The latest national clinical guideline for stroke recommends that all patients, regardless of age or how severe their stroke is, should be considered for thrombolysis. New research has shown that these categories of patient, formerly not thought to benefit from thrombolysis, should now be offered it with other patients within three hours of the appearance of stroke symptoms.
The recommendation is one of several updates to the guideline, which aims to improve the quality of care for stroke patients. It includes over 100 sources of evidence of major developments in stroke research during the past four years, and continues to include the NICE quality standards and guidelines for stroke care. Major recommendations, and changes to the previous guideline include:
• Commissioning stroke services across the whole stroke pathway, from acute to longterm care. Rehabilitation therapies should be commissioned alongside these services and available for the whole pathway. All acute patients should be considered for thrombolysis regardless of age or stroke severity.
• Patients with stroke should be offered 45 minutes of appropriate therapies for a minimum of five days a week in the early stages after stroke. This is to enable the patient to meet their rehabilitation goals and should continue for as long as the therapy is of benefit and the patient can tolerate it.
• Prescribing the anti-platelet drug clopidogrel as the first-line treatment after both stroke and transient ischaemic attack (TIA) because it is better tolerated and more costeffective, and to ensure a unified approach to managing both conditions. This contradicts the most recent NICE guidance, which recommends aspirin for TIA because clopidogrel is currently licensed only for the treatment of stroke and not TIA.
• All patients should have a brain scan within a maximum of 12 hours. This is a reduction from the previous 24 hours to ensure all patients admitted out of hours are scanned the following day.
• Carotid endarterectomy for asymptomatic carotid stenosis should not be routinely undertaken, other than in exceptional circumstances or as part of a randomised controlled trial.
Professor Tony Rudd, chair of the Intercollegiate Stroke Working Party, said: “This stroke guideline is the most comprehensive ever produced and acts as a template for the commissioning, organisation and delivery of stroke care at a time of major upheaval in the health service. It reinforces the message that care needs to be integrated all across the stroke care pathway, no matter who is providing the care.” For more information visit: www.rcplondon.ac.uk/stroke
