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1. Background

Stroke affects approximately 120,000 people per year in the UK with another 30-40,000 having transient ischemic attacks (TIA). The average age of stroke patients is 75 years but the condition can affect people of all ages including children. Stroke accounts for 10% of deaths in England (50,000 per year) and although good data are lacking, there are probably 900,000 people living with the consequences of stroke. One in four people can expect to have a stroke if they live to 85 years. Although stroke mortality rates have fallen over the last 20 years they have not reduced as much as coronary artery disease and look likely to miss target set in ‘Our Healthier Nation’ of a 40% reduction in the under 75’s by 2010. The chance of dying after a stroke has remained constant at around 24% while the risk of dying after a heart attack has fallen by about 1.5% per annum. Stroke is expensive. The average length of stay in hospital is 28 days but there is considerable variation. One in five acute beds and one in four long term beds are occupied at any one time by stroke patients and as society ages it is predicted that this will increase further. Geriatricians continue to provide the majority of stroke care in the UK on stroke units, geriatric wards, as out-patients and in care homes. The development of stroke as a separate sub-specialty has been important in raising awareness of the disease among health professionals. The National Audit Office report on stroke (Reducing Brain Damage: Faster access to better stroke care), published in 2005 showed that the overall cost of stroke to society is about £7b per year, of which £2.8b are direct healthcare costs compared to only £1.9b for coronary heart disease. The vast majority of this money is spent on diagnosis and inpatient care (£590m) with outpatient costs being £46m. Outpatient drug costs are however huge at £507m, but dwarfed by community care costs including the cost of institutional care at £1.7b. Informal care is estimated to cost £2.4b and indirect costs (loss of earnings and benefit payment £1.8b).

2. Prevention

Stroke is in most cases a preventable disease, through aggressive management of hypertension, hyperlipidemia, atrial fibrillation and other vascular risk factors. Geriatricians have a role in working with primary care clinicians to deliver high quality prevention, particularly to high risk patients. Although the evidence for many prevention treatments is lacking in older peole because of the failure to include older people in trials, the assumption should be in most cases that treatments appropriate for younger patients are equally applicable to older people.

3. Diagnosis and Investigation

Stroke is a clinical diagnosis defined by the WHO as “A focal (or at times global) neurological impairment of sudden onset, and lasting more than 24 hours (or leading to death), and of presumed vascular origin.” However, this is inadequate as a definition for clinicians needing to provide effective treatment and prevention advice. Clinical scoring systems to differentiate between infarction and haemorrhage are inadequate and the only way to define pathology accurately is by brain imaging. CT scanning is adequate for most patients and should be performed as soon as possible after stroke. Some patients require immediate scanning (those being considered for thrombolysis, patients on anticoagulants, possible subarachnoid haemorrhage and those with a depressed level of consciousness). The remaining patients should not have to wait more than 24 hours for the definitive investigation. MRI scanning is the investigation of choice for posterior circulation stroke and for patients where scanning has been delayed for more than 10 days after the onset of symptoms (haemorrhage can be difficult to differentiate from infarction after this time). The underlying cause for the stroke needs to be identified and will require a range of investigations including bloods, imaging of the cerebral circulation and cardiac assessment.

Investigation of TIA should be regarded as a medical emergency, particularly for high risk patients where the chances of progressing to stroke within the first month may be as high as 30%. Use of a scoring system to evaluate risk such as the ABCD 2 test is recommended. Patients with a high ABCD 2 score (4 or above) should be assessed and managed as a medical emergency. There is a strong argument to admit these patients for 24-48 hours so that they are readily treatable with thrombolysis if they have a completed stroke. Patients with a score of below 4 should be seen and investigated within (at the most) 7 days. Geriatricians running neurovascular clinics should develop close working relationships with the vascular surgeons and arrangements that enable patients to be admitted for carotid endarterectomy within as short a time as possible after the TIA (ideally within 48 hours). Where brain imaging is required then MRI is the modality of choice. Carotid imaging can be undertaken with ultrasound, MR angiography or CT angiography. There is no evidence to suggest that age should on its own influence clinical decision making in stroke and TIA. For example while the risks of surgery may increase with age the benefits will also increase.

4. Assessment and Acute Management

Stroke is a medical emergency. Rapid diagnosis and intervention can improve prognosis. Public awareness campaigns such as the FAST (Face, Arm, Speech Test) to inform the public how to respond have been beneficial but need constant reinforcement. Patients and carers should be advised to dial 999 if stroke symptoms develop. Paramedics and A&E staff should receive training in the recognition and acute management of stroke and patients should expect immediate admission to an acute stroke unit if there are any residual neurological symptoms or signs. Thrombolysis with alteplase significantly reduces death and disability when given to appropriate patients within three hours of the onset of symptoms but should only be administered in centres with the necessary expertise and experience as the treatment carries significant risk of precipitating intracerebral haemorrhage and this complication is more likely when treatment is given to inappropriate patients. Thrombolysis is not licensed for treatment of patients over the age of 80 years, however there are trials currently being performed looking at whether the benefits identified for younger patients are also present in the older stroke population. Geriatricians often take the lead in stroke management in acute trusts. Where this is not the case the ideal system is for close working between the stroke physician and the geriatric department.

5. Rehabilitation and Longer-term Management

Provision of high quality rehabilitation is essential for all stroke services and this should cover both the hospital and community sectors. Recovery after stroke is hugely variable between patients, but can continue for several years after the initial brain injury. It is therefore imperative that services are provided according to individual need that reflects these patterns of recovery. The vast majority of stroke patients should be managed initially in hospital and the evidence strongly supports the stroke unit model for all patients, with specialist interdisciplinary teams, programmes of professional, patient and carer education, information provision and regular multidisciplinary meetings. Early supported discharge, where the patient is transferred back to their own home as soon as practicable and then providing the equivalent of stroke unit care in the community has been shown to be an effective model of care that may be marginally superior to conventional hospital management in terms of clinical outcomes and cost. Longer term rehabilitation may be effectively provided in the patient’s own home, the day hospital or out-patient therapy departments. Close collaboration between primary and secondary health care is essential as well as integrating as closely as possible with social services. Patients discharged to care homes must not be neglected. They may still benefit from rehabilitation, specialist equipment and specialist medical supervision even if it is likely that they will require long-term institutional support.

6. Models of Service

Stroke Unit care for the acute and rehabilitation of patients is effective at reducing death, disability and institutionalisation when compared to management on general wards and should therefore be the model of care that is provided for most stroke patients. Some patients regardless of age will require intensive care units, particularly when respiratory support is required. There remains debate as to whether older patients with multiple co-morbidities where the stroke is only a small part of the reason for hospital admission are best managed on geriatric wards or stroke units. There is no evidence on which to base the decision.

Early supported discharge is a clinically and cost effective alternative to the late stages of hospital care so long as the team replicates the specialist stroke inpatient model with dedicated therapists and multidisciplinary teamwork. Longer term support is essential providing rehabilitation, prevention and social and emotional support.

7. Training and Education

Stroke is a recognised sub-specialty with PMETB with CCST available after a minimum of 1 year of training in a recognised post. It is available to SpRs in Geriatric Medicine, Cardiology, Neurology, General Internal Medicine and Rehabilitation Medicine. The British Association of Stroke Physicians (BASP, www.basp.ac.uk) runs regular educational events for physicians and are a partner in the UK Stroke Forum which has an annual meeting for all disciplines involved with stroke management

8. Imortant Recent and Future Policy Documents

• The DH National Stroke Strategy will be published in December 2007. It is currently available for consultation
• The 3 rd edition of the National Clinical Guidelines will be published in the summer of 2008
• The NICE Guidelines on Acute Stroke and TIA will be published in the summer of 2008
• NICE Technology Appraisal on Altepalse. www.guidance.nice.org/TA122
• Delivering Quality and Value. Focus on: Acute stroke. www.institute.nhs.uk
• Improving Stroke Services: A guide for commissioners. www.dh.gov.uk/en/publicationsand statistics/publications/publicationspolicyandguideance/dh_063260
• Action on Stroke Services: An evaluation toolkit (ASSET) for providers and commissioners. www.dh.gov.uk/en/publicationsand statistics/publications/publicationspolicyandguideance/dh_4134498

9. Good Practice Statements

• Intercollegiate Stroke Working Party, Royal College of Physicians ( London ) (ISWP-RCP). National Clinical Guidelines for Stroke (2nd Ed). London , UK : Royal College Physicians; 2004.
• National Audit Office/Department of Health (NAO/DOH). Reducing brain damage: faster access to better stroke care. London : The Stationery Office, 2005.
• Stroke Unit Trialists’ Collaboration (SUTC). Organised inpatient (stroke unit) care for stroke. Cochrane Database Syst Rev 2002;1:CD000197
• Wardlaw JM, Sandercock PA, Berge E. Thrombolytic therapy with recombinant tissue plasminogen activator for acute ischaemic stroke. Where do we go from here? A cumulative meta-analysis. Stroke 2003;34:1437–1442.
• Department of Health (2001) The National Service Framework for Older People. Department of Health, London
• Warlow CP, Dennis MS, van Gijn J, Hankey GJ, Sandercock PAG, Bamford JM, Wardlaw J. Stroke: a practical guide to management 2 nd Edition Blackwell Science Ltd 2003 Oxford
• Intercollegiate Working Party on Stroke. National Sentinel Audit 2006 www.rcplondon.ac.uk
• European Stroke Initiative (EUSI). Available at: http://www.eusi-stroke.com
• Langhorne P, Taylor G, Murray G, Dennis M, Anderson C, Bautz-Holter E, Dey P, Indredavik B, Mayo N, Power M, Rodgers H, Ronning OM, Rudd A, Suwanwela N, Widen-Holmqvist L, Wolfe C.Early supported discharge services for stroke patients: a meta-analysis of individual patients' data.
  Lancet. 2005 Feb 5-11;365(9458):501-6

10. Useful web sites

• UK Stroke Research Network: http://www.uksrn.ac.uk/
• The Stroke Association. www.stroke.org.uk/
• The UK Stroke Forum. www.ukstrokeforum.org/
• The Department of Health Stroke Team www.dh.gov.uk/stroke
• Royal College of Physicians. www.rcplondon.ac.uk
• British Association of Stroke Physicians. www.basp.ac.uk
• Safe Implementation of Thrombolysis in Stroke ( SITS ). Stroke — a growing disease. Available at:www.acutestroke.org/

11. Key References

1. CAST: randomised placebo-controlled trial of early aspirin use in 20,000 patients with acute ischaemic stroke. CAST (Chinese Acute Stroke Trial) Collaborative Group. Lancet. 1997;349:1641-9.
2. Coull A, Lovett J, Rothwell P, on behalf of the Oxford Vascular Study. Population based study of early risk of stroke after transient ischaemic attack or minor stroke: implications for public education and organisation of services. British Medical Journal 2004;328:326-8
3. Department of Health (2001) The National Service Framework for Older People. Department of Health, London
4. Hacke W, Donnan G, Fieschi C, et al. Association of outcome with early stroke treatment: pooled analysis of ATLANTIS, ECASS, and NINDS rt-PA stroke trials. Lancet 2004;363:768–774.
5. Hankey GJ, Warlow CP. Treatment and secondary prevention of stroke: evidence, costs, and effects on individuals and populations. Lancet 1999; 354:1457-63.
6. Heart Protection Study Collaborative Group. MRC / BHF heart protection study of cholesterol lowering with simvastatin in 20536 high-risk individuals: a randomised placebo-controlled trial. Lancet. 2002; 360: 7 – 22.
7. Intercollegiate Stroke Working Party National Sentinel Audit of Stroke 2004. Royal College of Physicians. www.rcplondon.ac.uk
8. Intercollegiate Stroke Working Party, Royal College of Physicians ( London ) (ISWP-RCP). National Clinical Guidelines for Stroke (2nd Edn). London , UK : Royal College Physicians; 2004.
9. Langhorne P, Taylor G, Murray G, Dennis M, Anderson C, Bautz-Holter E, Dey P, Indredavik B, Mayo N, Power M, Rodgers H, Ronning OM, Rudd A, Suwanwela N, Widen-Holmqvist L, Wolfe C. Early supported discharge services for stroke patients: a meta-analysis of individual patients' data. Lancet. 2005 Feb 5-11;365(9458):501-6
10. Mendelow AD, Gregson BA, Fernandes HM, Murray GD, Teasdale GM, Hope DT, Karimi A, Shaw MD, Barer DH; STICH Investigators. Early Surgery versus Initial conservative Treatment in Patients with Spontaneous Supratentorial Intracerebral Haemorrhage in the International Surgical Trial in Intracerebral Haemorrhage (STICH): a randomised trial. Lancet 2005;365:387-97
11. Mielke O, Wardlaw J, Liu M Thrombolysis (different doses, routes of administration and agents) for acute ischaemic stroke. Cochrane Database Syst Rev. 2004;( 4):CD000514.
12. National Audit Office/Department of Health (NAO/DOH). Reducing brain damage: faster access to better stroke care. London : The Stationery Office, 2005.
13. National Clinical Guidelines for Stroke 2 nd Edition Royal College of Physicians London . www.rcplondon.ac.uk
14. National Institute for Health and Clinical Excellence. Appraisal of clopidogrel and Modified release dipyridamole in the prevention of occlusive vascular events. 2005. www.nice.org.uk/pdf/appeal_panel_clopdyp.pdf
15. PROGRESS Collaborative Group. Randomised trial of a perindopril-based blood-pressure-lowering regimen among 6105 individuals with previous stroke or transient ischaemic attack. Lancet. 2001; 358: 1033 – 1041.
16. Rothwell P, Eliasziw M, Gutnikov S, Warlow C, Barnett H and Carotid Endarterectomy Triallists Collaboration. Endarterectomy for Symptomatic Carotid Stenosis in relation to clinical subgroups and timing of surgery. Lancet 2004;363:915-924
17. Rothwell PM, Giles MF, Flossman E, Lovelock CE, Redgrave JN, Warlow CP, Mehta Z. A simple score (ABCD) to identify individuals at high early risk of stroke after transient ischaemic attack Lancet 2005;366:29-36
18. Rudd AG, Lowe D Hoffman A Irwin P Pearson M. Secondary Prevention For Stroke In The United Kingdom : Results from the National Sentinel Audit of Stroke Age Ageing 2004;33:280-6
19. Stroke Unit Trialists’ Collaboration (SUTC). Organised inpatient (stroke unit) care for stroke. Cochrane Database Syst Rev 2002; 1:CD000197.
20. The International Stroke Trial (IST): a randomised trial of aspirin, subcutaneous heparin, both, or neither among 19435 patients with acute ischaemic stroke. International Stroke Trial Collaborative Group. Lancet. 1997; 349:1569-81.
21. Wardlaw JM, Zoppo G, Yamaguchi T, Berge E. Thrombolysis for acute ischaemic stroke. Cochrane Database Syst Rev 2003b; 3:CD000213.
22. Warlow CP, Dennis MS, van Gijn J, Hankey GJ, Sandercock PAG, Bamford JM, Wardlaw J. Stroke: a practical guide to management Blackwell Science Ltd 2000 Oxford
23. Wolfe C, Rudd T, Beech R. Stroke Services and Research. Stroke Association. 1996. London .
24. World Health Organization (WHO). The atlas of heart disease and stroke. Mackay J, Mensah G (eds). Geneva : WHO; 2004.

Review date: November 2010
Author: Dr T Rudd for BGS Policy Committee