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)

1. NHS
CANCER NHS Improvement
DIAGNOSTICS
Diagnostics and Stroke Improvement
HEART Why treat stroke and transient
ischaemic attacks (TIAs) as
LUNG emergencies?
STROKE

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. 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. 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. 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. NHS
CANCER
NHS Improvement
DIAGNOSTICS
HEART
NHS Improvement
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Improvement helps to transform, deliver and build sustainable improvements across
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