Surveillance decision

Surveillance decision

We will plan an update of the guideline on diagnosis and initial management of stroke and transient ischaemic attack (TIA). The update will focus on:

  • referral for specialist assessment and subsequent imaging in people with suspected transient ischaemic attack

  • use of pharmacological or mechanical methods for clearing blood clots

  • early antihypertensive treatment in haemorrhagic stroke

  • decompressive hemicraniectomy in people older than 60 years.

We will also amend the guideline to take account of updates to technology appraisals since it was published.

Reason for the decision

We found 349 new studies through surveillance of this guideline. New evidence that could affect recommendations was identified. Topic experts, including those who helped to develop the guideline, advised us about whether the following sections of the guideline should be updated:

Rapid recognition of symptoms and diagnosis

  • How accurately do scoring systems predict which patients with suspected TIA need to be referred urgently for specialist assessment?

Topic experts advised that the current recommendations on using the ABCD² score to triage people with suspected TIA are no longer appropriate. At the time of developing the guideline, stroke service capacity was more limited than it is now and was an important consideration. Topic experts thought that stroke services have now developed sufficiently that assessing people with suspected TIA within 24 hours is achievable. Additionally, the ABCD² score does not help to decide who to refer for specialist assessment.

The topic experts were concerned about service capacity due to inappropriate referrals to the stroke clinic. However, this issue was thought to need to be addressed by local networks rather than the guideline.

Decision: This review question should be updated.

  • After TIA, which modality (MRI or CT) should be used?

The NICE guideline on diagnosis and initial management of stroke and TIA and a Health Technology Assessment (Wardlaw et al. 2014) advise against routine imaging and recognise that specialist assessment is necessary to make decisions about imaging. However, topic experts indicated that imaging was performed routinely in some services, and sometimes involved both CT and MRI. This suggests that current recommendations are not being implemented appropriately.

The topic experts thought that routine CT imaging could waste resources and expose people to unnecessary radiation. Topic experts thought that current recommendations for specialist assessment with subsequent imaging only in people whose vascular territory or pathology is uncertain generally remained relevant. However, there may be a need to review the appropriate type of imaging and sequences to use.

Decision: This review question should be updated.

  • In patients with a suspected minor stroke/TIA, does early versus late expert assessment reduce mortality or morbidity?

The topic experts thought that reviewing the use of the ABCD² score would have implications on the recommendations resulting from this review question because late assessment would no longer be necessary.

The topic experts also agreed that it was important to address early aspirin use. They thought that the conclusion of Rothwell et al. (2016) about self-administering aspirin had potential health implications if haemorrhage was the cause of stroke. In TIA and minor stroke, the topic experts thought that consideration should be given to who should give the initial advice for people to take aspirin: initial telephone triage services (NHS 111), paramedics, or the first treating physician.

Topic experts thought that the guideline should also consider the risks of people with continuing symptoms taking aspirin without full medical assessment.

Decision: This review question should be updated and address early aspirin use.

Pharmacological treatments for people with acute stroke

  • Thrombolysis in people with acute ischaemic stroke.

Topic experts indicated that off-label uses of alteplase, particularly around its use in older patients should be addressed in the guideline.

The use of thrombectomy was also thought to need coverage in the guideline. Although these interventions are separate there is some overlap of populations: some people can have both treatments, some can have alteplase only, and some can have thrombectomy only.

Guidance on identifying patients who would benefit from thrombectomy and transporting patients to a centre that can perform thrombectomy was thought to be needed.

Decision: This review question should be updated to address off-label uses of thrombolysis and the place of mechanical thrombectomy in the care pathway.

Maintenance or restoration of homeostasis

  • What is the safety and efficacy of measures to manipulate blood pressure versus treatment as usual in patients with acute stroke?

Evidence consistently shows no benefit of blood pressure lowering in ischaemic stroke so the topic experts thought no update was necessary for antihypertensives in ischaemic stroke. Current recommendations to lower blood pressure to enable alteplase administration or in hypertensive emergencies remain sufficient.

However, the topic experts indicated a need to assess blood pressure lowering in haemorrhagic stroke.

Decision: This review question should be updated.

Surgery for people with acute stroke

  • Which patients should be referred for decompressive hemicraniectomy?

The topic experts agreed that this section needs to be updated. Clinicians may not want to do hemicraniectomy in patients older than 60 years because of poor functional outcome, but the topic experts thought that this approach would be paternalistic, and should not affect patients' choice.

Decision: This review question should be updated.

Other clinical areas

We also found new evidence that was not thought to have an effect on current recommendations. This evidence related to non-pharmacological treatments and interventions to prevent venous thromboembolism in people with acute stroke.

For any new evidence relating to published or ongoing NICE technology appraisals, the guideline surveillance review deferred to the technology appraisal decision.


No equalities issues were identified during the surveillance process.

Overall decision

After considering all the new evidence and views of topic experts, we decided that a partial update is necessary for this guideline.

See how we made the decision for further information.

This page was last updated: 30 January 2017