Hyperacute stroke patient pathway

Patient pathway

1. Pre alert if Face, Arm, Speech Test (FAST) +ve and Onset <6 hrs or Wake-up or unknown – do not pre-alert if definitely more than 6 hours and no advanced brain imaging possible
2. Default is to pre-alert nearest lysis spoke, unless there is a local protocol to by-pass nearest spoke to go to nearest thrombectomy hub (this will usually require prof to prof call and the patient would go to Emergency Dept (ED) at the thrombectomy hub)
3. Emergency Dept (ED) medical staff +/- stroke team will rapidly assess clinically and triage to
   • No hyperacute imaging for those without stroke or other indication
   • Non contrast computerised tomography (CT) only because stroke has not caused significant functional problem
   • CT+ CT angiography (CTA) (default for potentially disabling stroke) if thrombectomy within 6 hours is indicated and possible
   • CT+CTA+CT perfusion (CTP) if wake-up or unclear onset and hyperacute treatment otherwise indicated
4. Stroke physician in consultation with local radiologist or national neuroradiologist and/or artificial intelligence system determine if meet clinical and radiological criteria for lysis and/or thrombectomy
   • Stroke likely to lead to loss of function important to the patient (guide pre-stroke modified Rankin score (mRS) <4 & National Institutes of Health Stroke Scale (NIHSS) ≥ 6)
   • No acute intracerebral bleed or other contraindication(s) to lysis
   • No well established large infarct (guide of Alberta stroke program early CT score (ASPECTS) ≥ 6)
   • CTP/ Magnetic Resonance Imaging (MRI) shows significant mismatch indicating important volume of salvageable brain
5. Hub stroke physician in consultation where necessary with Interventional Neuroradiologist (INR) will review imaging to determine if thrombectomy appropriate and possible and agree transfer or not. See Eligibility for thrombectomy (Word .doc)
6. Scottish Ambulance service (SAS) special service desk will determine the best method of transfer from spoke to hub based on availability and location of ambulances/aircraft and relative transfer times
7. If patient’s condition has changed significantly from that reported from spoke, or it is not possible to carry out thrombectomy within 6 hours of onset, further imaging to confirm large artery occlusion (LAO) or salvageable brain may be needed prior to proceeding to thrombectomy
8. If the thrombectomy is carried out under under general anaesthetic (GA), rather than awake sedation, the patient may require to go to recovery or if the patient’s condition is poor they may require High Dependency Unit (HDU) or Intensive Care Unit (ICU) before transfer to a Hyperacute Stroke Unit (HASU).
9. Each spoke needs to agree to accept without any delay patients whom the hub has confirmed are fit for ambulance transfer. The SAS will arrange an ambulance transfer appropriate to the patients condition and needs of the service.