Excerpt

May 2019: NICE guideline CG68 (July 2008) has been updated and replaced by NG128.

This guideline covers interventions in the acute stage of a stroke (‘acute stroke’) or transient ischaemic attack (TIA). Most of the evidence considered relates to interventions in the first 48 hours after onset of symptoms, although some interventions of up to 2 weeks are covered as well. This guideline is a stand-alone document, but is designed to be read alongside the Intercollegiate Stroke Working Party guideline ‘National clinical guideline for stroke’ which considers evidence for interventions from the acute stage into rehabilitation and life after stroke. The Intercollegiate Stroke Working Party guideline is an update of the 2004 2nd edition and includes all the recommendations contained within this guideline. This acute stroke and TIA guideline is also designed to be read alongside the Department of Health’s (DH) ‘National stroke strategy’ (NSS). Where there are differences between the recommendations made within this acute stroke and TIA guideline and the NSS, the Guideline Development Group (GDG) members feel that their recommendations are derived from systematic methodology to identify all of the relevant literature.

Contents

• Guideline Development Group Members
• Preface
• Development of the Guideline
  • 1. Introduction
    • 1.1. Background
    • 1.2. Incidence and prevalence
    • 1.3. Health and resource burden
    • 1.4. Definition
  • 2. Methodology
    • 2.1. Aim
    • 2.2. Scope
    • 2.3. Audience
    • 2.4. Involvement of people with stroke and TIA
    • 2.5. Guideline limitations
    • 2.6. Other work relevant to the guideline
    • 2.7. Methodological background
    • 2.8. The process of guideline development
    • 2.9. Disclaimer
    • 2.10. Funding
  • 3. Key messages of the guideline
    • 3.1. Key priorities for implementation
    • 3.2. Algorithms
  • 4. Glossary and definitions
• The Guideline
  • 5. The rapid recognition of symptoms and diagnosis
    • 5.1. Pre-hospital prompt recognition of symptoms of TIA and stroke symptoms
    • 5.2. Early versus late assessment of people with TIA, and identifying those at high risk of stroke
  • 6. Imaging in TIA and non-disabling stroke
    • 6.1. Suspected TIA – referral for urgent brain imaging
    • 6.2. Type of brain imaging for people with suspected TIA
    • 6.3. Early carotid imaging in people with acute non-disabling stroke or TIA
    • 6.4. Urgent carotid endarterectomy and carotid stenting in people with carotid stenosis
  • 7. Specialist care in acute stroke
    • 7.1. Specialist stroke units
    • 7.2. Brain imaging for the early assessment of people with acute stroke
  • 8. Pharmacological treatments for people with acute stroke
    • 8.1. Thrombolysis in people with acute ischaemic stroke
    • 8.2. Aspirin and anticoagulant treatment in people with acute ischaemic stroke
    • 8.3. Antiplatelet and anticoagulant treatment in people with acute venous stroke
    • 8.4. Antiplatelet and anticoagulant treatment in people with stroke due to arterial dissection
    • 8.5. Antiplatelet and anticoagulant treatment in people with acute stroke due to antiphospholipid syndrome
    • 8.6. Reversal of anticoagulation treatment in people with haemorrhagic stroke
    • 8.7. Anticoagulation treatment for other comorbidities in people with acute stroke
    • 8.8. Statin treatment in people with acute stroke
  • 9. Maintenance or restoration of homeostasis
    • 9.1. Supplemental oxygen therapy
    • 9.2. Blood sugar control
    • 9.3. Blood pressure control
  • 10. Nutrition and hydration
    • 10.1. Assessment of swallowing function
    • 10.2. Timing of enteral feeding
    • 10.3. Oral nutritional supplementation
  • 11. Early mobilisation and optimum positioning of people with acute stroke
    • 11.1.1. Clinical introduction
    • 11.1.2. Clinical methodological introduction
    • 11.1.3. Health economic methodological introduction
    • 11.1.4. Clinical evidence statements
    • 11.1.5. From evidence to recommendations
    • 11.1.6. RECOMMENDATIONS
  • 12. Avoidance of aspiration pneumonia
    • 12.1.1. Clinical introduction
    • 12.1.2. Clinical methodological introduction
    • 12.1.3. Health economic methodological introduction
    • 12.1.4. Clinical evidence statements
    • 12.1.5. From evidence to recommendations
    • 12.1.6. RECOMMENDATION
  • 13. Surgery for people with acute stroke
    • 13.1. Surgical referral for acute intracerebral haemorrhage
    • 13.2. Surgical referral for decompressive hemicraniectomy
  • 14. Research recommendations
    • Additional research recommendations identified by the group
• References
• Appendices
  • Appendix A. Clinical question and search strategies
  • Appendix B. Scope of the guideline and referral from the Department of Health
  • Appendix C. Model to determine the cost effectiveness of immediate specialist assessment in a stroke unit compared to specialist assessment at a weekly clinic or no specialist assessment
  • Appendix D. GDG members’ declaration of interests
• Evidence Tables

Royal College of Physicians: The Royal College of Physicians plays a leading role in the delivery of high-quality patient care by setting standards of medical practice and promoting clinical excellence. We provide physicians in the United Kingdom and overseas with education, training and support throughout their careers. As an independent body representing over 20,000 Fellows and Members worldwide, we advise and work with government, the public, patients and other professions to improve health and healthcare.

National Collaborating Centre for Chronic Conditions: The National Collaborating Centre for Chronic Conditions (NCC-CC) is a collaborative, multiprofessional centre undertaking commissions to develop clinical guidance for the National Health Service (NHS) in England and Wales. The NCC-CC was established in 2001. It is an independent body, housed within the Clinical Standards Department at the Royal College of Physicians of London. The NCC-CC is funded by the National Institute for Health and Clinical Excellence (NICE) to undertake commissions for national clinical guidelines on an annual rolling programme.

Suggested citation:

National Collaborating Centre for Chronic Conditions. Stroke: national clinical guideline for diagnosis and initial management of acute stroke and transient ischaemic attack (TIA). London: Royal College of Physicians, 2008.