Stroke Care

Scottish Stroke Care Bundle

1. Swallow screen within four hours of admission to hospital (target 100%).
2. CT head scan within twelve hours of admission to hospital (target 90%).
3. Aspirin for ischaemic stroke within one day of admission to hospital (target 95%).
4. Transfer to the Acute Stroke Unit within one day of admission to hospital (target 90%).

Complete in-patient bundle ie all four of the above (Target 80%).

Pre-Hospital Care

1. People seen by ambulance clinicians outside hospital with sudden onset of focal neurological symptoms should be screened for hypoglycaemia and for stroke/TIA using validated tools such as FAST.  Those people with neurological symptoms who screen positive should be transferred to a hyperacute stroke service as soon as possible.
2. People who are negative when screened on FAST, but in whom stroke is still suspected should be treated as if they have stroke until diagnosis has been excluded by Stroke Clinician.
3. The pre-hospital care of people with suspected stroke should minimise time from call to arrival at hospital and should include a hospital pre-alert to expedite specialist assessment and treatment.
4. Patients with suspected TIA should be given 300mg of aspirin or clopidogrel immediately followed by 75mg OD and assessed in a Neurovascular Clinic  – Please see DGRefHelp for full referral guidance
5. Healthcare professionals should NOT use assessment tools such as ABCD2 score to stratify risk of TIA or to inform the urgency of referral or subsequent treatment.

Hyperacute Care (Thrombolysis)

1. Patients with acute ischaemic stroke, regardless of age or stroke severity, in whom treatment can be started within 4.5 hours of onset, should be considered for thrombolysis with Alteplase.
2. Patients with acute ischaemic stroke, otherwise eligible for treatment with thrombolysis should have their blood pressure lowered to below 185/110 mmHg before treatment.
3. Patients with acute ischaemic stroke treated with thrombolysis should be started on an anti-platelet agent after 24 hours unless contra-indicated once significant haemorrhage has been excluded.
4. Patients with middle cerebral artery infarction who meet the criteria below should be considered for decompressive hemi-craniectomy.   Patients should be referred to a Neurosurgical service within 24 hours of stroke onset and treated within 48 hours of stroke onset.

Criteria

1. Pre-stroke mRS score of 0 or 1.
2. Clinical deficit indicating infarction in the territory of the MCA.
3. NIHSS of more than 15. – See table on Page 2 of the NHSD&G Acute Stroke Thrombolysis Proforma
4. Decrease in level of consciousness to a score of 1 or more on Item I (a) of the NIHSS.
5. Signs on CT of an infarct of at least 50% of the MCA territory with or without additional infarction of the territory of the anterior or posterior cerebral artery on the same side, or infarct volume greater than 145 ml on MRI DWI.
6. For full information, see Handbook Page on Stroke Thrombolysis

Modified Rankine Score

Acute Care for Ischaemic Stroke/TIA

1. Patients with ischaemic stroke/TIA should receive treatment for secondary prevention as soon as diagnosis is confirmed, including:
   • Support to modify lifestyle factors, such as smoking, alcohol consumption, diet and exercise.
   • Anti-platelet or anti-coagulant therapy.
   • High intensity statin therapy.
   • Blood pressure lowering therapy – Click Here for Management of Hypertension in Acute Stroke
2. Patients with acute stroke should have their swallowing screened using a validated screening tool within 4 hours of arrival in hospital and before being given any oral food, fluid or medication.
3. Until a safe swallowing method is established, patients with dysphagia after acute stroke should:
   • Be immediately considered for alternative fluids.
   • Have a comprehensive specialist assessment of their swallowing.
   • Be considered for naso-gastric tube feeding within 24 hours.
   • Be referred to a dietician for specialist nutritional assessment, advice and monitoring.
   • Receive adequate hydration, nutrition and medication by alternative means.
   • Be referred to a Pharmacist to review the formulation and administration of medication.

Anti-Platelet Therapy

1. Patients with TIA or ischaemic stroke should be given anti-platelet therapy provided there is neither a contra-indication nor a high risk of bleeding.  The following regime should be considered.
2. TIA/Minor ischaemic stroke
   • For patients within 24 hours of onset of TIA or ischaemic stroke and with a low risk of bleeding (NIHSS 0 – 3), the following dual anti-platelet therapy should be given:
   • Clopidogrel – initial dose of 300mg followed by 75mg per day plus aspirin initial dose of 300mg followed by 75mg per day for 21 days and then followed by mono-therapy with clopidogrel 75mg once daily.  We advise caution in frail/elderly patients and clinicians should review the risk versus benefit of DAPT.
   • For patients with TIA or ischaemic stroke who are not appropriate for dual anti-platelet therapy (NIHSS > 3) should receive clopidogrel 300mg loading dose followed by 75mg daily.
   • Proton pump inhibitor should be considered for concurrent use with dual anti-platelet therapy to reduce the risk of gastro-intestinal hernia.
   • For patients with recurrent TIA or stroke whilst taking clopidogrel, consideration should be given to clopidogrel resistance.
3. Severe/disabling ischaemic stroke
   • Patients with severe/disabling acute ischaemic stroke should be given 300mg of aspirin, either orally if they are not dysphagic, or rectally or by enteral tube if they are dysphagic.   Thereafter aspirin 300mg daily should be continued until two weeks after the onset of stroke, at which time anti-thrombotic treatment should be initiated (clopidogrel 75mg once daily).

Statin Therapy

1. Patients with TIA or ischaemic stroke should receive high intensity statin therapy (atorvastatin 80mg once daily) started immediately.
2. A lower dose should be used if there is a potential for medication interaction or a high risk of adverse effects.
3. Alternative statin at maximum tolerated dose should be used if atorvastatin is either unsuitable or not tolerated.

Anti-Hypertensive Therapy

1. Patients with stroke or TIA should have their blood pressure checked and treatment should be initiated or increased as tolerated to achieve systolic blood pressures below 130 mmHg with the exception of people with severe bilateral carotid artery stenosis in whom systolic blood pressure target of 140-150 mmHg is appropriate.

Anti-Coagulation Therapy

1. Patients with non-disabling ischaemic stroke or TIA and paroxysmal/persistent/permanent atrial fibrillation (valvular or non-valvular) or atrial flutter, oral anti-coagulation should be commenced as soon as intracranial bleeding has been excluded and continued as standard long-term treatment.
2. Anti-coagulation treatment
   • should not be given if brain imaging has identified significant haemorrhage.
   • should not be commenced in people with severe hypertension (blood pressure of 180/120 mmHg or higher) which should be treated first.
   • may be considered for patients with moderate to severe stroke from five to fourteen days after onset.
   • should be considered for patients with mild stroke earlier than five days as long as benefit outweighs risk (aspirin 300mg should be used in the meantime).
   • should be initiated within fourteen days of onset of stroke in all those considered appropriate for secondary prevention.
   • should be initiated immediately after a TIA once brain imaging has excluded haemorrhage.
3. First line treatment for people with ischaemic stroke/TIA due to non-valvular AF should be anti-coagulation with a DOAC. (See Handbook Page on Anticoagulation in NVAF)
4. Patients with ischaemic stroke/TIA due to valvular/rheumatic atrial fibrillation or with mechanical heart valve replacement and those with contra-indication or intolerance to DOAC should receive anti-coagulation with adjusted dose warfarin (target INR 2.5).

Carotid Endarterectomy

1. Patients with ischaemic stroke or TIA who, after specialist assessment, are considered candidates for carotid intervention should have carotid imaging performed as soon as possible/ideally within twenty-four hours of assessment.  This should include carotid Duplex ultrasound or either CT angiography or MR angiography.
2. Symptomatic severe carotid stenosis of 50-99% (by NASCET method) should be assessed and referred for carotid endarterectomy as soon as possible within seven days of onset of symptoms and should also receive optimal medical treatment with control of blood pressure, anti-platelet agents and cholesterol reduction as well as dietary and lifestyle advice/smoking cessation advice.
3. Patients with mild to moderate carotid stenosis of less than 50% should receive best medical therapy and not undergo carotid surgical intervention.

Please see Referring Patients for Consideration of Urgent Carotid Revascularisation from Hairmyres Hospital.

Lifestyle Advice

1. Patients with stroke/TIA who smoke should be advised to stop immediately.  Smoking cessation should be promoted in an individualised prevention plan using interventions which may include pharmacotherapy, psychological support and referral to statutory Stop Smoking Services.
2. Patients should eat an optimum diet including five or more portions of fruit and vegetables per day, two portions of oily fish per week and aim to reduce or replace saturated fats by using low fat dairy products and products based on vegetable and plant oil, as well as limit red meat intake, especially fatty cuts and processed meat.
3. Patients should be supported to aid weight loss, limit alcohol intake to less than 14 units per week and take regular exercise and reduce their salt intake.

Monitoring

Patients with acute stroke should be admitted to Hyper-acute Stroke Unit with protocols to maintain normal physiological status and staff trained in their use.

1. Clinical status should be monitored closely including:
   • Level of consciousness.
   • Blood glucose.  Maintain blood glucose concentration between 5 and 15 mmol/l with close monitoring to avoid hypoglycaemia.
   • Blood pressure.    Patients with acute ischaemic stroke should receive blood pressure lowering treatment acutely if there is an indication for emergency treatment such as (a) thrombolysis, (b) hypertensive encephalopathy, (c) hypertensive nephropathy, (d) hypertensive cardiac failure or myocardial infarction, (e) aortic dissection and (f) pre-eclampsia/eclampsia.    Patients with acute stroke admitted on anti-hypertensive medication should receive oral treatment once they are medically stable and as soon as they can swallow medication safely.
   • Oxygen saturations.    Patients with acute stroke should only receive supplementary oxygen if their oxygen saturations are below 95% and there are no contra-indications.
   • Hydration and nutrition.  Hydration status should be assessed using standardised approach within four hours of arrival at hospital and reviewed regularly and managed so that normal hydration is maintained.
   • Temperature.
   • Cardiac rhythm and rate.    Patients with ischaemic stroke or TIA in whom no other cause of stroke has been found after comprehensive neurovascular investigations and in whom a cardio-embolic cause is suspected, should be considered for more prolonged sequential or continuous cardiac rhythm monitoring with a wearable recorder (R-test) if they are likely to be appropriate for anti-coagulation.

Intracerebral Haemorrhage

1. Patients with intracerebral haemorrhage in association with Vitamin K antagonist treatment should have the anti-coagulant urgently reversed with a combination of prothrombin complex concentrate and intravenous Vitamin K.
2. Patients with intracerebral haemorrhage in association with direct oral anti-coagulant treatment should have the anti-coagulation urgently reversed.   For patients taking dabigatran, Idarucizumab should be used.   If Idarucizumab is unavailable, four factor prothrombin complex concentrate may be considered.  For those taking Factor 10A inhibitors, four factor prothrombin complex concentrate should be considered and Andexanet Alpha may be considered in the context of randomised control trial.
3. Patients with acute spontaneous intracerebral haemorrhage with a systolic blood pressure of 150-220 mmHg should be considered for urgent treatment within six hours of symptom onset using a locally agreed protocol for blood pressure lowering, aiming to achieve a systolic blood pressure between 130-139 mmHg within one hour and sustained for at least seven days unless:
   • Glasgow Coma Scale score is 5 or less.
   • Haematoma is very large and death is expected.
   • A macrovascular or structural cause for haematoma is identified.
   • Immediate surgery to evacuate haematoma is planned in which case blood pressure should be managed according to locally agreed protocol.
4. Click here for Management of Hypertension in Acute Stroke and also to How to Use IV Labetolol and IV Nitrate in Hypertensive Emergencies
5. Patients with intracerebral haemorrhage should be admitted to a Hyperacute Stroke Unit for monitoring of consciousness level and referred for repeat brain imaging if deterioration occurs.  Patients who develop hydrocephalus should be considered for surgical intervention such as insertion of external ventricular drain.
6. Patients with primary intracerebral haemorrhage should only be started on statin therapy based on their cardiovascular disease risk and not for secondary prevention of intracerebral haemorrhage.
7. Early non-invasive cerebral angiography, CT/MRA within forty-eight hours of onset should be considered for all patients with acute spontaneous intracerebral haemorrhage age 18 – 70 years who were independent, without a history of cancer and not taking an anti-coagulant, except if they are aged more than 45 years with hypertension and the haemorrhage is in the basal ganglia, thalamus or posterior fossa.   If the CT/MRA is normal or inconclusive, MRI/MRA with SWI imaging should be considered at three months.

Subarachnoid Haemorrhage

1. Any person presenting with sudden, severe headache and an altered neurological state should have the diagnosis of subarachnoid haemorrhage investigated by:
   • Immediate CT brain scan (also including CT angiography if the protocol is agreed with a tertiary neuroscience centre).
   • Lumbar puncture twelve hours after ictus (all within fourteen days if presentation is delayed) if the CT brain is negative and does not show any contra-indications.
   • CSF analysis for xanthochromia.
2. Patients with spontaneous subarachnoid haemorrhage should be referred immediately to a tertiary neuroscience centre and receive nimodipine 60mg four-hourly unless contra-indicated, as well as frequent neurological observations for signs of deterioration.
3. Patients with residual symptoms or disability after definitive treatment of subarachnoid haemorrhage should receive specialist neurological rehabilitation including appropriate clinical/neuro-psychological support.

Cervical Artery Dissection

1. Any patients suspected of cervical artery dissection should be investigated with CT or MR, including angiography.
2. Patients with acute ischaemic stroke suspected to be due to cervical artery dissection should receive thrombolysis if they are otherwise eligible.
3. Patients with acute ischaemic stroke suspected to be due to cervical artery dissection should be treated with either an anti-coagulant or an anti-platelet agent for at least three months. (CADISS RCT in patients with symptomatic carotid and vertebral artery dissection showed no significant difference between anti-coagulants and anti-platelet treatment in the prevention of recurrent stroke or death).
4. For patients with acute ischaemic stroke or TIA secondary to cervical artery dissection, dual anti-platelet therapy with aspirin and clopidogrel may be considered for the first 21 days, followed by anti-platelet mono-therapy until at least three months after onset.

Cerebral Venous Thrombosis

1. Any patient suspected of cerebral venous thrombosis should be investigated with CT or MRI, including venography.
2. Patients with cerebral venous thrombosis (including those with secondary cerebral haemorrhage) should receive full dose anti-coagulation (initially full dose Heparin and then warfarin with target INR 2.0 – 3.0) for at least three months unless there are co-morbidities that preclude their use (DOACs are licensed for venous thrombo-embolism/DVT/PE, but not for CVT).

DVT/PE

1. Patients with immobility after acute stroke should be offered intermittent pneumatic compression within three days of admission to hospital for the prevention of DVT.  Treatment should be continued for 30 days or until the patient is mobile or discharged, whichever is sooner.  Patient should not routinely be given low molecular weight Heparin or graduated compression stockings (either full length or below knee) for the prevention of DVT.
2. Patients with ischaemic stroke and symptomatic DVT or PE should receive anti-coagulant treatment provided there are no contra-indications.
3. Patients with intracerebral haemorrhage and symptomatic DVT or PE should receive treatment with veno-caval filter.

Patent Foramen Ovale

PFO is probably more relevant to the aetiology of stroke in younger patients under 55 years of age, especially if there is a clear history of symptoms occurring during, or shortly after, a Valsalva manoeuvre in the setting of a DVT or where there are recurrent strokes in different arterial territories of otherwise undetermined aetiology.

Recommendations

1. People with ischaemic stroke or TIA with a PFO should receive optimal secondary prevention treatment including anti-platelet therapy, treatment for high blood pressure, lipid-lowering therapy and lifestyle modifications.   Anti-coagulation is not recommended unless there is another recognised indication.
2. Selected patients below the age of 60 with an ischaemic stroke/TIA of otherwise undetermined aetiology, in association with a PFO and a right to left shunt or an atrial septal aneurysm should be considered for endovascular PFO device closure within six months of the index event to prevent recurrent stroke.  This decision should be made after careful consideration of benefits and risks by a multi-disciplinary team, including Cardiology (initially locally and then to the Golden Jubilee Hospital, Glasgow).

Vertebral Artery Disease

1. Patients with ischaemic stroke or TIA and symptomatic vertebral artery stenosis should receive optimal secondary prevention including anti-thrombotic therapy, blood pressure treatment, lipid-lowering therapy and lifestyle modifications.  Angioplasty and stenting should only be offered in the context of clinical trials.

Anti-Phospholipid Syndrome

Screening

1. Patients with ischaemic stroke or TIA in whom other conditions such as atrial fibrillation and large or small vessel atherosclerotic disease have been excluded should be investigated for anti-phospholipid syndrome (with IgG and IgM anti-cardiolipin ELISA and lupus anti-coagulant), particularly if the patient is under 50 years of age, has an auto-immune rheumatic disease such as SLE and a history of one or more venous thrombosis or a history of recurrent first trimester pregnancy loss or at least one late pregnancy loss in the second or third trimester.

Treatment

1. Consult local Haematology service.
2. Patients with anti-phospholipid syndrome who have an ischaemic stroke or TIA should have decisions on long-term secondary prevention made on an individual basis in conjunction with specialist Haematology and/or Rheumatology advice.

Responsibility for Stroke Care in Dumfries

1. Dr Amy Conley, Consultant (33180)
2. Dr Ritesh Malik, Speciality Doctor (32191) Monday to Thursday
3. Susan Walden, Stroke Specialist ANP (32065) Monday to Friday 0800-1600
4. Secretary: 33349

Links

• National Clinical Guideline for Stroke for Great Britain & Northern Ireland 2023