Guidance

Update information

Update information

April 2022: We have:

  • reviewed the evidence on blood pressure control for people with acute intracerebral haemorrhage and

  • updated recommendations 1.5.4, 1.5.5, 1.5.6 and 1.5.8.

May 2019: We have reviewed the evidence on 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, we have addressed the use of aspirin when transient ischaemic attack (TIA) is first suspected, the role of conventional risk stratification in TIA and the best approach to intracerebral imaging after TIA. These recommendations are marked [2019].

We have also made some changes without an evidence review:

  • Recommendation 1.1.7 has been made consistent with new recommendations in relation to rapid referral and review in the TIA clinic. The remaining part of the recommendation has been replaced by recommendations 1.1.4 to 1.1.6.

  • Recommendation 1.2.3 has been made consistent with new recommendations in relation to rapid referral and review in the TIA clinic.

  • Recommendation 1.2.4 has been made consistent with new recommendations in relation to rapid referral and review in the TIA clinic and to omit the European Carotid Surgery Trial (ECST) criteria because these are no longer used.

  • Recommendation 1.3.2 has been amended because early coagulation therapy is not relevant in this context. Non-enhanced means 'plain'; it is the basic form of CT scan without any contrast (that is, not CT angiography/perfusion). At this very early stage in the diagnostic pathway, acute stroke is still 'suspected'; the CT may show up an alternative diagnosis or further clinical assessment may also reveal an alternative diagnosis (the CT is often performed directly off the ambulance when there is little more than 'FAST +ve' criteria). CT angiography and CT perfusion indications have been added to be consistent with the new recommendations on thrombectomy.

  • Recommendation 1.4.2 has been amended to clarify that the levels relate to the level of care required by the patient.

  • Recommendation 1.5.7 has been amended to be consistent with the subheading for this recommendation, which now applies to acute ischaemic stroke (that is, not haemorrhagic stroke). The remaining part of the recommendation has been replaced by recommendation 1.5.5.

These recommendations are marked [2008, amended 2019].

Recommendations marked [2008] last had an evidence review in 2008. In some cases, minor changes have been made to the wording to bring the language and style up to date, without changing the meaning.

Minor changes since publication

August 2023: We added links to the MHRA safety advice on DOACs and NICE's technology appraisal guidance on andexanet alfa for reversing anticoagulation from apixaban or rivaroxaban (TA697) to the section on reversal of anticoagulation treatment in people with haemorrhagic stroke.

July 2023: We added reference to the European Carotid Surgery Trial criteria in recommendation 1.2.4.

March 2023: We have corrected the link in recommendation 1.2.4.

October 2022: We added text to indicate that pulse oximetry may be less reliable in people with dark skin. We also added a link to the NHS patient safety alerton the risk of harm from inappropriate placement of pulse oximeter probes. See recommendation 1.5.1.

November 2021: We added a link to the NHS England and NHS Improvement National Stroke Service Model in section 1.3 on specialist care for people with acute stroke.

October 2020: We added the recommendations for research from the 2008 guideline.

April 2020: We corrected the links to the rationales in section 1.1 on rapid recognition of symptoms and diagnosis.

ISBN: 978-1-4731-3386-0