Diagnosis and management of transient ischaemic attack and ischaemic stroke in the acute phase
BMJ 2011; 342 doi: https://doi.org/10.1136/bmj.d1938 (Published 31 March 2011) Cite this as: BMJ 2011;342:d1938
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I congratulate the authors on their excellent summary of this complex
topic. I would like to make a small suggestion from a practical point of
view. Box 2 lists common conditions that mimic stroke. I think that this
box should specifically mention hypoglycaemia. It is covered in the
general "metabolic" term used but I believe that it is important and
common enough to deserve specific mention. It can be a particular problem
in elderly diabetic patients whose physicians are perhaps over
enthusiastic in achieving glycaemic control. I have seen it twice in my
career. These days a quick check with a glucometer followed by a dose of
glucose is sufficient to achieve the "cure".
Competing interests: No competing interests
We would like to thank Mr Harkin for his comments regarding the
importance of carotid intervention in the management of recurrent stroke
and agree wholeheartedly with the urgency with which this should be
addressed after ischaemic stroke or TIA. Our review (1) is part of a
series where the second part (2) refers in more detail to prevention of
recurrent stroke events, with more detailed discussion of the evidence for
carotid intervention.
(1) McArthur KS, Quinn TJ, Dawson J, Walters MR. Diagnosis and
management of transient ischaemic attack and ischaemic stroke in the acute
phase. BMJ 2011; 342: d1938
(2) McArthur KS, Quinn TJ, Higgins P, Langhorne P. Post-acute care
and secondary prevention after ischaemic stroke BMJ 2011; 342:d2083
Competing interests: No competing interests
Dear Editor
Re: Diagnosis and management of transient ischaemic
attack and ischaemic stroke in the acute phase. McArthur, et al. BMJ
2011;342:(Published 31 March 2011)
In their clinical review the Authors state that the care for both
stroke and transient ischaemic attack (TIA) has improved in recent years,
but they recognize that despite this it remains an important cause of
death and disability. From a medical perspective they quite correctly
stress the need for early diagnosis, appropriate investigation, and
specialist care. However, they make little or no mention of carotid
revascularization, by surgical carotid endarterectomy or endovascular
means, as an important early proven treatment in selected patients(1).
There is robust evidence that patients with acute ischaemic stroke or TIA,
in the presence of an ipsilateral moderate or severe carotid stenosis,
benefit from early carotid endarterectomy to reduce the risk of recurrent
ipsilateral stroke(1,2). Indeed the recent report from the "United Kingdom
Audit of Vascular Surgical Services and Carotid Endarterectomy" again
highlights concerns about the delay from symptoms to treatment, stating
that many patients are not being treated within the timeframe set by NICE
or the National Stroke Strategy, and recommends there is significant room
for improvement in this area(3,4). In this respect this article on the
management of TIA and Stroke in the acute phase fails to stress the value
of proper multidisciplinary team assessment including consideration extra-
cranial causes of stroke such as carotid stenosis. It is important we
raise awareness amongst those managing acute stroke of the importance of
early assessment for symptomatic carotid stenosis using duplex ultrasound
scanning and when diagnosed the need for urgent referral (less than 48
hours) to vascular surgery for consideration of carotid revascularization.
The accumulating clinical evidence stresses the need for early carotid
revascularization in those patients with TIA or stroke due to symptomatic
carotid stenosis, who have stable or improving neurological symptoms(2).
Perhaps by highlighting this proven evidence based treatment amongst
physicians managing acute TIA and stroke we may reduce the currently
excessive delays in diagnosis and onward referral for treatment, and
reduce the current excessive risk of recurrent stroke in the early post-
stroke recovery period.
1. Rothwell PM, Eliasziw M, Gutnikov SA et al for the Carotid
Endarterectomy Trialists' Collaboration. Analysis of pooled data from the
randomised controlled trials of endarterectomy for symptomatic carotid
stenosis. Lancet 2003; 361: 107-116.
2. Rothwell PM, Giles MF, Chandratheva A et al. Effect of urgent
treatment of transient ischaemic attack and minor stroke on early
recurrent stroke (EXPRESS Study): a prospective population-based
sequential comparison. Lancet 2007; 370: 1432-42.
3. Prepared on behalf of The Clinical Standards Department Royal
College of Physicians of London. UK Audit of Vascular Surgical Services
& Carotid Endarterectomy. July 2010 Public Report.
4. Department of Health. National Stroke Strategy London 2007.
www.dh.gov.uk/stroke
Denis W Harkin MD FRCS FEBVS
Senior Lecturer & Consultant Vascular Surgeon
Royal Victoria Hospital Belfast
Competing interests: No competing interests
We thank doctors Akporehwe and Garcia for their responses to our
article on emergency treatment of stroke and TIA.
We agree with Doctor Akporehwe that the statement "thrombolysis...is
not routinely used in patients who are already functionally impaired" is a
simplification of a complex field. Thrombolytic therapy has potential to
prevent stroke related disability, but it is not "neuro-restorative" and
at best will only maintain a patient at their pre stroke level of ability.
Although highly efficacious, thrombolysis is not always a benign
intervention and clinicians are faced with difficulty choices regarding
suitability of thrombolysis and potential risk / benefit in patients with
disability or complex comorbidity. In most clinical stroke trials and in
many stroke units "severe disability" is an exclusion criteria and so we
have little data on the outcomes for this cohort(1). Of course, the term
"severe disability" is open to interpretation and although rating scales
such as modified Rankin Scale (mRS) have been used to standardize
assessment, clinicians still struggle to agree on level of disability for
a particular patient(2). Often the decision can be made on clinical
grounds, as the most severely disabled patients commonly have a mix of co-
morbidities that taken together may preclude safe thrombolysis, for
example diabetes, uncontrolled hypertension, bleeding diathesis and
previous stroke. A take-home message from our article was that patients
with sudden onset neurology should be discussed with the local stroke team
and we would encourage this approach even if the referrer is unsure about
suitability on the basis of premorbid disability.
Doctor Garcia provides a synthesis of some "hot topics" in stroke
research, such as new definitions of stroke / TIA and optimal assessment
of suspected stroke. Editorial limits on manuscript size and the broad
target audience, necessarily resulted in a focused article that could not
cover all the exiting developments in stroke research. Doctor Garcia has
provided some useful references for the interested reader.
1. Quinn TJ, Paolucci S, Sunnerhagen KS, Sivenius J, Walker MF, Toni
D, et al. Evidence-based stroke rehabilitation: an expanded guidance
document from the European Stroke Organisation (ESO) guidelines for
management of ischaemic stroke and transient ischaemic attack 2008. J
Rehab Med. 2009;41:99-111.
2. Quinn TJ, Dawson J, Walters MR, Lees KR. Reliability of the
modified Rankin Scale:systematic review. Stroke.2009;40:3393-3395.
Competing interests: No competing interests
We read with keen interest the very informative and practice changing
clinical review of the diagnosis and management of TIA and ischaemic
stroke by K S McArthur et al [1].
This review highlighted the benefits of thrombolysis in the form of
rt-PA, in reducing longer term disability as opposed to improving survival
or immediate neurological impairment in suitable patients.
Although the authors did state that the landscape of contra-
indications to thrombolysis was evolving, they nevertheless advised,
'referral of all hyperacute suspected strokes to a specialist team unless
there is substantial premorbid disability'. Should we really be aiming to
exclude the 'already functionally impaired' in spite of the stated benefit
of reducing disability?
Disability, also known as Activity limitation, is any restriction or
lack of activity, resulting from an impairment to perform an activity in
the manner or range considered normal for people of the same age, sex and
culture (International Classification of Functioning, Disability and
Health (ICF) by the World Health Organisation (WHO).
We submit that if thrombolysis has a beneficial effect on activity
limitation (disability), it is likely to have a desirable clinical and
functional outcome even in those 'already functionally impaired'.
We take consolation in the evolving nature of the landscape and the
highlighted Questions For Future Research - How safe and effective is
thrombolysis in elderly patients or those with a previous stroke?
References
1. K S McArthur, T J Quinn, J Dawson, M R Walters. Diagnosis and
management of transient ischaemic attack and ischaemic stroke in the acute
phase. BMJ 2011; 342:d1938
Competing interests: No competing interests
Currently the diagnosis of transient ischemic attack (TIA) and stroke
entails special medical complexity. McArthur et al. recently made a broad
and interesting clinical review about the diagnosis and management of
acute cerebrovascular events (1). Nonetheless, some drawbacks were evident
in this article, especially regarding:
1) TIA and stroke definitions are likely to change based in some
recent precisions, but not according to the one hour versus twenty four
hours duration.
2) Patients under suspicion of acute cerebrovascular event (cerebral
TIA or stroke) always require accurate assessment based in clinical
examination, brain imaging examination, vessel imaging, cardiac test, and
blood test.
Previously, TIAs were operationally defined as any focal cerebral
ischemic event with symptoms lasting more than 24 hours. However, some
recent studies have demonstrated that this arbitrary time threshold was
too open because 33% to 50% of traditional defined TIAs show brain
infarction on diffusion weighted magnetic resonance imaging (MRI). The 24-
hour symptom duration rule misclassifies up to one third of patients who
have experienced underlying tissue infarction and has the potential to
delay the initiation of effective stroke therapies (2).
Several groups have proposed a more advanced, clinical and
neuroimaging criteria of TIA such as "a brief episode of neurological
dysfunction caused by focal brain or retinal ischemia, with clinical
symptoms typically lasting less than one hour, and without evidence of
acute infarction" (3). However, the expression "typically less than one
hour" in this operational definition is not helpful because the 1-hour
time point, like the 24-hour time point, does not accurately differentiate
between patients with or without cerebral infarction. A term such as
"acute neurovascular syndrome" or "acute cerebrovascular event" can be
used until the diagnostic evaluation is completed or if a diagnostic
evaluation is not performed. Terms such as "cerebral infarction with
transient symptoms or transient symptoms with infarction" have been
recommended to describe events that last more than 24 hours but are
connected with cerebral infarction while retaining the 24-hour time
threshold in syndrome definition (2).
For the above considerations, cerebral TIA is better defined as brief
episode of neurological dysfunction resulting from focal cerebral ischemia
not related with cerebral infarction (without a fixed time criterion). In
the same perspective, the term "stroke" is applied to a sudden focal
neurologic syndrome, specifically the type due to cerebrovascular disease
(infarction or hemorrhage) (4). The acute perspective is implicit in the
term stroke, and for this reason is unnecessary some derived compound
expressions; with the word "stroke" is enough.
The accuracy of the clinical examination is relevant for stroke
specialists, emergency physicians, and for other health personnel who may
be the first responder (paramedics, nursing, medical technicians).
Information necessary for decisions must be obtained in a structured
fashion to minimize the possibility of overlooking critical information.
During the course of care, standardized assessments of stroke patients
deficits improves the reliability of the clinical history and examination
(5). Relevant historical information can be include in two groups: 1)
Present illness history (time of symptom onset, the evolution of symptoms,
convulsion or loss of consciousness at onset, headache, chest pain at
onset), and 2) Medical history (prior intracerebral hemorrhage, risk
factors, recent head trauma or loss of consciousness, recent myocardial
infarction, recent surgical procedures, arterial puncture,
gastrointestinal or genitourinary bleeding, and anticoagulant therapy).
The neurological examination should focus on determining the level of
consciousness and the presence of a gaze deviation, aphasia, neglect, or
motor deficit. These neurological examination items may be established
within minutes of the initial encounter and can be integrated with
National Institute of Health Stroke Scale (NIHSS) (6-8). With training,
this useful assessment tool can be applied reliably by stroke physicians,
non-neurologist physicians as well as nurses. The general physical
examination, specially focused on the cardiovascular system, must not be
obviated in this context because may facilitate acute cerebrovascular
event diagnosis and influence treatment decisions. In addition, the first
priority is assessment of the patients airway, breathing, and circulation
(6).
Actually computed tomography (CT) maintains a primary role in the
evaluation of patients with stroke and remains the "gold standard" for
detection of cerebral hemorrhage (9,10). The optimal magnetic resonance
imaging (MRI) protocol in patients with acute ischemic cerebrovascular
event includes diffusion-weighted imaging (DWI) to show infarction and MR
perfusion study to estimate brain perfusion. DWI is superior to
conventional MRI, initial and follow-up CT in the examination of patients
with stroke within 24 hours of presentation. Perfusion CT offers various
advantages over other cerebral perfusion imaging methods as it can be
performed with spiral or multi-detector CT scanners immediately after
unenhanced CT, CT, and that the perfusion maps can be rapidly generated. A
caveat of CT perfusion is its limited coverage. In clinical practice,
patients with TIA or stroke should undergo neuroimaging evaluation (MRI,
or CT if MRI is not available) preferably within 24 hours of symptom
onset. The best time to image these patients is as soon as possible
according to the treatments that are assessed, as well as the imaging
tests that are available (10).
CT and MR angiography, transcranial Doppler ultrasonography, carotid
duplex sonography, and catheter angiography can detect intracranial or
extracranial vessel abnormalities. Noninvasive imaging of the
cervicocephalic vessels should be performed routinely, and noninvasive
testing of the intracranial vasculature is reasonable to obtain when the
diagnosis of intracranial steno-occlusive disease will alter management.
The indication of these tests needs to be customized to the individual
patient and clinical setting (2,6,9).
Some blood and cardiac test needs to be considered in a standard way
for patients with cerebral TIA or stroke. Recently published guidelines
recommend routine laboratory testing of blood glucose, electrolytes,
complete blood count, prothrombin time, activated partial thromboplastin
time, international normalized ratio, and renal function. Undoubtedly, a
12-lead electrocardiogram is also recommended for all patients (2,9).
In conclusion, the adoption of the most recent definitions and test
protocols offers a better diagnostic accuracy and improves the quality of
management in patients with cerebral TIA and/or stroke.
References
(1) McArthur KS, Quinn TJ, Dawson J, Walters MR. Diagnosis and
management of transient ischaemic attack and ischaemic stroke in the acute
phase. BMJ 2011;342:d1938.
(2) Easton D, Saver JL, Albers G, Alberts M, Chaturvedi S, Feldmann
E, et al. Definition and evaluation of transient ischemic attack. Stroke
2009;40;2276-93.
(3) Albers GW, Caplan LR, Easton JD, Fayad PB, Mohr JP, Saver JL,
Sherman DG, for the TIA Working Group. Transient ischemic attack: proposal
for a new definition. N Engl J Med. 2002;347:1713-16.
(4) Ropper AH, Brown RH. Adams and Victors Principles of Neurology. 8
ed. New York: McGraw-Hill;2005.
(5) Garcia PA, Alarcon MC, Cordido HF, Diaz OF, Vazquez AP,
Villanueva JA, et al. El empleo de un formulario estructurado mejora la
calidad de la historia clinica de urgencias de pacientes con ictus agudos.
Neurologia 2011.doi:10.1016/j.nrl.2011.01.012
(6) Barrett KM, Levine JM, Johnston KC. Diagnosis of stroke and
stroke mimics in the emergency setting. Continuum: Lifelong Learning
Neurol 2008;14:13-27.
(7) Goldstein LB, Simel DL. Is this patient having a stroke?. JAMA
2005;293:2391-2402.
(8) National Institutes of Neurological Disorders and Stroke (NINDS).
NIH Stroke Scale. 2003. In: www.ninds.nih.gov/doctors/NIH_Stroke_Scale.pdf
[01.04.2011].
(9) Adams HP, del Zoppo G, Alberts MJ, Bhatt DL, Brass L, Furlan A,
et al. Guidelines for the early management of adults with ischemic stroke.
Stroke 2007;38:1655-1711.
(10) Majda M. Thurnher, Mauricio Castillo. Imaging in acute stroke.
Eur Radiol 2005;15:408-15.
Competing interests: No competing interests
Dr Dudley suggests that the BHF estimate for costs of stroke are more
reliable than the NAO figures which we quote in our paper (1). As he gives
no methodological reason for this preference we are uncertain of his
rationale for rejection of the NAO figures. Both the NAO and BHF reports
are in broad agreement on the direct costs of stroke to the health
service. The disparity stems from the estimate of costs related to broader
economic productivity. Robust economic data are only available short term
following acute stroke, cost savings associated with improved treatment
due to reduced disability in the longer term make intuitive sense but are
difficult to confirm (2). Whether the British Heart Foundation group is
better placed to quantify economic productivity than the National Audit
Office is open to debate but outwith the remit of our paper. Those
practicing evidence based stroke medicine might choose to believe either
estimate of non-health care associated costs although it is notable that
the evidence based national clinical guideline for stroke funded by NICE
(3) quote the NAO figure. Regardless of estimate used, stroke is
associated with substantial direct and indirect economic costs. With an
ageing population and increasing financial constraints within the NHS we
must endeavour to control the economic burden of cerebrovascular disease.
With regard to thrombolysis eligibility, the 10% figure quoted in
table 2 is taken from an editorial published in the Lancet Neurology by
Professors Langhorne, Sandercock and Prasad (4). This reference was
supplied prior to publication in response to a reviewer, and we have
provided a caveat in the figure to suggest that numbers eligible will vary
with the demographics of the populations served. Any figure used in this
respect is an estimate: the aspirational nature of the estimate is in our
view commensurate with the modern aggressive and optimistic paradigm of
stroke care. We make no apology for being aspirational in this context,
and if we're delusional we're in good company.
(1) McArthur KS, Quinn TJ, Dawson J, Walters MR. Diagnosis and
management of transient ischaemic attack and ischaemic stroke in the acute
phase. BMJ 2011;342:d1938
(2) Quinn TJ, Dawson J. Acute 'strokenomics': efficacy and economic
analyses of alteplase for acute ischemic stroke. Expert Review of
Pharmacoeconomics & Outcomes Research. 2009; 9(6):513-22
(3) STROKE. National clinical guideline for diagnosis and initial
management of acute stroke and transient ischaemic attack (TIA). 2008.
ISBN 978-1-86016-339-5
(4) Langhorne, P. Sandercock P. Prasad, K. Evidence-based practice
for stroke. Lancet Neurology, 2009; Vol 8: 307-309
Competing interests: No competing interests
Given the fact that the British Heart Foundation and Stroke
Association 2009 Stroke Statistics recorded the cost of stroke and
transient ischaemic attack in England in 2006/07 to be ?3.9 billion, is
the ?8 billion figure for stroke costs in Kate McArthur and colleagues'
clinical review a considerable overestimate? [1,2] Which figure should be
believed and relied upon by those practising evidence-based stroke
medicine - one produced by the British Heart Foundation Health Promotion
Research Group and Health Economics Research Centre at the Department of
Public Health, University of Oxford or one by the Comptroller and Auditor
General (C&AG) and non-specialist auditors at the National Audit Office?
The authors did not clarify the basis of the 10% claim for
thrombolysis in table 2. They also failed to indicate if it was 10% of all
stroke patients from a defined population, 10% of the subgroup from that
larger population who are admitted to hospital, or 10% of the sub group
admitted to a hospital's specialist stroke unit. The 10% rate for a
population must surely be highly aspirational - if not somewhat delusional
- given the fact that despite considerable investment in hyperacute
services in England since 2005 - and especially in London - nowhere near
11,000 patients are being thrombolysed.
It is worth noting that with well designed stroke services and
targeted thrombolysis for selected patients, it is possible for individual
stroke units to achieve thrombolysis rates well in excess of 10%. In
2008/09, King's College Hospital in London thrombolysed 113 of 415 stroke
admissions (27%) and in 2009/10 achieved an even better result of 268 of
780 admissions (34%). However, the overall England population thrombolysis
rate based on the numbers treated from the South London Stroke Register
area - that is covered by King's College Hospital - works out at just
4.5%. [3]
[1] McArthur KS, Quinn TJ, Dawson J, Walters MR. Diagnosis and
management of transient ischaemic attack and ischaemic stroke in the acute
phase. BMJ 2011;342:d1938
[2] Stroke Statistics 2009.
www.heartstats.org.uk/datapage.asp?id=8615
[3] Addo J, Bhalla A, Critchon S et al. Provision of acute stroke
care and associated factors in a multiethnic population: prospective study
with the South London Stroke Register. BMJ 2011;342:d744
Competing interests: Peer reviewed the article for the BMJ
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 stroke which costs the NHS over ?2.8 billion.
The Government has launched a national stroke strategy to modernise
service provision and deliver the newest treatments for stroke. The
Government's target which aims to reduce the death rate from Stroke, CHD
and related diseases in people under 75 by at least 40 percent in 2010 has
already been achieved.
The Department of Health recognised the importance of developing
better stroke services by including specific milestones, targets and
actions in the National Service Framework (NSF) for Older People launched
in March 2001
The best approach to reduce the burden of stroke remains prevention. The
large majority of epidemiological data available focus only on western
countries. Among all the neurological diseases of adult life, stroke
clearly ranks first in frequency and importance, at least 50% of the
neurological disorders in a hospitalized patients are of this type
.Despite advances in medical care of stroke and the advent of treatment of
selected patients with acute ischemic stroke, prevention remains the best
approach to reduce the burden of stroke.
High-risk or stroke-prone individuals can be identified and targeted for
specific interventions .The prevalence of stroke is heterogeneous and is
greater among the elderly and men and is variable from one region to
another of the world.
Few data are available on Middle East and other developing
countries. Among different research studies age and hypertension are the
most important risk factors for incidence of stroke in the developing
world. Despite the availability of cost-effective intervention there are
significant gaps, in primary prevention of cerebrovascular diseases, in
low- and middle- income areas all over the world.
Lessons to learn
1. Mostly there is a need to facilitate the access to preventive drug
therapy and to promote healthy life-styles. Tailored policies are also
required to promote clinical prevention, strengthen infrastructures of
health-care facilities and providing continuing medical education for the
personnel.
2. Sudden onset focal neurological symptoms represent a medical emergency
and should be treated as such
3. sudden change in consciousness of an acute stroke patient may indicate
a treatable complication and warrants urgent investigation.
4. The risk of further cerebrovascular event following TIA is substantial,
immediate, quantifiable, and preventable.
5. Deranged physiology is common in acute stroke and associated with poor
prognosis.
Questions need to be answered in future researches
How safe and effective is thrombolysis in elderly patients or those with a
previous stroke?
How safe and effective is using aspirin from age of 40 for those with
family history of stroke or TIA ?
REFERENCES
* Barnett HJ, Taylor DW, Eliasziw M, Fox AJ, Ferguson GG, Haynes RB,
et al. Benefit of carotid endarterectomy in patients with symptomatic
moderate or severe stenosis.
* Giles MF, Rothwell PM. Risk of stroke early after transient
ischaemic attack: a systematic review and meta-analysis. Lancet
Neurol2007;6:1063-72.
* Norrving B, Lowenhielm P. Epidemiology of stroke in lund-orup
Sweden 1983-85, incidences of first stroke and age-related changes din
subtypes.
* Acta Neurol Scand 1988; 78: 413. Warlow CP. Introduction. Handbook of
neurology. Oxford: Blackwell
1991.
Competing interests: No competing interests
Diagnosis and management of transient ischaemic attack and stroke in the acute phase
We read with interest the recent Clinical Review and we agree
wholeheartedly with the authors' statement that MRI imaging is the
modality of choice for stroke1.
At Stoke Mandeville Hospital, MRI has been the standard imaging for
TIA and stroke since 2000. Our experience has confirmed the published
advantages of MRI over CT and we have reported on the practicality of MRI
in acute stroke2. Although not all patients can have MRI scans, we have
found that the vast majority of acute patients are able to undergo MRI3.
Use of limited MR sequences including diffusion-weighting takes little
longer than CT.
MRI can give valuable information for hyperacute stroke management
and thrombolysis. The paper quoted by the authors demonstrated a high
sensitivity of MRI v CT in patients presenting within three hours of
onset4 and other authors have confirmed the utility of MRI in this
situation5. Most importantly, in our experience and that of others, the
use of MRI does not prolong door-to-needle time5.
The important clinical advantage of MRI is the provision of much more
specific information about stroke pathology. There are limitations to
clinical determination of the vascular distribution of stroke, either for
distinguishing vertebrobasilar disease from carotid territory disease or
cortical from subcortical infarction6,7. The finding of additional
infarction (often small and asymptomatic) in another vascular territory
from the presenting stroke will lead to a more detailed search for a
cardiac source of embolism. In our practice those patients not in atrial
fibrillation at the time are referred for prolonged ambulatory ECG
recording (R test) to detect paroxysmal arrhythmia. Another important
group presenting with multiple territory infarction, often recurrent, is
patients with cancer, either as pre-existing disease or as a first
presentation with stroke8. Non-bacterial thrombotic endocarditis is the
underlying mechanism in a significant proportion of these patients and
anticoagulation may be of benefit9.
Despite these clear advantages, we regret that MRI is not yet
established as the standard stroke imaging in the UK and we trust that
this timely review will advance the debate about access to superior
imaging for our stroke patients. Now is the time for a policy of scan
immediately with MRI for stroke whenever possible.
Dr Chris Durkin, Consultant Geriatrician
Dr Dennis Briley, Consultant Neurologist
Dr Tom Meagher, Consultant Radiologist
Stoke Mandeville Hospital,
Buckinghamshire Healthcare NHS Trust,
Aylesbury,
Bucks HP21 8AL, UK
chris.durkin@buckshealthcare.nhs.uk
1. McArthur KS, Quinn TJ, Dawson J, Walters MR. Diagnosis and
management of transient ischaemic attack and stroke in the acute phase.
British Medical Journal 2011;342:d1938
2. Tan PL, King D, Durkin CJ, Meagher TM, Briley D. Diffusion weighted MRI
for acute stroke: practical and popular. Postgraduate Medical Journal
2006;82:289-92.
3. Briley DP, Meagher T, King D. Practical limitations of acute stroke MRI
due to patient related problems. Neurology 2005;328:400 (letter)
4. Chalela JA, Kidwell CS, Nentwich LM. Luby M et al. Magnetic resonance
imaging and computed tomography in emergency assessment of patients with
suspected acute stroke: a prospective comparison. Lancet 2007;369:293-98
5. Schellinger PD, Thomalla G, Fiehler J, Kohrmann M et al. MRI-based and
CT-based thrombolytic therapy in acute stroke within and beyond
established time windows. Stroke 2007;38:2640-2645
6. Flossmann E, Redgrave JNE, Briley D, Rothwell PM. Reliability of
clinical diagnosis of the symptomatic vascular territory in patients with
recent transient ischemic attack or minor stroke. Stroke 2008;39:2457-
2460.
7. Potter G, Doubal F, Jackson C, Sudlow C, Dennis M, Wardlaw J.
Associations of clinical stroke misclassification ("Clinical-Imaging
Dissociation") in acute ischemic stroke. Cerebrovascular Disease
2010;29:395-402.
8. Kwon HM, Kang BS, Yoon BW. Stroke as the first manifestation of
concealed cancer. Journal of the Neurological Sciences 2007;258/1-2(80-
3):0022-510X.
9. Taccone FS, Jeangette SM, Blecic SA. First ever stroke as initial
presentation of systemic cancer. Journal of Stroke & Cerebrovascular
Diseases 2008;17/4(169-74):1532-8511.
Competing interests: No competing interests