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National Collaborating Centre for Chronic Conditions (UK). Stroke: National Clinical Guideline for Diagnosis and Initial Management of Acute Stroke and Transient Ischaemic Attack (TIA). London: Royal College of Physicians (UK); 2008. (NICE Clinical Guidelines, No. 68.)

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Stroke: National Clinical Guideline for Diagnosis and Initial Management of Acute Stroke and Transient Ischaemic Attack (TIA).

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Appendix BScope of the guideline and referral from the Department of Health


1. Guideline title

Stroke: national clinical guideline for diagnosis and initial management of acute stroke and transient ischaemic attack (TIA).

1.1. Short title


2. Background

  1. The National Institute for Health and Clinical Excellence (‘NICE’ or ‘the Institute’) has commissioned the National Collaborating Centre for Chronic Conditions (NCC-CC) to develop a clinical guideline on acute stroke and TIA for use in the NHS in England and Wales. This follows referral of the topic by the Department of Health (DH). The guideline will provide recommendations for good practice that are based on the best available evidence of clinical and cost effectiveness.
  2. The Institute’s clinical guidelines will support the implementation of National Service Frameworks (NSFs) in those aspects of care where a Framework has been published. The statements in each NSF reflect the evidence that was used at the time the Framework was prepared. The clinical guidelines and technology appraisals published by the Institute after an NSF has been issued will have the effect of updating the Framework.
  3. In parallel to the development of the Institute’s acute stroke and TIA clinical guideline, the Royal College of Physicians’ Intercollegiate Stroke Working Party will also be updating their guideline to focus on longer-term management and rehabilitation. The developers will work closely with the Intercollegiate Stroke Working Party to ensure continuity and to avoid any overlapping or gaps.
  4. The DH has developed a National Stroke Strategy which was published in 2007. This addresses many of the issues regarding service models, structures and staffing. Where possible, this guideline will work closely with the Stroke Strategy Project Executive.
  5. NICE clinical guidelines support the role of healthcare professionals in providing care in partnership with patients, taking account of their individual needs and preferences, and ensuring that patients (and their carers and families, where appropriate) can make informed decisions about their care and treatment.

3. Clinical need for the guideline

  1. Stroke is the third most common cause of death in the UK, and one of the most important causes of significant adult disability. Each year in the UK, approximately 120,000 people have a first stroke, 30% of whom die within a month. In addition, about 30,000 recurrent strokes occur. The risk of having a stroke before the age of 85 years is one in four for men, and one in five for women.
  2. Stroke is a medical emergency and brain damage can be reduced if stroke is identified early enough.
  3. Stroke and transient ischaemic attack (TIA) are very similar, the only difference being that the symptoms of TIA resolve completely within 24 hours, and stroke symptoms and signs persist. With refined sensitive imaging techniques, it has been clearly shown that many people who have experienced a TIA have sustained significant permanent cerebral damage. TIA is not, therefore, a benign condition. Stroke and TIA management depends upon accurate diagnosis of the underlying pathology and aetiology.
  4. The risk of stroke within the first month after a TIA can be as high as 32% for some patient groups. With effective diagnosis, investigation and treatment, many strokes could be prevented.
  5. The recent National Audit Office report ‘Reducing brain damage: faster access to better stroke care’ identified major problems with the consistent delivery of high-quality stroke care to all patients in England. Evidence clearly demonstrating that stroke is both a preventable and treatable disease has accumulated rapidly over recent years, but health services have been slow to reflect this.
  6. The National Sentinel Audit in 2006 covering all hospitals in England, Wales and Northern Ireland showed that 78% of hospitals have a neurovascular clinic where only 35% of patients are seen within 7 days. Few hospitals had protocols agreed between the ambulance service and the acute Trust to ensure rapid transfer of patients with stroke to casualty, and access to brain scans remains difficult for some, particularly outside normal working hours.
  7. The cost of stroke care is high, with an estimate in the National Audit Office report of £7 billion per year. Much of this is spent on providing longer-term healthcare, social services and financial support to people with residual disability. More effective acute treatment would save lives and money.

4. The guideline

  1. The guideline development process is described in detail in two publications which are available from the NICE website (see ‘Further information’). ‘The guideline development process: an overview for stakeholders, the public and the NHS’ describes how organisations can become involved in the development of a guideline. ‘The guidelines manual’ provides advice on the technical aspects of guideline development.
  2. This document is the scope. It defines exactly what this guideline will (and will not) examine, and what the guideline developers will consider. The scope is based on the referral from the DH.
  3. The areas that will be addressed by the guideline are described in the following sections.

4.1. Population

4.4.1. Groups that will be covered
  • Patients with transient ischaemic attacks (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

    primary intracerebral haemorrhage of any cause, including venous thrombosis.

4.4.2. Groups that will not be covered
  1. Specific issues relating to the general management of underlying conditions will not be considered, but the immediate management to reduce the extent of brain damage will be included.
  2. Subarachnoid haemorrhage.
  3. Children (16 and under).

4.2. Healthcare setting

Primary and secondary NHS healthcare settings, including referral to tertiary care.

  • Pre-hospital emergency care settings, including ambulance services.

4.3. Clinical management

The purpose of the guideline is to describe the initial and early management (without specifying a fixed time) aimed at reducing the ischaemic brain damage, and in the case of TIAs, preventing subsequent stroke. This includes:

  1. the rapid recognition of symptoms and diagnosis
  2. initial and early management of stroke and TIA
  3. diagnostic procedures aimed to delineate the nature and location of the pathology
  4. treatment interventions that aim to minimise the pathology
  5. management and maintenance of homeostasis (including fluids, nutrition and oxygen therapy)
  6. initial and early pharmacotherapies including thrombolysis (note that guideline recommendations will normally fall within licensed indications; exceptionally, and only where clearly supported by evidence, use outside a licensed indication may be recommended. The guideline will assume that prescribers will use the ‘Summary of product characteristics’ to inform their decisions for individual patients).
  7. management of complications where these are likely to affect the area of brain damage (for example, the early use of anticoagulants for venous thromboembolism in acute stroke)
  8. non-pharmacological management, including the role of early mobilisation and positioning
  9. indications for referral for specific interventions (for example, carotid angioplasty, carotid endarterectomy)
  10. identification of people who need continuing or early anticoagulation.

4.4. Status

4.4.1. Scope

This is the final version of the scope. It has been out for consultation, modified in response to comments received and signed off by one of NICE’s independent Guidelines Review Panels.

4.4.2. Development of guideline recommendations

The development of the guideline recommendations began in November 2006.

5. Further information

Information on the guideline development process is provided in:

  • ‘The guideline development process: an overview for stakeholders, the public and the NHS
  • ‘The guidelines manual’.

These booklets are available as PDF files from the NICE website:

5.1. Referral from the Department of Health

The Department of Health (DH) asked the Institute:

‘To prepare a clinical guideline on the diagnosis and acute management of stroke and transient ischaemic attack, concentrating on initial treatment.’

Copyright © 2008, Royal College of Physicians of London.

All rights reserved. No part of this publication may be reproduced in any form (including photocopying or storing it in any medium by electronic means and whether or not transiently or incidentally to some other use of this publication) without the written permission of the copyright owner. Applications for the copyright owner’s written permission to reproduce any part of this publication should be addressed to the publisher.

Bookshelf ID: NBK53292
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