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26-09-2012 | Stroke | Article

UK guideline update focuses on whole stroke pathway


Royal College of Physicians

medwireNews: The fourth edition of the UK National Clinical Guideline for Stroke challenges healthcare professionals to deliver quality stroke services across the whole pathway, including rehabilitative care.

The guideline, from the Intercollegiate Stroke Working Party, is comprehensive, taking in commissioning of services, through delivery of medical care, to provision of rehabilitation.

"What I'm pleased about is the re-emphasis of the really core important things," Peter Langhorne, President of the British Association of Stroke Physicians, told medwireNews.

"It talks about… commissioning across the whole pathway; it's not all focused on the very sexy front-end stuff. It's the whole pathway."

The guideline is aimed at all disciplines that are involved in delivering stroke care, including sections aimed at nurses, dietitians, and rehabilitation therapists. "In the round, if you look at the whole guideline together, it's more about getting the right care to the right people, as many of the right people as quickly as possible, and that's the recurring theme through the whole guideline," says Langhorne.

The International Stroke Trial (IST)-3 makes its presence felt in the guideline, with thrombolysis now recommended for patients older than 80 years who present within 3 hours of symptom onset.

The previous exclusion of the over 80s from thrombolysis was down to their absence from most of the pivotal clinical trials, resulting in a very weak evidence base. "I think what IST-3 has managed to do is to capitalize on that uncertainty and really give us good evidence now," said Langhorne.

Other specific recommendations are for prompt oral anticoagulation for patients with transient ischemic attack (TIA) and atrial fibrillation; carotid surgery, where indicated, to be performed within 7 days; and for all patients to undergo brain imaging within 12 hours of presentation - down from 24 hours in the previous guideline.

Clopidogrel should now be the first-line antiplatelet treatment for TIA patients, as well as for stroke patients.

The guideline also contains cautions, advising against carotid surgery for asymptomatic stenosis, preferring carotid surgery to stenting in patients with symptoms, and restricting intra-arterial intervention to clinical trials.

But delivering such comprehensive care is no easy task, with the National Sentinel Stroke Audit routinely finding large variations in stroke care across England and Wales.

Langhorne believes that many barriers occur when stroke care falls at the boundary between two different departments or disciplines, and there is no clear ownership.

Where delivering stroke care requires a change of practice, "you've got to take time out, think how to do things differently, and plan a different way of providing care," said Langhorne. "And I think that's where something like the guidelines are really good for focusing minds and encouraging people to look at things differently."

medwireNews ( is an independent clinical news service provided by Springer Healthcare Limited. © Springer Healthcare Ltd; 2012

By Eleanor McDermid, Senior medwireNews Reporter