1. Dr Andy Beale – National Clinical Lead

3. December 2007

4. The campaign reached 92% of the population and awareness improved ‘Slumped’ face 64% rose to 87% Unable to raise both arms 46% rose to 72% Slurred speech 46% rose to 74%

5. 20052010

7.  Produced by large group of stakeholders  Published in 2008  Provides further detail on recommendations relating to imaging for TIA and stroke.  Describes best practice

8.  Provides guidance for commissioners of imaging services and…  Professionals dealing with  Stroke patients  Management of Imaging Services  The training and education of staff

9.  Suggests practical changes that can and should be made NOW But also……  Provides aspirations for the future.

10.  7 days a week  CEMRA.  Duplex Ultrasound Imaging  CT Angiography

11.  7 days a week, during the daytime  Can include:  Contrast enhanced MRA (CEMRA) for 1 st line carotid imaging.  Software for Diffusion Weighted Imaging (DWI) & Gradient Echo Imaging

13.  24 hour access to CT – within 1 hour of request, 24 hours a day.  Rapid access to MRI when required  Access to more complex imaging for stroke subtypes when required.

15.  Thrombolysis candidate  On anticoagulation  Bleeding tendency  GCS < 13 (12 or less)  Unexplained fluctuating or progressive symptoms  Severe headache at onset  Papilloedema, neck stiffness, fever

16.  Will entail significant new work – many not currently imaged  Few currently imaged as ‘urgent’.

17.  Per 500,000 population  approx 30 pts per week  50% will require brain imaging (66% within 24 hrs)  80% will require carotid imaging (66% within 24 hrs)

18.  Per 500,000 population  approx 30 pts per week  50% will require brain imaging (66% within 24 hrs)  80% will require carotid imaging (66% within 24 hrs)  Anticipated imaging during the week  12 MRI/MRA Brain and 10 Carotid Imaging (+/- C.T)  Anticipated imaging during the week-end  3 MRI/MRA Brain and 2 Carotid Imaging (+/- C.T)

19.  Per 500,000 population  approx 25 pts per week  Almost 100% will require brain imaging (c.50% within 1 hr)  10-20% of urgent cases will require additional imaging within 24 hours e.g. MRI  Anticipated imaging during the week  15-17 Brain CT and 3-4 MRI  Anticipated imaging during the week-end  7-9 cases with 1-2 a month requiring further brain imaging

20.  I.T. infrastructure is being developed  Guidance documents are available  National Diagnostic Imaging Board  The role of teleradiology in supporting the delivery of Diagnostic Imaging Services  RCR document  Teleradiology – A guidance document for radiologists (2004).  CfH website  PACS – Image Sharing Policy

21.  Includes staff to acquire images and staff to report on images.  Radiologists  Radiographers  Support staff  Imaging nurses  X-ray Department Assistants  A&C Staff  PORTERS

22.  Needs careful workforce planning  Evaluation of skill mix  Currently insufficient in many areas  Not all radiographers can do CT head scan  SCoR committed to training all emerging radiographers to do this.  Only senior CT radiographers should be taught additional skills in image interpretation.

23. WRT (workforce review team) - Assessment of Workforce Priorities (Summer 2008) – Stroke Workforce  acknowledges increased demand for imaging workforce to carry out computed tomography, magnetic resonance imaging (MRI) scans and ultrasound investigations,  and to provide extended cover  2010 WRT agree no reductions in training No’s for radiology  http://www.cfwi.org.uk/intelligence/previous-projects/workforce- summaries/clinical-radiology

24. Suggested mitigation strategies SHAs, deaneries and employers concentrate on ensuring sufficient access to specialist training in stroke inc neuroradiology and thrombolysis. focus on providing appropriate post registration training and development opportunities to fill locally identified gaps in workforce …as well as developing assistant practitioner workforce. SHAs increase no. of trainee vascular scientists reduce attrition rate in diagnostic radiography training fund post registration training in MRI and US

25.  RCR and SCoR has detailed guidance on structured training.  If other professions are going to undertake some aspects of imaging  should be to the same standard  requires support from imaging teams

26.  Additional investment in equipment required in CT, MRI and US  Good opportunity to review where equipment is located  e.g. as close as possible to where the patient is brought into the hospital

28.  Intravenous fibrinolytic therapy within the first 3 hours of ischemic stroke onset offers substantial net benefits for virtually all patients with potentially disabling deficits.  Intravenous fibrinolytic therapy within 3-4.5 hours offers moderate net benefits when applied to all patients with potentially disabling deficits.  MRI (CT perfusion) of the extent of the infarct core (already irreversibly injured tissue) and the penumbra (tissue at risk but still salvageable) can likely increase the therapeutic yield of lytic therapy, especially in the 3- to 9-hour window.  Intra-arterial fibrinolytic therapy in the 3- to 6-hour window offers moderate net benefits when applied to all patients with potentially disabling deficits and large artery cerebral thrombotic occlusions.

30. The National Institute for Health and Clinical Excellence (NICE) sets a time frame of two weeks from symptoms to surgery, - 37% Government’s National Stroke Strategy (NSS) the time frame is 48 hours. - 3%

31.  Intercollegiate Stroke Working party  Voluntary, from 4/5/10 to 31/3/11  First 72 hrs after admission

32.  Available in 88% of hospitals  24/7in 50%  Estimated national percentage of 3.8%  Comparable with other European countries  Rates of 10-25% being achieved in some sites

35. Median time 121 mins

36. Median time 324 mins

37. The national median is: 185 minutes

38. The national median is: 66 minutes

40.  Imaging the brain:  Not all need it.  Helpful when:  vascular territory unclear and for Carotid surgery  ?haem, e.g on warfarin, longer symptoms  Other diagnosis, e.g tumour etc  If ABCD2 score high or crescendo – within 24hrs  If ABCD2 score less than 4 – within 1 week

41.  MRI Diffusion  In hospital and at 3 months - a DWI abnormality on presentation is a predictor of stroke and recurrent TIA  Gradient echo (GRE) sensitive for blood

43.  Only one-third of stroke units meet all basic criteria used to define quality  Almost half of hospitals admit patients to non- specialised beds  Majority of hospitals still use general assessment beds for acute stroke admissions despite best practice tariff requiring direct admission to ASU

44.  Only one third of TIA patients in hospital were being managed in specialised beds  Only one in ten hospitals provide seven day out-patient TIA assessment  Almost half of centres admit low risk TIA patients - wasting resources

46. 68.1% of patients are spending 90% of their time on a stroke unit

48.  All SHAs have held an event to mark the start of ASI.  Updated Data packs have been produced for each SHA bringing together all the available data on stroke into one place. (data from 2010 SENTINEL and carotid endarterectomy audits.)  9 key indicators have been identified that will provide a good picture of progress across the pathway  A steering group has been established.  SIP has identified a number of associates, front line professionals with a track record in delivering the stroke strategy. They are available to help other Trusts who have not been able to make the changes necessary to improve performance.

49. Key Indicators

50.  Specific project measures include: Percentage of eligible patients receiving initial FAST test prehospital Time from call for help (or first professional contact) to arrival at A&E Time from arrival at A&E to CT scan Percentage of eligible patients that receive thrombolysis Percentage of patients treated for 90% of stay in a stroke unit Percentage of patients admitted directly to the acute stroke unit from A&E Percentage of patients admitted within four hours of arrival to hospital to an acute stroke unit Percentage of patients that are admitted to the acute stroke unit on the day of their stroke Percentage of eligible patients receiving a brain scan within 60 minutes of arrival to hospital (NICE recommendations) Percentage of eligible patients receiving a brain scan within 24 hours of arrival to hospital Percentage of patients that receive a swallow assessment within 24 hours of admission Percentage of patients that receive a physiotherapy assessment within the first 72 hours of admission Length of stay on acute stroke unit Overall hospital length of stay (including rehabilitation) Time from decision to discharge to actual discharge date.

51.  By March 2011:  60% of high risk people with TIA should be investigated and treated within 24 hours  % of patients spending 90% time on specialist stroke units.

52. Percentage of high risk TIA cases treated within 24 hours (Vital Sign definition). Percentage of patients for whom it is appropriate who receive carotid imaging within 24 hours. Percentage of patients who require brain imaging who receive brain imaging (MRI) within 24 hours. Percentage of confirmed TIA patients with high grade stenosis who receive carotid intervention within 48 hours

53. Lower risk: Percentage of lower risk TIA cases treated within seven days. Percentage of patients for whom it is appropriate who receive carotid imaging within seven days. Percentage of confirmed TIA patients with high grade stenosis who receive carotid intervention within two weeks. Time from first contact to TIA clinic. Time from first contact to carotid imaging. Time from first contact to brain imaging. Time from first contact to carotid intervention. Time from seen in clinic to carotid imaging. Time from seen in clinic to brain imaging (MRI). Time from carotid imaging to referral for carotid intervention Time from referral for carotid intervention to carotid intervention. Time from carotid imaging to carotid intervention. Percentage of confirmed TIA patients having follow up at one month after event (primary or secondary care). Percentage of confirmed TIA patients who have had a stroke at 30 days following event. Percentage of all patients seen confirmed as TIA high and low risk. Percentage of confirmed TIA patients who are high risk. Percentage of confirmed TIA patients who are lower risk. Percentage of confirmed TIA patients who are in atrial fibrillation (AF). Percentage of confirmed TIA patients who have AF receiving anticoagulation therapy. Percentage of confirmed patients who have AF who are commenced on anticoagulation or referred for anticoagulation.

55. ACUTE STROKE  Immediate CT (<1 hour) for thrombolysis  CT same day for all other acute stroke = 7 day service  MR available in same time frame if needed = 7 day service  CT/MR angiography - ?dissection, venous thrombosis

56.  CDUS required in %80, (not in post circ TIA)  CDUS within 7 days if low risk  CDUS same day for high risk = 7 day service  MRA/CTA in same timeframe if US equivocal = 7 day MRI service  DWI in all equivocal cases (about 50%)

57.  Hyperacute - Thrombolysis  Emergency - Acute stroke  Very Urgent - TIA in high risk patients  Urgent – all TIA’s

58. Full implementation of the NSS will require routine 365 days per year availability of: CDUS CT +/- CTA & CTP MRI and DWI +/- MRA Very few departments currently have a routine weekend service in many of these modalities

59. Prevention Clinical assessment Diagnostics Immediate therapy Stroke unit care Rehabilitation Longer term care Community support Family care But Needed at front end of care Needed immediately Significant numbers New technologies

60.  CT brain  Exclude haemorrhage  Confirm diagnosis (early signs)  MR brain  MR angiography  Circle of willis  Extracranial carotid  DWI – diffusion weighted imaging  Catheter angiography

61.  CT angiography  CT perfusion mapping  Intra-arterial thrombolysis  Interventional clot retrieval

62.  Confirm acute penumbra  ‘wake up’ stroke  3-6 hour thrombolysis Area of decreased cerebral blood volume (yellow arrow), which represents tissue that is irreversibly damaged. A larger area of decreased cerebral blood flow and increased mean transit time (green arrows), which represents tissue that is oxygen deficient, but not yet irreversibly damaged; ‘The mismatch’

64. Mismatch-Based Delayed Thrombolysis. A Meta-Analysis STROKE Jan 2010 Mishra, Albers, Davis et al Conclusions—Delayed thrombolysis amongst patients selected according to mismatch imaging is associated with increased reperfusion/recanalization. Recanalization/reperfusion is associated with improved outcomes. However, delayed thrombolysis in mismatch patients was not confirmed to improve clinical outcome, although a useful clinical benefit remains possible. Thrombolysis carries a significant risk of symptomatic intracerebral hemorrhage and possibly increased mortality. Criteria to diagnose mismatch are still evolving. Validation of the mismatch selection paradigm is required with a phase III trial. Pending these results, delayed treatment, even according to mismatch selection, cannot be recommended as part of routine care.

65. Mismatch-Based Delayed Thrombolysis. A Meta-Analysis STROKE Jan 2010 Mishra, Albers, Davis et al Conclusions—Delayed thrombolysis amongst patients selected according to mismatch imaging is associated with increased reperfusion/recanalization. Recanalization/reperfusion is associated with improved outcomes. However, delayed thrombolysis in mismatch patients was not confirmed to improve clinical outcome, although a useful clinical benefit remains possible. Thrombolysis carries a significant risk of symptomatic intracerebral hemorrhage and possibly increased mortality. Criteria to diagnose mismatch are still evolving. Validation of the mismatch selection paradigm is required with a phase III trial. Pending these results, delayed treatment, even according to mismatch selection, cannot be recommended as part of routine care.

66.  Patient risk  Patient cooperation  Clinical need  Safety concerns, no history  Time  Availability

67. No Panacea for all Resources are different DGH v Teaching hospital Geography is different Rural v urban Radiology resources CT and MRI machines

69. Use of CT/MRI machines 2007/08 Patients scanned

71.  Cancer targets (31 and 62 days)  13/18 week target  Inpatient pressures and reporting turnaround  Relentless increasing general demand with new techniques e.g. CT coronaries, Ct colonsocopy  National shortage of radiologists  IR  Regional variation in numbers of radiographers  Variable availability & quality of equipment

72.  CT radiographer on call  CT radiographer on extended working  General radiographer trained in CT  Only for stroke.  General radiographers not able to do complex trauma imaging  Generalists will struggle as CTA & CTP become more prevalent

73.  On call local radiologist  Network radiologist  Neuroradiologist (+/- network)  IS (teleradiology – nighthawk etc)  CT reading radiographers  Trained stroke physicians

74.  Sonographer  Vascular technician  Nurse specialist  Radiologist  Neuroradiologist  Stroke physician  Vascular surgeon Most appropriate Trained Available Health professional? Will vary from place to place Can sonographers request MRI (Why not?)

75.  Network stroke service  Hub and spoke  Telemedicine & virtual hub  Teleradiology support  Network reporting  Neurocentre reporting  Outsourcing

76. Addresses :  Stroke agenda  Demand / activity surges  Thrombolysis  NICE MSCC  Access agenda  Modern life  Total quality of care £

77.  There is pressure from above to provide prompt Stroke and TIA imaging  Response is still patchy  Departments are different in attitude, efficiency, staffing, resources  Help and advice is available

78.  Rate limiting: time in the room.  Scanning time is not adjustable. (cf MRI)  Concentrate on patient preparation, (imaging assistants)  How do we optimise  Joint lists. No ‘ownership’.  4 rooms, 3 scanning. The ‘spare room’  Utilise the lunch hour.  Allocate complex procedures outside lists to unblock room. Scan

79.  CT scanning time is short.  Time saved from single slice to 128 slice is only ‘seconds’.  Concentrate on patient preparation.  Cannulate outside the room.  2 radiographers, 1 to enter pt details, 1 to transfer and prepare room e.g. contrast etc.  Protocol driven  Keep radiologist away from interfering.  Always run lists. Don’t let A/L cause cancellations. Scan

80.  Scanning time is long (cf CT).  Concentrate on sequences.  Protocol driven with uniformity between lists. (Also helps clinicians)  Keep radiologist away!  Patient preparation:  Imaging assistants do questionnaire (and iv)  Also place coils (freeing Radiographer to enter details)  Minimise coil changes  Extend hours (capacity), shift working.  Scanning appts, 20 mins. Scan