New Stroke Guidance

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New Stroke Guidance

• Adrian Bergin
• Jon Scott
• Clinical Advisors for Stroke
• North East Cardiovascular Network

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NECVN Stroke Area

• Northumbria Healthcare FT
• Wansbeck
• North Tyneside
• Hexham
• Newcastle Hospitals FT
• Wearside
• Gateshead healthcare FT
• City Hospitals Sunderland FT
• South Tyneside FT

• County Durham and Darlington FT
• North Tees and Hartlepool FT
• South Tees Acute Trust
• Northern part of Yorkshire PCT

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What is Our Role?

• Provide clinical advice to the Network
• Distil clinical opinions from across the patch
• Foundation Trusts
• PCTs
• Summarise and comment upon
• New recommendations
• Guidance
• Models of service

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By the end of this session

• Be aware of the 2 recently published sources of
  guidance on stroke care
• Be able to broadly describe the new guidelines
  for stroke and TIA
• Be able to describe the differences and
  controversies within and between the guidelines
• Be aware of some of the recommendations for
  rehabilitation contained within the guidelines

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National Clinical Guidelines for Stroke

• July 2008 incorporating NICE guidance on acute
  stroke and TIA
• Over 300 specific recommendations covering almost
  every aspect of stroke management

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Chapters

• Introduction give it a miss
• Commissioning
• Structure
• Acute Care ( NICE guidance)
• Secondary Prevention
• Recovery and Rehabilitation
• Long-term care

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Chapter 4 Acute Phase Care (NICE Guidelines)
Rapid Symptom recognition and Diagnosis
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Implications for the Management of TIA

• High risk patients need to be seen within 24 hrs
  and brain imaging within 24 hr where indicated
  7 day service required
• Low risk patients assessed within one week
• Carotid imaging and referral for symptomatic
  carotid stenosis within one week (NSS 24 hours)
• CEA/stenting within two weeks (NSS 48 hours)
• Major changes in radiology and vascular surgery
  support

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Implications for the Management of Acute Stroke

• Access to brain imaging similar guidance
  remains problematic in head injury
• Delivery of thrombolysis personnel and support
  service / environment
• Access to stroke units (direct admission) by
  passing AE and AAU
• Need to decide within clinical network how
  services can be organised to deliver these
  standards

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Controversies

• Many of the recommendations based on consensus
  opinion
• Discrepancy between NSS and NICE on how quickly
  Carotid imaging and CEA should be performed
• Very early use of NG feeding
• Aspirin dose of 300 mg for first 2 weeks
• Evidence for Hyperacute stroke care-
  Concentration of services in a relatively small
  number of regional centres

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Chapter 5 Secondary Prevention

• Identify risk factors
• Personalised comprehensive approach
• Life style measures
• Blood pressure -130/80
• Lipid lowering therapy
• Anti-thrombotics-
• AspirinDipyridamole
• Anticoagulation for AF(after 14 days)
• Recurrent events no change in management
• Recommendations in CVT, Arterial dissection and
  antiphospholipid syndrome.

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Chapter 5 Secondary Prevention

• Carotid Stenosis
• Confirmatory imaging recommended
• Individualised risk assessments
• Imaging reports should state which measurement
  criteria used (NASCET / ECST)
• Angioplasty / stenting preferably only as part of
  a randomised clinical trial

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Chapter 3 Structure of Stroke Services
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Chapter 3 Structure of Stroke Services
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Chapter 6 Recovery Phase rehabilitation

• Only recommendation listed as key from this
  chapter.

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Chapter 6 Recovery Phase Rehabilitation. There
are 52 Recommendations in this chapter

• General principles
• Evaluating / stopping treatment
• Acupuncture
• Aerobic training
• Arm re-education
• FES
• Biofeedback
• Gait retraining etc
• Mental practice
• Orthoses
• Positioning
• Robotics
• Self efficacy training
• Splinting and stretching
• Resisted exercise
• Task specific training

• Balance impairment
• Shoulder pain / subluxation
• Neuropathic pain
• Depression and anxiety
• Cognitive impairments , memory, executive
  function
• Neglect, agnosia, Apraxia
• Mental capacity
• Aphasia, Apraxia, dysarthria
• Visual loss
• Bowel / bladder impairment
• Swallowing
• Nutrition
• Driving
• Equipment and adaptations
• Vocational activities

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Chapter 6 Recovery Phase rehabilitation 6.20
Spasticity
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Chapter 6 Recovery Phase rehabilitation 6.20
Shoulder pain
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Chapter 6 Recovery Phase rehabilitation 6.20
Swallowing problems
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Chapter 7 Long term Management
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Profession specific Concise guidelines

• Nursing
• Nutrition and dietetics
• Occupational therapy
• Physiotherapy
• Speech and Language therapy

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Chapter 2 Commissioning