National Clinical Guideline for Stroke (Fifth Edition 2016)

A lot has changed in the world of stroke over the four years since the last edition of the Royal College of Physicians National Clinical Guideline for Stroke was published. The quality of stroke care provided in the UK has continued to improve as judged by the Sentinel Stroke National Audit Programme, which started collecting data in 2013. The number of high-quality research publications has rapidly increased and we now have a much better understanding of what works and what doesn’t, particularly in areas of rehabilitation. The randomised trials of intra-arterial treatment clearly show that for a proportion of patients, outcomes can be improved and we have further evidence showing that the way stroke care is organised and staffed can make a big difference to the chances of recovery.

This guideline is the most comprehensive and up to date document on how stroke care should be provided covering the whole pathway from pre-hospital care to long-term management. It is designed not just for clinicians but also for patients and their families and carers, and those with responsibility for commissioning stroke services. However, there are still too many areas where the recommendations are based on a consensus of the experts on the guideline development group. We desperately need the research to confirm or refute these views, so the other important role for this guideline is to help researchers and the funding bodies to identify the key questions that still need to be answered through research. The work involved in developing a clinical guideline is enormous, and unlike some guideline development organisations the stroke team at the Royal College of Physicians do not have a big group of people to undertake the searching, critical appraisal, drafting and editing. We are very grateful to all the members of the Intercollegiate Stroke Working Party who in addition to their day jobs have devoted huge amounts of time to undertaking these tasks. Audrey Bowen, Martin James and Gavin Young have skilfully performed the role of editors, and Kaili Stanley has been fantastic at co-ordinating the process and ensuring that everyone does as instructed. Alex Hoffman as the Stroke Programme Manager has as usual provided the expertise and wisdom necessary to see the project through to its successful conclusion. We are also grateful to everyone who has supported the Working Party either through reviewing papers or peer reviewing drafts of the guidelines. A special mention needs to go to the our user representatives who in addition to providing advice throughout the whole process have worked very hard to produce the patient version of the guideline, which we hope those who suffer a stroke and those who support people who have had a stroke will find helpful.

The available evidence for the treatment of stroke continues to grow steeply, signs of which include the growth in new journals on the topic and the increased number of systematic reviews in stroke available through the Cochrane collaboration. The growth of the evidence base means that this latest edition of the guideline includes some significant updates from the 2012 edition, just a few of which are listed below. It also lies behind the Working Party’s decision to move publication of the guideline to online-only, to facilitate a more responsive cycle of evidence-based updates.

What’s new in 2016

1. Mechanical thrombectomy for acute ischaemic stroke (Section 3.5)
2. Urgent brain imaging within 1 hour of hospital arrival for suspected acute stroke (Section 3.4)
3. Acute blood pressure management in intracerebral haemorrhage (Section 3.6)
4. Urgent management of suspected minor stroke and TIA irrespective of risk stratification (Section 3.2)
5. Incorporation of clinical psychology/clinical neuropsychology, dietetics and orthoptics expertise into the multidisciplinary stroke rehabilitation team (Section 2.4)
6. Changes in the practice of early mobilisation after acute stroke (Section 3.12)
7. Pragmatic management of swallowing difficulties in end-of-life stroke care (Section 2.15)
8. Mechanically-assisted methods for gait training in people unable to walk after stroke (Section 4.9.4)
9. Lower blood pressure targets for secondary stroke prevention compared with previous NICE guidelines (Section 5.4).