Stroke and transient ischaemic attack in over 16s: diagnosis and initial management

Context

Since NICE published its guideline on stroke and transient ischaemic attack (TIA) in 2008, the management of stroke has changed. New evidence has emerged in areas such as thrombectomy (clot retrieval procedures) in ischaemic stroke, controlling high blood pressure in people with acute haemorrhagic stroke, the role of hemicraniectomy and early mobilisation and optimum positioning of people with acute stroke. In addition, there is some uncertainty about the use of aspirin when TIA is first suspected, the role of conventional risk stratification in TIA and the best approach to intracerebral imaging after TIA. This guideline update includes recommendations on these specific issues.

A stroke occurs when the blood supply to a part of the brain is acutely compromised. Most strokes (85%) are caused by a blockage in a blood vessel (artery) that supplies blood to the brain. A TIA or 'mini stroke' has the same clinical presentation as a stroke except that symptoms disappear within 24 hours.

The symptoms experienced depend on the part of the brain that is affected. They usually occur suddenly and without any warning. Common symptoms include loss of movement or sensation in an arm or leg, problems speaking, a drooping of one side of the face or problems with vision.

A stroke can occur at any age. The average age for stroke varies across the UK, with a median age of 77 years (interquartile range 67 to 85). A quarter of strokes occur in people of working age.

First-ever stroke affects 230 people per 100,000 each year, with over 80,000 people hospitalised per year in England. Although the death rate has been falling, figures from the Sentinel Stroke National Audit Programme show that 13.6% of people admitted to hospital with stroke in England and Wales died (either in hospital or after being discharged from inpatient care) within 30 days. There are approximately 1.2 million stroke survivors in the UK. The risk of recurrent stroke is 26% within 5 years of a first stroke and 39% by 10 years.

Stroke is the single biggest cause of disability in adults. The Stroke Association has estimated an annual cost to the NHS in England of £2.98 billion per year. In addition, annual social care costs have been estimated at £4.55 billion with almost half of that estimated to be from public funds. Of stroke survivors, 1 in 12 have to move into a care home because of the effects of their stroke. There is also a substantial burden to families of people who have had a stroke in terms of informal unpaid care. The importance of stroke care in the NHS is also highlighted in the NHS Long Term Plan, the National Stroke Programme, the Intercollegiate Stroke Working Party national clinical guideline for stroke, and the 2018 publication of NHS England's clinical commissioning policy for mechanical thrombectomy for acute ischaemic stroke in the NHS. Also, the Royal College of Paediatrics and Child Health published guidelines in 2017 on the treatment of stroke in those under 18 years old.

This guideline covers people over 16 with suspected or confirmed TIAs or completed strokes, that is, an acute neurological event presumed to be vascular in origin and causing cerebral ischaemia, cerebral infarction or cerebral haemorrhage. This includes first and recurrent events, thrombotic and embolic events and primary intracerebral haemorrhage of any cause, including venous thrombosis. Areas that are not covered include specific issues relating to the general management of underlying conditions and subarachnoid haemorrhage.