect or mass effect from haemorrhage can result in occlusion of the 4th ventricle and
obstructive hydrocephalus with coning.

Events can proceed rapidly with rapid and catastrophic deterioration. Close observation of
such patients is required including neuro-observation (including Glasgow Coma Scale) at
least hourly for the first 48 hours.

Basilar artery occlusion can also cause significant morbidity and mortality.

It may be advisable for patients to be monitored in a neurological centre with immediate


access to neurosurgical decompressive facilities for 48 hours following onset, even if signs
of hydrocephalus are not yet evident.

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6.3

Cerebral Venous Sinus Thrombosis (CVT)

Cerebral venous thrombosis is a rare cause of stroke, accounting for 0.5% of all strokes per
annum. Diagnosing cerebral venous thrombosis is difficult and CVT are often assumed to
be ischaemic infarcts. Clinical symptoms are very variable and non-specific. CT
appearances can be subtly different and other imaging such as MR or CT venography may
be required. The aetiology is often multifactorial and underlying thrombophilias are found in
22% of patients (SIGN).

Patients with CVT should be discussed with a stroke specialist either locally or at the
Western General Hospital, Edinburgh.

Anticoagulation appears to be safe following cerebral venous thrombosis (despite the


presence of associated secondary haemorrhage on scanning) and may be associated with
an improvement in mortality and outcome (SIGN)

Treatment with IV unfractionated heparin or low molecular weight heparin followed by


warfarin should be considered in patients with cerebral venous sinus thrombosis (SIGN,
NICE).
Long term treatment with warfarin (INR range 2.0-3.0) for 6-12 months is recommended
(SIGN)

6.4

Extra-cranial Cervical Arterial Dissection

Extra-cranial cervical arterial dissection is an uncommon cause of stroke, accounting for


2.5% of all strokes and 5-22% of strokes in young people (<45 years). The incidence of
carotid artery dissection is two to three per 100,000 per year. Aetiologies include
chiropractic neck manipulations & other neck trauma and arteriopathies such as
fibromuscular dysplasia and cystic medial necrosis.

The most likely cause of stroke in cervical artery dissection is embolism from the
dissection flap.

It is important to be aware of the possibility of intracranial extension of the dissection


resulting in subarachnoid haemorrhage. This diagnosis should be excluded in the
usual way if symptoms are suggestive prior to initiating treatment with antiplatelets or
anticoagulation. (SIGN)

In patients with extracranial cervical arterial dissection consider treatment with either
anticoagulation for three to six months or antiplatelet agents (SIGN, NICE).

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Section 7:

Scottish Stroke Care Audit

The Scottish Stroke Care Audit (SSCA) has been collecting information about stroke care
since 2002 and includes all hospitals managing acute stroke in Scotland. Its function is to
improve stroke care and outcomes using evidence-based medicine and audit standards. It
lies within the structure of NHS Quality Improvement Scotland (NHS QIS).

Data is collected on all patients admitted to hospital with stroke or TIA and all patients
attending outpatient cerebrovascular/TIA clinics.

The Scottish Government recognises stroke as a key health issue for the people of
Scotland and the Scottish NHS. HEAT targets have been used to emphasise the
importance of access to specialist stroke services.

Further information on the Scottish Stroke Care Audit including annual reports can be
accessed on their website.
http://www.strokeaudit.scot.nhs.uk

NHS QIS Standards for 2014

Stroke Unit Care


o 90% of stroke patients should be admitted to a Stroke Unit on the day of admission
(day 0) or the day after (day 1).

Swallow Screen
o 90% of stroke patients should have a swallow screening assessment on the day of
hospital admission (day 0.

Brain Imaging
o 90% of stroke patients should have a brain scan within 24 hours of hospital
admission.

Administration of Aspirin
o 100% of patients with acute ischaemic stroke (where there is no contra-indication to
aspirin therapy) should receive aspirin within one day of admission (day 0 or day 1).

It is anticipated that the above four standards will be accepted as a Stroke Bundle and that there
will be a future standard set for the percentage of stroke patients who achieve the full stroke
bundle standards.
Use of the Stroke Bundle Sticker (Section 1.7) in case notes will help prompt tasks being carried
out and recording of the time achieved.

Thrombolytic Therapy
o 80% of patients receiving thrombolytic therapy for acute ischaemic stroke should
receive the initial bolus dose of Actilyse within 60 minutes of arrival at hospital).

Out-patient Clinics
o 80% of patients with a definite cerebrovascular diagnosis (stroke, TIA, transient
monocular blindness or retinal artery occlusion) should be assessed at a
neurovascular clinic with 4 calendar days of receipt of referral.

Carotid Surgery
o 80% of patients undergoing carotid intervention for symptomatic carotid artery
disease should have the intervention within 14 days of the event that led to the
patient first seeking medical assistance.

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Appendix 1: Oxford Classification of Stroke


Total Anterior Circulation Stroke (TACS)
-carries poorer prognosis

Partial Anterior Circulation Stroke (PACS)

All of the below:


Weakness +/- sensory deficit of at least 2 out of 3 of
face, arm and leg
Homonymous visual field defect
Higher cortical dysfunction e.g. dysphasia, dyspraxia

2 out of 3 criteria from TACS criteria


OR

Isolated dysphasia or other cortical dysfunction


OR

Lacunar stroke (LACS)

Motor/sensory deficit more restricted than a LACS


e.g. single limb, hand only.

Pure motor (commonest) or pure sensory deficit


affecting contiguously 2 out of 3 of face, arm and
leg, or a sensorimotor stroke (basal ganglia or
internal capsule)
OR

Ataxic hemiparesis (cerebellar-type ataxia with


ipsilateral pyramidal signs internal capsule or
pons)
OR

Dysarthria plus clumsy hand


OR

Acute onset movement disorders (hemichorea,


hemiballismus basal ganglia)

Lacunar syndromes should not affect higher cortical function

Posterior Circulation Stroke (POCS)

Include

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Isolated homonymous hemianopia


Isolated cerebellar stroke
Disorders of conjugate eye movement
Cranial nerve deficit with contralateral motor or
sensory deficit
Bilateral motor/sensory symptoms

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Publications in Alternative Formats


NHS Forth Valley is happy to consider requests for publications in other language or formats such
as large print.
To request another language for a patient, please contact 01786 434784.
For other formats contact 01324 590886,
text 07990 690605,
fax 01324 590867 or
e-mail - fv-uhb.nhsfv-alternativeformats@nhs.net

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