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

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

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

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

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

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

Chapter 4 Acute Phase Care (NICE Guidelines) Rapid Symptom recognition and Diagnosis

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

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 A+E and AAU Need to decide within clinical network how services can be organised to deliver these standards

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

Chapter 5 –Secondary Prevention Identify risk factors Personalised comprehensive approach Life style measures Blood pressure -130/80 Lipid lowering therapy Anti-thrombotics- Aspirin+Dipyridamole Anticoagulation for AF(after 14 days) Recurrent events – no change in management Recommendations in CVT, Arterial dissection and antiphospholipid syndrome.

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

Chapter 3 – Structure of Stroke Services

Chapter 6 : Recovery Phase rehabilitation Only recommendation listed as key from this chapter.

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

Chapter 6 : Recovery Phase rehabilitation – 6.20 Spasticity

Chapter 6 : Recovery Phase rehabilitation – 6.20 Shoulder pain

Chapter 6 : Recovery Phase rehabilitation – 6.20 Swallowing problems

Chapter 7 – Long term Management

Profession specific Concise guidelines Nursing Nutrition and dietetics Occupational therapy Physiotherapy Speech and Language therapy

Chapter 2 – Commissioning