There may need to be networked arrangements for spoke sites around a thrombectomy 'hub' with fast image transfer, referral, eligibility assessment and responsive repatriation systems. The positive implications for other aspects of stroke care help to address the balance in demand for resources. For example, it is expected that there will be a decrease in demand for decompressive hemicraniectomies and inpatient rehabilitation. There may also be a reduction in the need for long-term social care. Return to recommendations Blood pressure control for people with acute intracerebral haemorrhage Why the committee made the recommendations For the groups covered, moderate-quality evidence from a large clinical trial showed a modest benefit treatment effect on haematoma expansion and quality of life (EQ-5D utility index) in rapidly lowering blood pressure to a target systolic blood pressure of 140 mmHg or lower compared with less intensive blood pressure lowering treatment. The committee acknowledged the uncertainty over the evidence. They discussed the additional potential harms relating to rapid blood pressure lowering in people who present after 6 hours or who have a systolic blood pressure greater than 220 mmHg, and agreed that these factors should be taken into account when considering rapid blood pressure lowering for these groups. The committee decided to remove the aim of reaching the target within 1 hour because only a minority (33.4%) of participants in the INTERACT2 trial achieved the target of 140 mmHg within 1 hour and, more importantly, to avoid the potential harm of reducing systolic blood pressure by more than 60 mmHg in the first hour. 2022 There was evidence that rapidly lowering blood pressure does not increase the risk of neurological deterioration caused by reduced blood flow to the brain and has the potential to improve quality of life. In contrast, the committee noted that in another clinical trial, there was no benefit to rapidly lowering blood pressure and there was an increase in adverse renal events. The committee noted the treatment regimens were more aggressive in this trial compared with the other trials included in the review. The committee agreed that while there is some evidence that rapid blood pressure lowering treatment is beneficial, there may be an increase in adverse renal events, and they were concerned about the lack of evidence in people who are frail. Taking this into account, the committee agreed that rapid blood pressure lowering treatment should be considered as a treatment option except for the groups highlighted in recommendation 1.5.7. There was evidence that a moderate reduction of up to 60 mmHg within the first hour was associated with better outcomes such as functional independence. A reduction of more than 60 mmHg within 1 hour was associated with significantly worse outcomes such as renal failure, early neurological deterioration, and death, compared with standard treatment. Therefore, the committee agreed that a large reduction of 60 mmHg or more within 1 hour should be avoided. The 2019 guideline included a 130 mmHg lower target limit. However, the committee were concerned that a narrow range would be too restrictive, and the variation in the class of drugs used in practice means it is difficult to predict the blood pressure reduction. The committee decided to remove the 130 mmHg lower target limit. The committee considered the potential risk of systolic blood pressure dropping too low but noted that this potential concern is addressed by the avoidance of a large reduction of 60 mmHg or more within 1 hour. The committee also agreed that the target systolic blood pressure and the systolic blood pressure reduction should be made into a separate recommendation (1.5.6). There was little evidence on people presenting beyond 6 hours or those with a systolic blood pressure over 220 mmHg. However, the committee agreed that some guidance is needed on treating hypertension in these groups and that it is appropriate to extrapolate from the available data to these groups, but that healthcare professionals should take into account the individual risk of harm when considering rapid blood pressure lowering using clinical judgement on a case-by-case basis. 2022 The committee agreed that the evidence to support maintaining the target blood pressure for at least 7 days is weak. They were also concerned about the potential impact on patient flow, bed management and resources in the NHS, so removed the timeframe. The committee discussed the uncertainty about how long to continue acute treatment. However, this evidence review is primarily concerned with treatment within the first 24 hours. The committee highlighted that blood pressure should still remain lowered after acute treatment in order to reduce the longer-term effect of the acute intracerebral haemorrhage. The committee agreed that people receiving intensive blood pressure treatment would not need to stay in hospital for acute management for 7 days. This can be managed through secondary prevention, which can be indicated when treatment is changed from intravenous to an oral route of administration. The committee also noted that longer-term management of blood pressure can be managed in primary care. The committee did not change the existing practice of not offering rapid blood pressure lowering to specific groups that were excluded from the key clinical trial. This is because there is no evidence of whether this would be safe or beneficial. The committee discussed rapid blood pressure lowering for young people aged 16 and 17. The evidence reviewed covers adults 18 and over, but the committee agreed that this can be extrapolated for young people after seeking advice from a paediatric specialist. The committee wanted to consider the long-term effect of intensive blood pressure lowering on quality of life, but limited evidence was available to show how it affected quality of life at 6 and 12 months, and no evidence was available on cognitive function or functional ability. Given the lack of evidence for these important outcomes, the committee made a research recommendation about the impact of intensive interventions to lower blood pressure on cognitive function, functional ability and quality of life compared with less intensive interventions. The committee identified a gap in the evidence on the impact of intensive blood pressure treatment on people who are frail. There is currently no guidance or treatment pathway for people who are frail, so the committee also made a research recommendation about the impact of intensive blood pressure lowering on people who are frail, and encouraged the use of frailty scores to evaluate the impact of frailty on outcomes and treatment prognoses. 2022 Other factors the committee took into account The committee were aware of the European Stroke Organisation (ESO) guideline on blood pressure management in acute ischaemic stroke and intracerebral haemorrhage, which suggests 'In patients with hyperacute (presenting within 6 hours) intracerebral haemorrhage, lowering blood pressure to below 140 mmHg (and to keep it above 110 mmHg) to reduce haematoma expansion'. The committee agreed that this is broadly in line with NICE recommendations. How the recommendations might affect practice The recommendations reflect a small change to current best practice. The difference in target blood pressure range and magnitude in drop from starting treatment up to the first hour in the 2022 update might need additional planning and closer management by the nursing team. Given that these people currently need close monitoring, any change is likely to be very small. There may be an increased cost of intravenous antihypertension medication, but the recommendations should save resources because of reduced harms. Overall, the recommendations should not have a resource impact to the NHS in England. Return to recommendations Optimal positioning for people with acute stroke Why the committee made the recommendation The evidence did not indicate any difference in outcomes between lying flat or with the head elevated. No cost-effectiveness evidence was identified and no cost difference between the 2 strategies is expected. Therefore, the committee used their knowledge and experience to recommend positioning people according to their preferences and individual requirements. How the recommendation might affect practice Optimal positioning is an important part of early acute stroke management and rehabilitation. In current practice, people are assessed in bed and optimal head positioning 2022 is determined based on clinical presentation, medical needs and patient comfort. The recommendation therefore reflects current practice in most hospitals and so the committee agreed that there should be little or no change. Return to recommendation Early mobilisation for people with acute stroke Why the committee made the recommendations Regarding the recommendation to mobilise people after having a stroke when their clinical condition permits, there was no clear evidence of benefit or harm for early mobilisation within the first 48 hours after symptom onset compared with standard care. Therefore, the committee made a recommendation based on their knowledge and experience. The committee agreed that early mobilisation may be appropriate in some cases where people need minimal assistance to mobilise, such as in those who have suffered a mild stroke, or are experiencing language and/or upper limb dysfunction alone. Regarding the recommendation not to offer high-intensity mobilisation within the first 24 hours of symptom onset, a published within-trial cost-effectiveness analysis from the Australian hospital perspective was identified. However, the treatment effect for the health outcome mRS 0 to 2 used in the study differed from the treatment effect calculated in the clinical review. Because the cost-effectiveness evidence was incompatible with the results of the clinical review, the committee chose to make a recommendation based on the clinical evidence for mortality. The evidence suggested clinical harm associated with high- intensity mobilisation within the first 24 hours after acute stroke. However, based on their clinical experience they discussed that this harm was most relevant to those who need help to sit out of bed, stand or walk. Therefore, they limited the recommendation to this group because they did not want to prevent appropriate early mobilisation in people who are independently mobile after having a stroke. How the recommendations might affect practice The committee was confident that making these recommendations would not have a resource impact, because there was no indication that mobilising later and with a lower 2022 intensity leads to a longer length of stay. The committee noted that people will still be assessed and mobilised and there are unlikely to be differences in staff costs. In current practice, mobilisation strategies differ according to stroke severity and the clinical condition of the person with stroke. The strategy may also be impacted by the availability of different types of specialist seating. The recommendations may change current practice in stroke units where there is an 'as soon as possible' focus on mobilisation. They will encourage healthcare professionals to consider the intensity of very early mobilisation and advice on intensity of activities to people discharged from hospital early after a stroke. Return to recommendations Decompressive hemicraniectomy for people with acute stroke Why the committee made the recommendations The evidence showed that surgery improved mortality rates and, to a lesser extent, functional outcomes as measured by the mRS. The benefit on mortality was seen in all age groups considered, although the benefit for functional outcome was smaller in people aged over 60 years than in people under 60 years. Based on this, and to ensure that people over 60 have similar opportunities for the surgery as younger people, the committee removed the previous age cut-off for considering surgery. The committee also acknowledged that although surgery results in more people surviving and better functional outcome than without surgery, many still have overall poor functional outcome and their quality of life may be low. The acceptability of this trade-off was agreed to be a very individual judgement. Some people may choose not to have surgery if there is a risk of severe disability, whereas others may wish to go ahead based on mortality benefit alone. Therefore, the committee highlighted the need for careful discussion about risks and benefits between clinicians and family members or carers. They noted that patients would not be able to be involved at the time because of the severity of the stroke, so the family or carers would be responsible for making the decision. In deciding whether to opt for surgery, considerations should include pre-stroke functional status, because surgery would not be appropriate for people with severe disability before stroke. The committee noted that although some of the trials included people who had surgery as 2022 long as 96 hours after symptom onset, the benefits in terms of reduced mortality and improved functional outcome were largely driven by studies that only allowed surgery up to a maximum of 48 hours after onset. Therefore, it agreed to retain the reference to surgery being performed within 48 hours of onset from the original recommendations. The committee also reviewed the criteria used to determine eligibility for hemicraniectomy from NICE's stroke guideline published in 2008. It was agreed that these were still appropriate and reflect the populations included in the studies used to inform the new recommendations. The committee agreed that although the cost effectiveness of decompressive hemicraniectomy remains uncertain, it should be considered for some people because of the clear mortality benefit and the improved functional outcomes. Shared decision making between physicians, surgeons, families and carers is important given the high likelihood of residual moderate or severe disability after surgery. How the recommendations might affect practice In current practice, around 5% of people on the stroke unit are referred for decompressive hemicraniectomy. Decompressive hemicraniectomy is currently considered for those aged under 60. This recommendation will require a change from current practice by all providers. The guidance will also require healthcare professionals to take into account people's pre-stroke functional status and to have a discussion about the risks and benefits. The committee believed that including people over 60 years would not necessarily lead to significantly more people undergoing surgery because informed discussion of the outcomes might reduce its uptake in this population. In addition, increasing the population eligible for endovascular therapy and its provision is likely to decrease the population referred for decompressive hemicraniectomy. The committee therefore did not anticipate a substantial resource impact to result from this recommendation. Return to recommendations 2022 Context Since NICE published its guideline on stroke and transient ischaemic attack (TIA) in 2008, the management of stroke has changed. New evidence has emerged in areas such as thrombectomy (clot retrieval procedures) in ischaemic stroke, controlling high blood pressure in people with acute haemorrhagic stroke, the role of hemicraniectomy and early mobilisation and optimum positioning of people with acute stroke. In addition, there is some uncertainty about the use of aspirin when TIA is first suspected, the role of conventional risk stratification in TIA and the best approach to intracerebral imaging after TIA. This guideline update includes recommendations on these specific issues. A stroke occurs when the blood supply to a part of the brain is acutely compromised. Most strokes (85%) are caused by a blockage in a blood vessel (artery) that supplies blood to the brain. A TIA or 'mini stroke' has the same clinical presentation as a stroke except that symptoms disappear within 24 hours. The symptoms experienced depend on the part of the brain that is affected. They usually occur suddenly and without any warning. Common symptoms include loss of movement or sensation in an arm or leg, problems speaking, a drooping of one side of the face or problems with vision. A stroke can occur at any age. The average age for stroke varies across the UK, with a median age of 77 years (interquartile range 67 to 85). A quarter of strokes occur in people of working age. First-ever stroke affects 230 people per 100,000 each year, with over 80,000 people hospitalised per year in England. Although the death rate has been falling, figures from the Sentinel Stroke National Audit Programme show that 13.6% of people admitted to hospital with stroke in England and Wales died (either in hospital or after being discharged from inpatient care) within 30 days. There are approximately 1.2 million stroke survivors in the UK. The risk of recurrent stroke is 26% within 5 years of a first stroke and 39% by 10 years. Stroke is the single biggest cause of disability in adults. The Stroke Association has estimated an annual cost to the NHS in England of 2.98 billion per year. In addition, annual social care costs have been estimated at 4.55 billion with almost half of that estimated to be from public funds. Of stroke survivors, 1 in 12 have to move into a care home because of the effects of their stroke. There is also a substantial burden to families 2022 of people who have had a stroke in terms of informal unpaid care. The importance of stroke care in the NHS is also highlighted in the NHS Long Term Plan, the National Stroke Programme, the Intercollegiate Stroke Working Party national clinical guideline for stroke, and the 2018 publication of NHS England's clinical commissioning policy for mechanical thrombectomy for acute ischaemic stroke in the NHS. Also, the Royal College of Paediatrics and Child Health published guidelines in 2017 on the treatment of stroke in those under 18 years old. This guideline covers people over 16 with suspected or confirmed 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 and primary intracerebral haemorrhage of any cause, including venous thrombosis. Areas that are not covered include specific issues relating to the general management of underlying conditions and subarachnoid haemorrhage. 2022 Finding more information and resources To find NICE guidance on related topics, including guidance in development, see the NICE topic page on cardiovascular conditions. For full details of the evidence and the guideline committee's discussions, see the evidence reviews. You can also find information about how the guideline was developed, including details of the committee. NICE has produced tools and resources to help you put this guideline into practice. For general help and advice on putting NICE guidelines into practice, see resources to help you put guidance into practice. 2022 Update information April 2022: We have: reviewed the evidence on blood pressure control for people with acute intracerebral haemorrhage and updated recommendations 1.5.4, 1.5.5, 1.5.6 and 1.5.8. May 2019: We have reviewed the evidence on thrombectomy (clot retrieval procedures) in ischaemic stroke, controlling high blood pressure in people with acute haemorrhagic stroke, the role of hemicraniectomy, and early mobilisation and optimum positioning of people with acute stroke. In addition, we have addressed the use of aspirin when transient ischaemic attack (TIA) is first suspected, the role of conventional risk stratification in TIA and the best approach to intracerebral imaging after TIA. These recommendations are marked [2019]. We have also made some changes without an evidence review: Recommendation 1.1.7 has been made consistent with new recommendations in relation to rapid referral and review in the TIA clinic. The remaining part of the recommendation has been replaced by recommendations 1.1.4 to 1.1.6. Recommendation 1.2.3 has been made consistent with new recommendations in relation to rapid referral and review in the TIA clinic. Recommendation 1.2.4 has been made consistent with new recommendations in relation to rapid referral and review in the TIA clinic and to omit the European Carotid Surgery Trial (ECST) criteria because these are no longer used. Recommendation 1.3.2 has been amended because early coagulation therapy is not relevant in this context. Non-enhanced means 'plain'; it is the basic form of CT scan without any contrast (that is, not CT angiography/perfusion). At this very early stage in the diagnostic pathway, acute stroke is still 'suspected'; the CT may show up an alternative diagnosis or further clinical assessment may also reveal an alternative diagnosis (the CT is often performed directly off the ambulance when there is little more than 'FAST +ve' criteria). CT angiography and CT perfusion indications have been added to be consistent with the new recommendations on thrombectomy. 2022 Recommendation 1.4.2 has been amended to clarify that the levels relate to the level of care required by the patient. Recommendation 1.5.7 has been amended to be consistent with the subheading for this recommendation, which now applies to acute ischaemic stroke (that is, not haemorrhagic stroke). The remaining part of the recommendation has been replaced by recommendation 1.5.5. These recommendations are marked [2008, amended 2019]. Recommendations marked [2008] last had an evidence review in 2008. In some cases, minor changes have been made to the wording to bring the language and style up to date, without changing the meaning. Minor changes since publication March 2023: We have corrected the link in recommendation 1.2.4. October 2022: We added text to indicate that pulse oximetry may be less reliable in people with dark skin. We also added a link to the NHS patient safety alerton the risk of harm from inappropriate placement of pulse oximeter probes. See recommendation 1.5.1. November 2021: We added a link to the NHS England and NHS Improvement National Stroke Service Model in section 1.3 on specialist care for people with acute stroke. October 2020: We added the research recommendations from the 2008 guideline. April 2020: We corrected the links to the rationales in section 1.1 on rapid recognition of symptoms and diagnosis. 2022 Accreditation 2022