The National Stroke Strategy sets out clear targets for imaging services. Can they deliver?
INTRODUCTION Stroke is the third biggest cause of death in the UK and the largest single cause of severe disability. Each year more than 110,000 people in England will suffer from a first stroke and a further 30,000 will suffer a recurrent stroke. Prior to stroke, one in five people experience a transient ischaemic attack (TIA), providing an opportunity for interventions to reduce vascular risk. The total cost of strokes to society is £8 billion per year, but less than 8 per cent of this is spent on initial medical diagnosis and management. The majority accrues from rehabilitation, nursing and indirect costs.
The National Stroke Strategy1 in England, was launched in December 2007, and set a
clear direction for the development of stroke services in England over the next 10 years. Much work has taken place to improve stroke services and the quality of care received by all who need it. There has been a recent concurrent public awareness campaign publicising the Act FAST criteria (Face, Arms, Speech and Time) for stroke and reinforcing the emphasis on ‘time is brain’. Research quantifying cell damage estimates that two million brain cells are lost each minute in an acute middle cerebral artery infarct2
.
Therefore one of the biggest challenges set out in the strategy is the need for rapid imaging, both for TIA and stroke.
WHY BOTHER? Previously, the management of cerebral ischaemia was based on optimal medical treatment. Now there are more specific treatment options for both strokes and TIAs. In
for imaging departments there are huge impliCations
strokes, thrombolysis has been shown to significantly improve outcomes if administered within three hours of onset3 is extended to 4.5 hours4
and shows moderate benefit if the window for treatment . In addition, intra-arterial fibrinolytic therapy can offer a
moderate benefit in the 3-6 hour window5
For TIAs, carotid recanalisation and, specifically, carotid endarterectomy (CEA), if performed early within two weeks of onset, can also improve outcome, leading to a reduction in subsequent debilitating stroke6
towards a 48-hour target from presentation to treatment (performing CEA) and has accepted that this needs to be implemented as soon as possible.
THE GUIDANCE The emphasis on thrombolysis and CEA has led to the need for rapid access to imaging services as a key element in the gold standard service envisioned in the National Stroke Strategy. The chapter describing acute care of TIA and stroke, Time is Brain, contains two Quality Markers (QM) related specifically to brain imaging.
QM5 Assessment – referral to specialist (TIA and minor stroke) Immediate referral for appropriately urgent specialist assessment and investigation is
considered in all patients presenting with a recent TIA or minor stroke, using a system which identifies as urgent those with early risk of potentially preventable full stroke. To be assessed within 24 hours in high-risk cases; all other cases are assessed within seven days. (Using the ABCD2 criteria*). Provision to enable brain imaging within 24 hours and carotid intervention, echocardiography and ECG within 48 hours, where clinically indicated.
QM7 Urgent response (stroke) All patients with suspected acute stroke are immediately transferred by ambulance
to a receiving hospital providing hyper-acute stroke services (where a stroke triage system, expert clinical assessment, timely imaging and the ability to deliver intravenous thrombolysis treatment are available throughout the 24 hour period).
THE TARGETS (BY APRIL 2011) 1. 60% of high risk people (ABCD2 score 4 or more*) with TIA should be investigated and treated within 24 hours.
2. 50% of stroke patients to be scanned within one hour of hospital arrival. 3. 100% of stroke patients to be scanned within 24 hours of hospital arrival.
* ABCD2 score is calculated using the patient’s age (A); blood pressure (B); clinical features (C); duration of TIA symptoms (D); and presence of diabetes (2). Scores are between 0 and 7 points. Low risk = 0–3 points; moderate risk = 4–5 points; high-risk = 6–7 points.
55 2011
IMAGING & ONCOLOGY
. The College of Vascular Surgeons is working
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