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TIA/Stroke Care Pathway Overview

There is evidence that rapid treatment improves outcome after stroke or transient ischaemic attack (TIA). This guidance covers the rapid diagnosis of people who have had sudden onset of symptoms that are indicative of stroke and TIA, the interventions in the acute and later stages and referral process. It incorporates the most recent NICE guideline updates (2019); please note the key points below:

  • In the event of a likely stroke – bluelight to Gloucester Royal Hospital (GRH) Emergency Department, up to 24 hours from onset.
  • Any suspected TIA (bearing in mind that their symptoms must be compatible with a TIA) should be referred urgently for specialist assessment and investigation within 24 hours of onset of symptoms (or as near to 24 hours as possible) via the TIA Assessment Service.
  • ABCD2 score is no longer recommended to assess risk of subsequent stroke or to inform urgency of referral for people who have had a suspected or confirmed TIA
  • Consider the appropriateness of a TIA referral carefully; about 50% of patients referred as suspected TIAs turn out to have an alternative diagnosis.

Please click the relevant flowchart box to be taken directly to textual information.

                

Presentation

Stroke and transient ischaemic attack (TIA) is the sudden onset of focal neurological dysfunction of presumed vascular origin. With a TIA this resolves within 24 hours (usually much sooner), whereas with a Stroke this persists beyond 24 hours.

Symptoms and signs are usually "negative" i.e. loss of function (they can be "positive" i.e. pins and needles, shaking, scintillations in vision, but this is rare):

  • Unilateral Face / arm / leg weakness and/or sensory loss
  • Speech disturbance e.g. dysphasia or dysarthria
    • Dysphasia =  impairment of the power of expression by speech, writing, or signs, or  impairment of the power of comprehension of spoken or written language
    • Dysarthria = slurred speech, problems articulating words
  • Visual disturbance e.g. Hemianopia = loss of vision to one side
  • Cerebellar signs: e.g. Ataxia, Vertigo, Vomiting, Nystagmus –
  • Dizziness or loss of balance or coordination
  • Confusion / inattention

A transient ischemic attack (TIA) is like a stroke, producing similar symptoms, but usually lasting only a few minutes and causing no permanent damage. The onset is abrupt, without intensification or spread. Maximal deficit usually occurs in a few seconds.  The offset is usually within 1 hour and always, by definition, within 24 hours.

Sudden, severe headaches can occur (but may also suggest an alternative diagnosis such as migraine).  Loss of consciousness is uncommon and syncope or seizures are more likely to cause loss of consciousness than a TIA.

TIAs can recur but frequent stereotyped attacks over weeks and months raises the possibility of partial seizure, hypoglycaemic episodes or other alternative diagnoses.

Red Flags
Stroke
Stroke is a medical emergency; with every minute that thrombolysis or thrombectomy is delayed impacting on the extent of the patient’s future recovery. The priority is to ensure the patient is conveyed to hospital for assessment for revascularisation immediately.
Symptoms and signs are usually "negative" i.e. loss of function (they can be "positive" i.e. pins and needles, shaking, scintillations in vision, but this is rare):
  • Unilateral Face / arm / leg weakness and/or sensory loss
  • Speech disturbance e.g. dysphasia or dysarthria
    • Dysphasia =  impairment of the power of expression by speech, writing, or signs, or  impairment of the power of comprehension of spoken or written language
    • Dysarthria = slurred speech, problems articulating words
  • Visual disturbance e.g. Hemianopia = loss of vision to one side
  • Cerebellar signs: e.g. Ataxia, Vertigo, Vomiting, Nystagmus –
  • Dizziness or loss of balance or coordination
  • Confusion / inattention
IN THE EVENT OF A LIKELY STROKE - BLUELIGHT TO Gloucester Royal Hospital (GRH) Emergency Department, up to 24 hours from onset. All patients will be assessed for Thrombolysis or Thrombectomy as appropriate.
Differential Diagnosis
  • Migraine
  • Epilepsy
  • Structural brain lesions:
    • Tumours
    • Chronic subdural haematomas
    • Vascular malformation
  • Other non-vascular causes:
    • Multiple sclerosis
    • Meniere’s disease
    • Hypoglycaemia
    • Hysteria
  • In patients with transient monocular symptoms:
    • Giant cell arteritis
    • Malignant hypertension
    • Glaucoma
    • Papilloedema
  • Transient global amnesia
Initial Assessment

TIA

Transient ischaemic attack (TIA) is the sudden onset of focal neurological dysfunction of presumed vascular origin that, by definition, resolves within 24 hours (usually much sooner). People who have had a suspected TIA may be at high risk of stroke if their symptoms are due to cerebrovascular disease i.e. if they have had a TIA.

Key Point

Consider the appropriateness of a TIA referral carefully. About 50% of patients referred as suspected TIAs turn out to have an alternative diagnosis.  Patients whose symptoms are not typical of a TIA or stroke may have their risk category downgraded during triage, at the discretion of stroke physicians.

What is not a TIA?

The following are unlikely to be due to a TIA:

  • Generalised weakness or sensory disturbance
  • Light-headedness
  • Faintness
  • Blackouts
  • Incontinence
  • Confusion

The following, if isolated, are also unusual - vertigo, tinnitus, dysphagia, dysarthria, diplopia, ataxia. 

If YES to any of the following features at onset, the diagnosis of TIA is unlikely and an appropriate alternative referral pathway should be used e.g. syncope clinic:

  • Gradual onset of spread of symptoms
  • Seizure or loss of consciousness
  • Transient amnesia
  • Isolated vertigo with no cranial nerve features
  • Migraine type visual auras with spreading tingling and numbness

Practice Point

ABCD2 score is no longer recommended to assess risk of subsequent stroke or to inform urgency of referral for people who have had a suspected or confirmed TIA

If patients have symptoms for which there is a strong clinical suspicion of a TIA, they should be referred to the TIA Assessment Service. The following factors will increase the urgency of referral to the TIA Assessment Service and put patients at a high risk of stroke:

  • TIA like symptoms and event within the last week  
  • People with crescendo TIA (two or more TIAs in a week) , within the last two weeks
  • Patients in atrial fibrillation
  • Patients on anticoagulants
  • Patients with known carotid stenosis (>50%)
Initial Primary Care Management

Any suspected TIA (bearing in mind that their symptoms must be compatible with a TIA) should be treated with:

  • Aspirin (or Clopidogrel if Aspirin allergic) started immediately 300mg stat then 75mg daily. Do not alter medication if currently on Aspirin; Warfarin or a NOAC (e.g. Rivaroxaban).
  • Specialist assessment and investigation within 24 hours of onset of symptoms (or as near 24 hours as possible) – via urgent referral to the TIA Assessment Service.
  • Measures for secondary prevention introduced as soon as the diagnosis is confirmed, including discussion of individual risk factors.

Advise all patients to:

  1. NOT drive until they have been seen by a specialist (when definitive guidance will be given).
  2. Return to ED or call 999 if positive FAST symptoms reoccur
  3. Have someone with them over night if possible, in case symptoms reoccur, until they have been seen by a specialist
When to Refer

Stroke

In the event of a likely stroke – bluelight patient to Gloucester Royal Hospital (GRH) Emergency Department, up to 24 hours from onset.

If delayed presentation, admit to GRH in most instances, particularly if there are persistent/ ongoing symptoms and if they are not improving. An admission for confirmation of the diagnosis and therapy reviews and rehabilitation will be helpful. However, non-disabling strokes where the patient is safe at home, has no dysphagia and is improving may be referred to TIA clinic which is an efficient way of assessing and investigating such patients.

TIA

All clear TIAs should be reviewed in a TIA clinic within 24hrs, where possible. Clinic slots are available at weekends for high risk patients.

Where a second opinion is needed about a suspected TIA, they will be reviewed in a TIA clinic review as soon as possible. Situations where lower priority may be given include:

  • Symptoms not typical of a TIA but for which a specialist opinion is needed
  • Symptoms several weeks or months ago

Please see the Services & Referrals section for details on how to refer.

Services
  • TIA services are based at Gloucestershire Royal Hospital (GRH). Clinics run from 1.30pm Monday - Friday and on weekend mornings (for high risk patients only)

  • Acute stroke services are located at Gloucester Royal Hospital providing 24/7 cover. This is run by 4 consultants and stroke specialist nurses

  • A thrombectomy service has been developed in Southmead Hospital for intra-arterial clot extraction for certain patients with acute ischaemic stroke – currently patients come to their local emergency department (i.e. GRH) and are then assessed and transferred if appropriate

  • Community based Early Supported Discharge is available 7/7

  • Community Stroke Nurse Service is available weekdays only

Please see the Services and Referrals Section for further information and contact details.

Secondary Care Management

Stroke

Urgent specialist assessment in ED. This includes a clinical assessment for thrombolysis or thrombectomy if appropriate with immediate CT brain scan and CT angiogram if necessary. Other patients get a CT within one hour of arrival if possible.

Decided on a case by case basis but may include:

  • unenhanced CT brain
  • CT angiogram
  • CT perfusion (expected to be available mid 2020  in GRH)
  • MRI brain scan
  • MR angiogram
  • CT or MR venogram
  • ECGs
  • Inpatient telemetry
  • Holter monitoring
  • Routine and special blood tests

Decided on a case by case basis but may include some of the following;

  • Aspirin 300mg after CT scan if haemorrhage excluded
  • Urgent BP management for haemorrhages
  • Intravenous alteplase

Admission to the acute stroke unit for ongoing management which includes acute physiological monitoring, hydration, swallow assessment, artificial nutrition if necessary, multidisciplinary therapy assessment, DVT prophylaxis,  further targeted investigations.

Typically antiplatelets, anticoagulants for AF, antihypertensives, statins

Typically 6-8 weeks for first OP assessment (not if patients are on end of life care or severely disabled and discharged to nursing homes). Some patients need further secondary care appointments for specific issues e.g. spasticity management. Six month follow up by community stroke coordinators.

 

TIA

 

Priority will be assessed by stroke consultants with higher priority given to those:

  • whose symptoms fit a TIA
  • with events within the last week
  • with crescendo TIAs
  • with AF, known carotid stenosis or those on anticoagulants
Ongoing Care

Ongoing care following a stroke

Follow up care

Typically 6-8 weeks for first Out Patient assessment (not if patients are on end of life care or severely disabled and discharged to nursing homes).

Some patients need further secondary care appointments for specific issues e.g. spasticity management.

Six month follow up by community stroke coordinators (see below).

 

Community Stroke Co-ordinator Service

The service provides:

  • Follow up after hospital discharge (6 monthly)
  • Support and education at home for people living with the effects of stroke in the community.
  • Education through the Life after Stroke Programme for self-management of the effects of stroke.
  • Support and advise to the carers of stroke survivors in the community and signposting them to support services.
  • Involvement in educational programmes for anyone involved in the care of stroke patients in community hospitals/acute hospitals trust/social services and care homes.

The team receive referrals from the acute hospitals, community and primary care services, please see the referral form.

Please follow this link for further information.

 

Early Supported Discharge Team

The Early Supported Discharge (ESD) team are based in the community and provide intensive rehabilitation for stroke patients at their place of residence for up to 6 weeks. The team consists of occupational therapists, physiotherapists, speech and language therapists, rehabilitation assistants, community stroke co-ordinators, administration assistants and psychologists.  Referrals are received through the acute stroke units at GRH.

 

Ongoing Care following a TIA

Primary Care Management

  • Long term risk factor management e.g. Blood Pressure and Lipids
  • Monitor blood pressure-lowering treatment frequently and adjust treatment as tolerated to achieve a target systolic blood pressure below 130 mmHg (or 140–150 mmHg in people with severe bilateral carotid artery stenosis).
  • Lipid target - the aim of statin therapy is to reduce non-HDL cholesterol by more than 40%.If this reduction is not achieved within 3 months, consider adherence, diet, lifestyle, and increasing dose.
  • Optimizing diabetes control and lifestyle advice.
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