NHSCANCER                                        NHS ImprovementDIAGNOSTICS              Diagnostics and Stroke Improvemen...
1   Why treat stroke and transient ischaemic attacks (TIAs) as emergencies?    Stroke    During a stroke 1.9 million neuro...
2   Why treat stroke and transient ischaemic attacks (TIAs) as emergencies?    So the old response ‘we can’t cope    with ...
3   Why treat stroke and transient ischaemic attacks (TIAs) as emergencies?    Transient ischaemic attacks (TIA)         •...
4   Why treat stroke and transient ischaemic attacks (TIAs) as emergencies?    References    1.   Stroke management guidel...
NHSCANCER                                                                                        NHS ImprovementDIAGNOSTIC...
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Why treat stroke and transient ischaemic attacks as emergencies?


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Diagnostics and Stroke Improvement launched this publication on “Why treat stroke and transient ischaemic attacks (TIAs) as emergencies”. This publication highlights the benefits and provides examples of how radiology departments have managed to meet these demands
(Jun 2010)

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Why treat stroke and transient ischaemic attacks as emergencies?

  1. 1. NHSCANCER NHS ImprovementDIAGNOSTICS Diagnostics and Stroke ImprovementHEART Why treat stroke and transient ischaemic attacks (TIAs) asLUNG emergencies?STROKE
  2. 2. 1 Why treat stroke and transient ischaemic attacks (TIAs) as emergencies? Stroke During a stroke 1.9 million neurons die every minute. In that same minute, the brain loses 14 billion synapses and 7.5 miles of myelinated fibres. Surrounding the dead cells is a penumbra of salvageable but at-risk neurons. In the past, stroke was diagnosed on clinical grounds and we only scanned the occasional suspected haemorrhage. Recent improvements in clinical management have demonstrated that stroke outcome can be significantly improved by early active interventions such as thrombolysis, specialist nursing care, physiotherapy and speech therapy. There is abundant guidance telling Saving penumbra saves functioning This has led to the development of us what we need to do and why - neural tissue, but also saves neurons stroke units akin to coronary care Intercollegiate guidelines, National for improved plasticity response in units – a good stroke unit improves Stroke Strategy, NICE Stroke regaining function – quality of life, outcome for the patient by: Guidance.1 2 3 4 5 5 independence etc. • Reducing mortality; There is also plenty of evidence that Further - there is a large body of • Reducing length of stay; active stroke management does research and analysis that shows • Improving functional recovery make a difference, and increasingly that immediate brain imaging for and minimising residual disability; our own speciality is leading the way stroke has high clinical utility and is • Increasing the chance of a return in demonstrating ways in which the very cost-effective.9 10 Who can to independent existence. brain adapts and recovers argue against reducing bed days, (functional MRI, functional improving clinical outcome and To achieve this, physicians need to PET, etc).7 8 saving money – particularly at a time confirm the diagnosis, exclude of financial stringency? haemorrhage, eliminate stroke The recovery potential of the brain is mimics, and have some idea of the amazing. We can help to maximise vascular territory affected and the salvage of the penumbra so size of the infarct. Most or all of this minimising the amount of dead can be gained from an early CT brain, and the ‘plasticity’ of the scan. Currently most of us don’t do brain then enables it to recover too well on this: 6 function even further.
  3. 3. 2 Why treat stroke and transient ischaemic attacks (TIAs) as emergencies? So the old response ‘we can’t cope with all the urgent head trauma and Real recent data from a UK radiology department abdominal CTs - why should we rush to scan stroke patients when it 500 doesn’t make any difference?’ is no 450 longer appropriate. It does make a 400 Number of Patients difference, particularly where patient 350 management is based on proper 300 processes and a dedicated stroke 250 unit, and radiology should be 200 pleased to be part of improving 150 stroke patient outcome. 100 For example - can you devise a 50 process where stroke patients go 0 from the point of admission (A&E 0 4 8 12 16 20 24 28 32 36 40 44 48 etc) via CT directly to the stroke Time from stroke to first brain scan (hours) unit? Others have. We are going to scan all stroke patients sooner or later, lets try to make it sooner, and be useful. To review the current guidance: The RCP Sentinel Audit for Stroke 2008 • Patients with stroke who are candidates for thrombolysis or 100 for some other urgent categories should take the next available CT Optimal Recovery Neurological score slot in-hours and be scanned within an hour out-of-hours. • No stroke patient should wait Plasticity longer than 24 hours before they No Recovery have a CT scan of the brain. 30 ..… and a new target: 0 3 months 6 months • 50% of stroke patients to be Time after stroke scanned within one hour of hospital arrival (by April 2011).
  4. 4. 3 Why treat stroke and transient ischaemic attacks (TIAs) as emergencies? Transient ischaemic attacks (TIA) • High risk TIAs should have • Patients are assessed and have Transient ischaemic attacks (TIA) carotid imaging and treatment their acute stroke diagnosed by have traditionally been diagnosed within 48 hours. trained ambulance paramedics. on clinical grounds, with relatively • Low risk TIAs should have carotid When the patient is a suitable few patients being imaged in the imaging within seven days, and candidate for thrombolysis the acute phase. Evidence has emerged definitive treatment within two ambulance crew pre-warns CT recently that there is a higher risk of weeks. staff. The patient is delivered a stroke in the period immediately • All these investigations need to straight to CT. Where this is done after a TIA than previously thought. be reported within this time the median door-to-needle time This risk is around 20% in the first frame. for thrombolysis is as short as 10 four weeks. The ABCD2 scoring minutes. system allows patients to be How to do it • Extended working day and/or stratified into high and low risk For most departments in the UK weekend working in CT and MR groups according to age, blood these are challenging (but increases capacity and allows pressure, clinical features, duration achievable) ambitions. more timely stroke and TIA of symptoms and co-existent imaging. diabetes. So why should we bother? Because • Shift working of radiographers It is important therefore that this is a setting in which our input and training of additional patients who have suffered a TIA can make a huge difference to radiographers to perform head undergo prompt assessment and individual patients and to the CT allows scans to be performed treatment, particularly if they fall population as a whole. In contrast to promptly by staff already working into the high risk group. Around many of the things that we willingly in the department at night and 80% of patients with TIAs require offer, the potential benefit is actually during the weekend. carotid imaging and around half will based on very good evidence. Yes, it • Outsourcing of out-of-hours CT require bain imaging. will be difficult, but it will be worth reporting to other trusts or private the effort. providers reduces the additional The current guidance for imaging in demand on radiologists. TIAs is: Some examples of how radiology • Instead of performing a full head departments have managed to meet MR protocol for TIA patients • MRI with diffusion-weighted these demands:11 several weeks after the event imaging should be available for (which is of no benefit), some patients with suspected TIA if • The patient pathway is redesigned units have adopted a one-stop there is doubt about the diagnosis so that stroke patients always service by using an abbreviated or the vascular territory (ie carotid have a CT on their way from but still effective scan protocol (eg or vertebrobasilar). In high risk A&E/Medical Assessment Unit to axial T2W and DWI only). cases this should be done within the stroke unit. Where this is 24 hours, otherwise within a routine practice there is no week. difficulty in scanning all stroke patients within 24 hours.
  5. 5. 4 Why treat stroke and transient ischaemic attacks (TIAs) as emergencies? References 1. Stroke management guidelines. Intercollegiate working party, 2004 www.rcplondon.ac.uk/pubs/books/stroke/stroke_guidelines_2ed.pdf 2. National Stroke Strategy. Department of Health, 2007 www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_081062 3. National clinical guideline for diagnosis and initial management of acute stroke and transient ischaemic attack (TIA) - NICE guidance (published by RCP 21st July 2008) http://guidance.nice.org.uk/CG68/Guidance/pdf/English 4. Guidelines for Management of Ischaemic Stroke and Transient Ischaemic Attack 2008 The European Stroke Organization (ESO) Executive Committee and the ESO Writing Committee www.eso-stroke.org/pdf/ESO08_Guidelines_English.pdf Presentation based on - Guidelines for Management of Ischaemic Stroke 2008 www.eso-stroke.org/ppt/ESO08_Slides_25thApril.PPT 5. Guidelines for the Early Management of Adults With Ischemic Stroke Stroke. 2007;38:1655 Guideline From the American Heart Association/ American Stroke Association Stroke Council, Clinical Cardiology Council, Cardiovascular Radiology and Intervention Council, and the Atherosclerotic Peripheral Vascular Disease and Quality of Care Outcomes in Research Interdisciplinary Working Groups. 6. Dr Foster Case Notes BMJ Volume 328 14 February 2004 7. Functional Recovery After Stroke Reviews on Recent Clinical Trials, 2006, Vol. 1, No. 1 77 8. Functional Neuroimaging Studies of Motor Recovery After Stroke in Adults: A Review Stroke 2003;34;1553-1566; originally published online May 8, 2003; Cinzia Calautti and Jean-Claude Baron 9. Immediate Computed Tomography Scanning of Acute Stroke Is Cost-Effective and Improves Quality of Life Stroke 2004;35;2477-2483; originally published online Sep 30, 2004; Joanna M. Wardlaw, Janelle Seymour, John Cairns, Sarah Keir, Steff Lewis and Peter Sandercock 10. What is the best imaging strategy for acute stroke? Health Technology Assessment 2004; Vol. 8: No. 1 JM Wardlaw, SL Keir, J Seymour, S Lewis, PAG Sandercock, MS Dennis and J Cairns 11. Case Studies - NHS Improvement A selection of case studies demonstrating how clinical teams have implemented changes in CT, MR and Doppler Ultrasound to support the National Stroke Strategy www.improvement.nhs.uk/diagnostics
  6. 6. NHSCANCER NHS ImprovementDIAGNOSTICSHEART NHS Improvement With over ten years practical service improvement experience in cancer, diagnosticsLUNG and heart, NHS Improvement aims to achieve sustainable effective pathways and systems, share improvement resources and learning, increase impact and ensure value for money to improve the efficiency and quality of NHS services. Working with clinical networks and NHS organisations across England, NHS Improvement helps to transform, deliver and build sustainable improvements acrossSTROKE the entire pathway of care in cancer, diagnostics, heart, lung and stroke services. NHS Improvement 3rd Floor | St John’s House | East Street | Leicester | LE1 6NB Telephone: 0116 222 5184 | Fax: 0116 222 5101 www.improvement.nhs.uk Delivering tomorrow’s improvement agenda for the NHS