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SECTION 2: ORGANISATION OF SERVICES 2.4 K Acute stroke services should participate in national and local audit, multicentre research and quality improvement programmes.(Required)
2.5 Resources – inpatient stroke services A People with stroke should be treated in a specialist stroke unit throughout their hospital stay unless their stroke is not the predominant clinical problem.(Required) B A hyperacute, acute and rehabilitation stroke service should provide specialist medical, nursing, and rehabilitation staffing levels matching the recommendations in Table 2.5 in the guideline)(Required) A separate form (Part 2) will collect more detailed information on actual vs recommended staffing levels. Only answer "fully" if your services meets the recommendations for medical, nursing, all therapies, dietetics and clinical psychology. Respond with "partially" if you comply for at least one profession and "Not" if you do not meet recommended levels for any profession.
C A hyperacute stroke unit should have immediate access to: specialist medical staff trained in the hyperacute and acute management of people with stroke, including the diagnostic and administrative procedures needed for the safe and timely delivery of emergency stroke treatments; specialist nursing staff trained in the hyperacute and acute management of people with stroke, covering neurological, general medical and rehabilitation aspects; stroke specialist rehabilitation staff; diagnostic, imaging and cardiology services; tertiary services for endovascular therapy, neurosurgery and vascular surgery.(Required) D A hyperacute stroke unit should have continuous access to a consultant physician with expertise in stroke medicine, with consultant review 7 days per week.(Required) E An acute stroke unit should provide: specialist medical staff trained in the acute management of people with stroke; specialist nursing staff trained in the acute management of people with stroke, covering neurological, general medical and rehabilitation aspects; stroke specialist rehabilitation staff; access to diagnostic, imaging and cardiology services; access to tertiary services for neurosurgery and vascular surgery.(Required) F An acute stroke unit should have continuous access to a consultant physician with expertise in stroke medicine, with consultant review 5 days per week.(Required) G Where telemedicine is used for the assessment of people with suspected stroke by a specialist physician, the system should enable the physician to discuss the case with the assessing clinician, talk to the patient and/or family/carers directly and review radiological investigations. Telemedicine should include a high quality video link to enable the remote physician to observe the clinical examination.(Required) H Staff providing care via telemedicine (at both ends of the system) should be appropriately trained in the hyperacute assessment of people with suspected acute stroke, in the delivery of thrombolysis and the use of this approach and technology. The quality of care and decision making using telemedicine should be regularly audited.(Required) I A stroke rehabilitation unit should predominantly care for people with stroke, and should the maintain the staffing and skill levels required of a stroke unit regardless of size, location or mix of conditions of the patients being treated.(Required) J A stroke rehabilitation unit should have a single multidisciplinary team including specialists in: medicine; nursing; physiotherapy; occupational therapy; speech and language therapy; dietetics; clinical psychology/neuropsychology; social work; orthoptics; with timely access to rehabilitation medicine, specialist pharmacy, orthotics, specialist seating, assistive technology and information, advice and support (including life after stroke services) for people with stroke and their family/carers.(Required) K A stroke rehabilitation unit should have access to a consultant specialising in stroke rehabilitation (medical or non-medical, i.e. nurse or therapist, where professional regulation permits) at least 5 days a week, with twice weekly consultant-led ward rounds.(Required) L Stroke rehabilitation units with non-medical consultant leadership should have daily medical cover (ward doctors, GPs), enabling admissions and discharges 7 days a week, with support available from stroke physicians as required. 24 hour on-site medical cover may not be required depending on patient admission criteria, with adequate out of hours arrangements.(Required) M A facility that provides treatment for inpatients with stroke should include: a geographically-defined unit; a co-ordinated multidisciplinary team that meets at least once a week for the exchange of information about inpatients with stroke; information, advice and support for people with stroke and their family/carers; management protocols for common problems, based upon the best available evidence; close links and protocols for the transfer of care with other inpatient stroke services, early supported discharge teams and community services; training for healthcare professionals in the specialty of stroke.(Required) N Specialist inpatient stroke services should include sufficient administration and management (including data management) support.(Required)
2.6 Location of service delivery A People with acute stroke who cannot be admitted to hospital should be seen by the specialist team at home or as an outpatient within 24 hours for diagnosis, treatment, rehabilitation, and risk factor management at a standard comparable to that for inpatients.(Required)
2.7 Transfers of care – general principles A Transfers of care for people with stroke between different teams or organisations should: occur at the appropriate time, without delay; not require the person to provide information already given; ensure that all relevant information is transferred, especially concerning medication; maintain a set of person-centred goals; preserve any decisions about medical care made in the person’s best interests.(Required) B People with stroke should be: involved in decisions about transfers of their care if they are able; offered copies of written communication between organisations and teams involved in their care.(Required) C Organisations and teams regularly involved in caring for people with stroke should use a common, agreed terminology and set of data collection measures, assessments and documentation.(Required)
2.8 Transfers of care from hospital to home – community stroke rehabilitation A Hospital inpatients with stroke who have mild to moderate disability should be offered early supported discharge, with treatment at home beginning within 24 hours of discharge.(Required) B Patients undergoing rehabilitation after stroke who are not eligible for early supported discharge should be referred to community stroke rehabilitation if they have ongoing rehabilitation needs when transferred from hospital.(Required) C Early supported discharge and community stroke rehabilitation should be provided by a service predominantly treating people with stroke(Required) D Therapy provided as part of early supported discharge should be at the same intensity as would be provided if the person were to remain on a stroke unit.(Required) E The intensity and duration of intervention provided by the community stroke rehabilitation team should be established between the stroke specialist, the person with stroke and their family/carers, and be based on clinical need tailored to goals and outcomes.(Required) F A multidisciplinary service providing early supported discharge and community stroke rehabilitation should adopt a minimum core team structure staffing levels matching the recommendations in Table 2.8 in the guideline(Required) A separate form will collect more detailed information on actual vs recommended staffing levels. Only answer "fully" if your services meets the recommendations for medical, nursing, all therapies, social worker, rehab assistants and clinical psychology. Respond with "partially" if you comply for at least one profession and "Not" if you do not meet recommended levels for any profession.
G Early supported discharge and community stroke rehabilitation services should include: a co-ordinated multidisciplinary team that meets at least once a week for the exchange of information about people with stroke in their care; provision of needs-based stroke rehabilitation, support and any appropriate management plans, with the option for re-referral after discharge if stroke rehabilitation needs and goals are defined, and with access to support services on discharge; information (aphasia-friendly), advice, and support for people with stroke and their family/carers; management protocols for common problems, based upon the best available evidence; collaboration, close links and protocols for the transfer of care with inpatient stroke services, primary care, community services and the voluntary sector; training for healthcare professionals in the specialty of stroke.(Required) H People with stroke and their family/carers should be involved in decisions about the transfer of their care out of hospital, and the care that will be provided.(Required) I Members of the early supported discharge and community stroke rehabilitation services should be involved in hospital discharge planning and decision making by attending stroke unit multidisciplinary team meetings.(Required) J Before the transfer of care for a person with stroke from hospital to home (including a care home) occurs: the person and their family/carers should be prepared, and have been involved in planning their transfer of care if they are able; primary healthcare teams and social services should be informed before or at the time of the transfer of care; all equipment and support services necessary for a safe transfer of care should be in place; any continuing treatment the person requires should be provided without delay by a co-ordinated, specialist multidisciplinary service; the person and their family/carers should be given information and offered contact with relevant statutory and voluntary agencies (e.g. stroke key worker).(Required) K Before the transfer home of a person with stroke who is dependent in any activities, the person’s home environment should be assessed by a visit with an occupational therapist. If a home visit is not considered appropriate, they should be offered an access visit or an interview about the home environment including viewing photographs or videos taken by family/carers.(Required) L People with stroke who are dependent in personal activities (e.g., dressing, toileting) should be offered a transition package before being transferred home that includes: visits or leave at home prior to the final transfer of care; training and education for their carers specific to their needs; telephone advice and support for three months.(Required) M Before the transfer of care for a person with stroke from hospital to home (including a care home) they should be provided with: a named point of contact for information and advice; personalised written information in an appropriate format about their diagnosis, medication, and management plan.(Required) N People with stroke, including those living in care homes, should continue to have access to specialist services after leaving hospital, and should be provided with information about how to contact them, and supported to do so if necessary.(Required) O Early supported discharge and community stroke rehabilitation services should participate in national and local audit, multicentre research, and quality improvement programmes.(Required)
2.10 Measuring rehabilitation outcomes A Assessment measures used in stroke rehabilitation should meet the following criteria as far as possible: they should collect relevant data across the required range (i.e. they are valid and fulfil a need); they should have sufficient sensitivity to detect change within a person and differences between people; their reliability should be known when used by different people on different occasions and in different settings; they should be simple to use under a variety of circumstances; they should provide scores that are easily understood.(Required) C A stroke service should have protocols for determining the routine collection and use of data that: specify the reason for and proposed use of each assessment measure; provide individual clinicians with a choice of assessment measures where no measure is obviously superior; review the utility of each assessment measure regularly.(Required) D A stroke service should have protocols for the use of more complex assessment measures, describing: when it is appropriate or necessary to consider their use; which assessment measure(s) should be used; what specific training or experience is needed to use the assessment measure(s).(Required)
2.11 Psychological care – organisation and delivery A Services for people with stroke should have a comprehensive approach to delivering psychological care that includes specialist clinical psychology/neuropsychology input within the multidisciplinary team.(Required) B Services for people with stroke should offer psychological support to all patients regardless of whether they exhibit specific mental health or cognitive difficulties, and use a matched care model to select the level of support appropriate to the person’s needs.(Required) C Services for people with stroke should provide training to ensure that clinical staff have an awareness of psychological problems following stroke and the skills to manage them.(Required) D Services for people with stroke should ensure that the psychological screening and assessment methods used are appropriate for use with people with aphasia and cognitive impairments.(Required) E Services for people with stroke should provide screening for mood and cognitive disturbance within six weeks of stroke (in the acute phase of rehabilitation and at the transfer of care into post-acute services) and at six and 12 months using validated tools and observations over time.(Required) F Services for people with stroke should include specialist clinical psychology/neuropsychology provision for severe or persistent symptoms of emotional disturbance, mood or cognition.(Required) G Services for people with stroke should consider a collaborative care model for the management of people with moderate to severe neuropsychological problems who have not responded to high-intensity psychological interventions or pharmacological treatments. This care model should involve collaboration between the GP, primary and secondary physical health services and case management, with supervision from a senior mental health professional and should include long-term follow-up.(Required)
2.14 Stroke services for younger adults A All stroke care, including (hyper-) acute care for younger adults with stroke, should be based on an assessment of the person’s individual needs and priorities.(Required) C People who have had a stroke in childhood and require ongoing healthcare into adulthood should have their care transferred in a planned manner to appropriate adult services.(Required)
2.15 End-of-life (palliative) care A Services providing acute and long-term care for people with stroke should provide high quality end-of-life care for those who need it.(Required) B Staff caring for people dying of stroke should be trained in the principles and practice of end-of-life care, including the recognition of people who are approaching the end of life.(Required) C Decisions to withhold or withdraw life-prolonging treatments after stroke including artificial nutrition and hydration should, whenever possible, take the person’s prior expressed wishes and preferences into account and should be taken in the best interests of that person. When withdrawing artificial nutrition and hydration, a recognised nutrition and hydration decision-making process should be considered.(Required) D End-of-life (palliative) care for people with stroke should include an explicit decision not to have burdensome restrictions that may exacerbate suffering. In particular, following assessment this may involve a decision, taken together with the person with stroke, their family/carers, and the multidisciplinary team, to allow oral food or fluids despite risks including aspiration and choking.(Required) E People with stroke with limited life expectancy, and their family where appropriate, should be offered advance care planning, with access to specialist inpatient and community palliative care services when needed. The multidisciplinary team should establish whether there is any existing documentation of the patient’s wishes regarding management of risks associated with continued eating and drinking and whether it remains relevant, and agree with the patient and/or family/carers an advanced care plan where appropriate.(Required) F People dying of stroke should have access to specialist palliative care, including the timely transfer of care to their home or to a hospice or care home according to the wishes of the person and their family/carers. This should also include timely communication and involvement of the primary care team.(Required)
2.16 Carers A The views of the person with stroke should be sought, to establish the extent to which they wish family/carers and others to be involved in the planning and delivery of their care.(Required) B If the person with stroke agrees, family/carers should be involved in significant decisions as an additional source of information about the person both clinically and socially.(Required) C The primary carer(s) of a person with stroke should be offered an educational programme which: explains the nature, consequences and prognosis of stroke and what to do in the event of a further stroke or other problems e.g. post-stroke epilepsy; teaches them how to provide care and support; gives them opportunities to practise giving care; provides advice on secondary prevention, including lifestyle changes.(Required) D When care is transferred out of hospital to the home or care home setting, the carer of a person with stroke should be offered: an assessment of their own needs, separate to those of the person with stroke; the practical or emotional support identified as necessary; guidance on how to seek help if problems develop.(Required) E The primary carer(s) of a person with stroke should be provided with the contact details of a named healthcare professional (e.g. a stroke co-ordinator or key worker) who can provide further information and advice.(Required) F After a person with stroke has returned to the home or care home setting, their carer should: have their need for information and support reassessed whenever there is a significant change in circumstances (e.g. if the health of the carer or the person with stroke changes); be shown how to seek further help and support.(Required)
2.17 People with stroke in care homes A People with stroke living in care homes should be offered assessment and treatment from community stroke rehabilitation services to identify activities and adaptations that might improve quality of life.(Required) B Staff caring for people with stroke in care homes should have training in the physical, cognitive, communication, psychological and social effects of stroke and the management of common activity limitations.(Required) C People with stroke living in care homes with limited life expectancy, and their family where appropriate, should be offered advance care planning, with access to community palliative care services when needed.(Required)
2.18 Service governance and quality improvement A Clinicians providing care for people with stroke should participate in national stroke audit to enable comparison of the clinical and organisational quality of their services, and use the findings to plan and deliver service improvements.(Required) B Services for people with stroke should take responsibility for all aspects of service quality by: keeping a quality register of all people admitted to their organisation with a stroke; regularly reviewing service provision against the evidence-based standards set out in relevant national clinical guidelines; providing practical support and multidisciplinary leadership to the process of clinical audit; encouraging patients to participate in research whenever possible; participating actively in regional and national quality improvement initiatives such as Clinical Networks.(Required) D The views of people with stroke and their family/carers should be actively sought when evaluating service quality and safety, and when planning service developments.(Required) E People with stroke and their family/carers should be offered any practical support necessary to enable participation in service user consultations.(Required)
SECTION 3: ACUTE CARE
3.2 Management of TIA and minor stroke – assessment and diagnosis A Patients with acute focal neurological symptoms that resolve completely within 24 hours of onset (i.e. suspected TIA) should be given aspirin 300 mg immediately unless contraindicated and assessed urgently within 24 hours by a stroke specialist clinician in a neurovascular clinic or an acute stroke unit.(Required) B Healthcare professionals should not use assessment tools such as the ABCD2 score to stratify risk of TIA, inform urgency of referral or subsequent treatment options.(Required) C Patients with suspected TIA that occurred more than a week previously should be assessed by a stroke specialist clinician as soon as possible within 7 days.(Required) D Patients with suspected TIA and their family/carers should receive information about the recognition of stroke symptoms and the action to be taken if they occur.(Required) E Patients with suspected TIA should be assessed by a stroke specialist clinician before a decision on brain imaging is made, except when haemorrhage requires exclusion in patients taking an anticoagulant or with a bleeding disorder when unenhanced CT should be performed urgently.(Required) F For patients with suspected TIA, MRI should be the principal brain imaging modality for detecting the presence and/or distribution of brain ischaemia.(Required) G For patients with suspected TIA in whom brain imaging cannot be undertaken within 7 days of symptoms, MRI (using a blood-sensitive sequence, e.g. SWI or T2*-weighted imaging) should be the preferred means of excluding haemorrhage.(Required)
3.3 Management of TIA and minor stroke – treatment and vascular prevention A Patients with minor ischaemic stroke or TIA should receive treatment for secondary prevention as soon as the diagnosis is confirmed, including: support to modify lifestyle factors (smoking, alcohol consumption, diet, exercise); antiplatelet or anticoagulant therapy; high intensity statin therapy; blood pressure-lowering therapy with a thiazide-like diuretic, long-acting calcium channel blocker or angiotensin-converting enzyme inhibitor.(Required) B Patients with TIA or minor ischaemic stroke should be given antiplatelet therapy provided there is neither a contraindication nor a high risk of bleeding. The following regimens should be considered as soon as possible: For patients within 24 hours of onset of TIA or minor ischaemic stroke and with a low risk of bleeding, the following dual antiplatelet therapy should be given: Clopidogrel (initial dose 300 mg followed by 75 mg per day) plus aspirin (initial dose 300 mg followed by 75 mg per day for 21 days) followed by monotherapy with clopidogrel 75 mg once daily OR Ticagrelor (initial dose 180 mg followed by 90 mg twice daily) plus aspirin (300 mg followed by 75 mg daily for 30 days) followed by antiplatelet monotherapy with ticagrelor 90 mg twice daily or clopidogrel 75 mg once daily at the discretion of the prescriber; For patients with TIA or minor ischaemic stroke who are not appropriate for dual antiplatelet therapy, clopidogrel 300 mg loading dose followed by 75 mg daily should be given; A proton pump inhibitor should be considered for concurrent use with dual antiplatelet therapy to reduce the risk of gastrointestinal haemorrhage; For patients with recurrent TIA or stroke whilst taking clopidogrel, consideration should be given to clopidogrel resistance.(Required) C Patients with TIA or ischaemic stroke should receive high-intensity statin therapy (e.g. atorvastatin 20-80 mg daily) started immediately.(Required) D Patients with non-disabling ischaemic stroke or TIA in atrial fibrillation should be anticoagulated, as soon as intracranial bleeding has been excluded, with an anticoagulant that has rapid onset, provided there are no other contraindications.(Required) E Patients with ischaemic stroke or TIA who after specialist assessment are considered candidates for carotid intervention should have carotid imaging performed within 24 hours of assessment. This includes carotid duplex ultrasound or either CT angiography or MR angiography.(Required) F The degree of carotid artery stenosis should be reported using the North American Symptomatic Carotid Endarterectomy Trial (NASCET) method.(Required) G Patients with TIA or acute non-disabling ischaemic stroke with stable neurological symptoms who have symptomatic severe carotid stenosis of 50–99% (NASCET method) should: be assessed and referred for carotid endarterectomy to be performed as soon as possible within 7 days of the onset of symptoms in a vascular surgical centre routinely participating in national audit; receive optimal medical treatment: control of blood pressure, antiplatelet treatment, cholesterol reduction through diet and medication, and lifestyle advice including smoking cessation.(Required) H Patients with TIA or acute non-disabling ischaemic stroke who have mild or moderate carotid stenosis of less than 50% (NASCET method) should: not undergo carotid intervention; receive optimal medical treatment: control of blood pressure, antiplatelet treatment, cholesterol reduction through diet and medication, and lifestyle advice including smoking cessation.(Required) I Patients with recurrent attacks of transient focal neurological symptoms despite optimal medical treatment, in whom an embolic source has been excluded, should be reassessed for an alternative neurological diagnosis.(Required) J Patients who meet the criteria for carotid intervention but who are unsuitable for open surgery (e.g. inaccessible carotid bifurcation, re-stenosis following endarterectomy, radiotherapy-associated carotid stenosis) should be considered for carotid angioplasty and stenting.(Required) K Patients who have undergone carotid revascularisation should be reviewed post-operatively by a stroke clinician to optimise medical aspects of vascular secondary prevention.(Required)
3.4 Diagnosis and treatment of acute stroke – imaging A Patients with suspected acute stroke should be admitted directly to a hyperacute stroke service and be assessed for emergency stroke treatments by a specialist clinician without delay.(Required) B Patients with suspected acute stroke should receive brain imaging as soon as possible (at most within 1 hour of arrival at hospital).(Required) C Interpretation of acute stroke imaging for decisions regarding reperfusion treatment should only be made by healthcare professionals who have received appropriate training.(Required) D Patients with ischaemic stroke who are potentially eligible for mechanical thrombectomy should have a CT angiogram from aortic arch to skull vertex immediately. This should not delay the administration of intravenous thrombolysis.(Required) E Patients with stroke with a delayed presentation for whom reperfusion is potentially indicated should have CT or MR perfusion as soon as possible (at most within 1 hour of arrival at hospital). An alternative for patients who wake up with stroke is MRI measuring DWI-FLAIR mismatch.(Required) F MRI brain with stroke-specific sequences (DWI with SWI or T2*-weighted imaging) should be considered in patients with suspected acute stroke when there is diagnostic uncertainty.(Required)
3.5 Management of ischaemic stroke A Patients with acute ischaemic stroke, regardless of age or stroke severity, in whom treatment can be started within 4.5 hours of known onset, should be considered for thrombolysis with alteplase or tenecteplase.(Required) B Patients with acute ischaemic stroke, regardless of age or stroke severity, who were last known to be well more than 4.5 hours earlier, should be considered for thrombolysis with alteplase if: ‒ treatment can be started between 4.5 and 9 hours of known onset, or within 9 hours of the midpoint of sleep when they have woken with symptoms AND ‒ they have evidence from CT/MR perfusion (core-perfusion mismatch) or MRI (DWI-FLAIR mismatch) of the potential to salvage brain tissue (see Table 3.5.1 below). This should be irrespective of whether they have a large artery occlusion and require mechanical thrombectomy.(Required) C Patients with acute ischaemic stroke otherwise eligible for treatment with thrombolysis should have their blood pressure reduced to below 185/110 mmHg before treatment.(Required) D Thrombolysis should only be administered within a well-organised stroke service with: processes throughout the emergency pathway to minimise delays to treatment to ensure that thrombolysis is administered as soon as possible after stroke onset; staff trained in the delivery of thrombolysis and monitoring for post-thrombolysis complications; nurse staffing levels equivalent to those required in level 1 or level 2 nursing care with training in acute stroke and thrombolysis; timely access to appropriate imaging and trained staff; protocols in place for the management of post-thrombolysis complications.(Required) E Emergency medical staff, if appropriately trained and supported, should only administer thrombolysis for the treatment of acute ischaemic stroke provided that patients can be subsequently managed within a hyperacute stroke service with appropriate neuroradiological and stroke specialist support.(Required) F Patients with acute ischaemic stroke eligible for mechanical thrombectomy should receive prior intravenous thrombolysis (unless contraindicated) irrespective of whether they have presented to an acute stroke centre or a thrombectomy centre. Every effort should be made to minimise process times throughout the treatment pathway and thrombolysis should not delay urgent transfer to a thrombectomy centre.(Required) G Patients with acute anterior circulation ischaemic stroke, who were previously independent (mRS 0-2), should be considered for combination intravenous thrombolysis and intra-arterial clot extraction (using a stent retriever and/or aspiration techniques) if they have a proximal intracranial large artery occlusion causing a disabling neurological deficit (NIHSS score of 6 or more) and the procedure can begin within 6 hours of known onset.(Required) H Patients with acute anterior circulation ischaemic stroke and a contraindication to intravenous thrombolysis but not to thrombectomy, who were previously independent (mRS 0-2), should be considered for intra-arterial clot extraction (using a stent retriever and/or aspiration techniques) if they have a proximal intracranial large artery occlusion causing a disabling neurological deficit (NIHSS score of 6 or more) and the procedure can begin within 6 hours of known onset.(Required) I Patients with acute anterior circulation ischaemic stroke and a proximal intracranial large artery occlusion (ICA and/or M1) causing a disabling neurological deficit (NIHSS score of 6 or more) of onset between 6 and 24 hours ago, including wake-up stroke, and with no previous disability (mRS 0 or 1) should be considered for intra-arterial clot extraction (using a stent retriever and/or aspiration techniques, combined with thrombolysis if eligible) providing the following imaging criteria are met: between 6 and 12 hours: an ASPECTS score of 3 or more, irrespective of the core infarct size; between 12 and 24 hours: an ASPECTS score of 3 or more and CT or MRI perfusion mismatch of greater than 15 mL, irrespective of the core infarct size.(Required) J Clinicians interpreting brain imaging for eligibility for mechanical thrombectomy should have the appropriate knowledge and skills and should consider all the available information (e.g. plain and angiographic images, colour maps, AI-derived figures for core/penumbra and mismatch overlays).(Required) K Patients with acute ischaemic stroke in the posterior circulation within 12 hours of onset should be considered for mechanical thrombectomy (combined with thrombolysis if eligible) if they have a confirmed intracranial vertebral or basilar artery occlusion and their NIHSS score is 10 or more, combined with a favourable PC-ASPECTS score and Pons-Midbrain Index. Caution should be exercised when considering mechanical thrombectomy for patients presenting between 12 and 24 hours of onset and/or over the age of 80 owing to the paucity of data in these groups.(Required) L The selection of anaesthetic technique for thrombectomy should be guided by local protocols for general anaesthesia, local anaesthesia and conscious sedation which include choice of anaesthetic agents, timeliness of induction, blood pressure parameters and postoperative care. Selection of anaesthesia should be based on an individualised assessment of patient risk factors, technical requirements of the procedure and other clinical characteristics such as conscious level and degree of agitation. General anaesthesia should be considered in the following circumstances: patients with agitation or a reduced level of consciousness, or those judged to be at high risk of requiring conversion to general anaesthesia; patients with airway compromise or who are already intubated, or at risk of aspiration due to nausea or vomiting; patients in whom, due to technical or anatomical factors, thrombectomy is anticipated to be more complicated.(Required) M Hyperacute stroke services providing endovascular therapy should participate in national stroke audit to enable comparison of the clinical and organisational quality of their services with national data, and use the findings to plan and deliver service improvements.(Required) N Patients with middle cerebral artery (MCA) infarction who meet the criteria below should be considered for decompressive hemicraniectomy. Patients should be referred to neurosurgery within 24 hours of stroke onset and treated within 48 hours of stroke onset: pre-stroke mRS score of 0 or 1; clinical deficits indicating infarction in the territory of the MCA; NIHSS score of more than 15; a decrease in the level of consciousness to a score of 1 or more on item 1a of the NIHSS; signs on CT of an infarct of at least 50% of the MCA territory with or without additional infarction in the territory of the anterior or posterior cerebral artery on the same side, or infarct volume greater than 145 mL on MRI DWI.(Required) O Patients with acute ischaemic stroke treated with thrombolysis should be started on an antiplatelet agent after 24 hours unless contraindicated, once significant haemorrhage has been excluded.(Required) P Patients with disabling acute ischaemic stroke should be given aspirin 300 mg as soon as possible within 24 hours (unless contraindicated): orally if they are not dysphagic; rectally or by enteral tube if they are dysphagic. Thereafter aspirin 300 mg daily should be continued until 2 weeks after the onset of stroke at which time long-term antithrombotic treatment should be initiated. Patients being transferred to care at home before 2 weeks should be started on long-term treatment earlier.(Required) Q Patients with acute ischaemic stroke reporting previous dyspepsia with an antiplatelet agent should be given a proton pump inhibitor in addition to aspirin.(Required) R Patients with acute ischaemic stroke who are allergic to or intolerant of aspirin should be given an alternative antiplatelet agent (e.g. clopidogrel).(Required)
3.6 Management of intercerebral haemorrhage A Patients with intracerebral haemorrhage in association with vitamin K antagonist treatment should have the anticoagulant urgently reversed with a combination of prothrombin complex concentrate and intravenous vitamin K.(Required) B Patients with intracerebral haemorrhage in association with direct oral anticoagulant (DOAC) treatment should have the anticoagulant urgently reversed. For patients taking dabigatran, idarucizumab should be used. If idarucizumab is unavailable, 4-factor prothrombin complex concentrate may be considered. For those taking factor Xa inhibitors, 4-factor prothrombin complex concentrate should be considered and andexanet alfa may be considered in the context of a randomised controlled trial.(Required) C Patients with acute spontaneous intracerebral haemorrhage with a systolic BP of 150-220 mmHg should be considered for urgent treatment within 6 hours of symptom onset using a locally agreed protocol for BP lowering, aiming to achieve a systolic BP between 130-139 mmHg within one hour and sustained for at least 7 days, unless: the Glasgow Coma Scale score is 5 or less; the haematoma is very large and death is expected; a macrovascular or structural cause for the haematoma is identified; immediate surgery to evacuate the haematoma is planned, in which case BP should be managed according to a locally agreed protocol.(Required) D Patients with intracerebral haemorrhage should be admitted directly to a hyperacute stroke unit for monitoring of conscious level and referred immediately for repeat brain imaging if deterioration occurs.(Required) E Patients with intracranial haemorrhage who develop hydrocephalus should be considered for surgical intervention such as insertion of an external ventricular drain.(Required) F Patients with intracerebral haemorrhage in whom the haemorrhage location or other imaging features suggest cerebral venous thrombosis should be investigated urgently with a CT or MR venogram.(Required) G The DIAGRAM score (or its components: age; intracerebral haemorrhage location; CTA result where available; and the presence of white matter low attenuation [leukoaraiosis] on the admission non-contrast CT) should be considered to determine the likelihood of an underlying macrovascular cause and the potential benefit of intra-arterial cerebral angiography.(Required) H Early non-invasive cerebral angiography (CTA/MRA within 48 hours of onset) should be considered for all patients with acute spontaneous intracerebral haemorrhage aged 18-70 years who were independent, without a history of cancer, and not taking an anticoagulant, except if they are aged more than 45 years with hypertension and the haemorrhage is in the basal ganglia, thalamus, or posterior fossa. If this early CTA/MRA is normal or inconclusive, MRI/MRA with susceptibility-weighted imaging (SWI) should be considered at 3 months. Early CTA/MRA and MRI/MRA at 3 months may also be considered in patients not meeting these criteria where the probability of a macrovascular cause is felt to justify further investigation.(Required)
3.7 Management of subarachnoid haemorrhage A Any person presenting with sudden severe headache and an altered neurological state should have the diagnosis of subarachnoid haemorrhage investigated by: immediate CT brain scan (also including CT angiography if a protocol is agreed with the neurosciences centre); lumbar puncture 12 hours after ictus (or within 14 days if presentation is delayed) if the CT brain scan is negative and does not show any contraindication; spectrophotometry of the cerebrospinal fluid for xanthochromia.(Required) B Patients with spontaneous subarachnoid haemorrhage should be referred immediately to a neurosciences centre and receive: nimodipine 60 mg 4 hourly unless contraindicated; frequent neurological observation for signs of deterioration.(Required) C Following transfer to the neurosciences centre, patients with spontaneous subarachnoid haemorrhage should receive: CT or MR angiography (if this has not already been done by agreed protocol in the referring hospital) with or without intra-arterial angiography to identify the site of bleeding; specific treatment of any aneurysm related to the haemorrhage by endovascular embolisation or surgical clipping if appropriate. Treatment to secure the aneurysm should be undertaken within 48 hours of ictus for patients of appropriate status (Hunt and Hess or World Federation of Neurological Sciences grades 1-3), or within a maximum of 48 hours of diagnosis if presentation was delayed.(Required) D After any immediate treatment, patients with subarachnoid haemorrhage should be monitored for the development of treatable complications, such as hydrocephalus and cerebral ischaemia.(Required) E After any immediate treatment, patients with subarachnoid haemorrhage should be assessed for hypertension treatment and smoking cessation.(Required) F Patients with residual symptoms or disability after definitive treatment of subarachnoid haemorrhage should receive specialist neurological rehabilitation including appropriate clinical/neuropsychological support.(Required) G People with two or more first-degree relatives affected by aneurysmal subarachnoid haemorrhage and/or polycystic kidney disease should be referred to a neurovascular and/or neurogenetics specialist for information and advice regarding the risks and benefits of screening for cerebral aneurysms.(Required)
3.8 Cervical artery dissection A Any patient suspected of cervical artery dissection should be investigated with CT or MR including angiography.(Required) B Patients with acute ischaemic stroke suspected to be due to cervical arterial dissection should receive thrombolysis if they are otherwise eligible.(Required) C Patients with acute ischaemic stroke suspected to be due to cervical arterial dissection should be treated with either an anticoagulant or an antiplatelet agent for at least 3 months.(Required) D For patients with cervical arterial dissection treated with an anticoagulant, either a DOAC or a Vitamin K antagonist may be used for three months.(Required) E For patients with acute ischaemic stroke or TIA secondary to cervical artery dissection, dual antiplatelet therapy with aspirin and clopidogrel may be considered for the first 21 days, to be followed by antiplatelet monotherapy until at least three months after onset.(Required)
3.9 Cerebral venous thrombosis A Any patient suspected of cerebral venous thrombosis should be investigated with CT or MRI including venography.(Required) B Patients with cerebral venous thrombosis (including those with secondary cerebral haemorrhage) should receive full-dose anticoagulation (initially full-dose heparin and then warfarin with a target INR of 2–3) for at least three months unless there are comorbidities that preclude their use.(Required)
3.10 Acute stroke care A Patients with acute stroke should be admitted directly to a hyperacute stroke unit with protocols to maintain normal physiological status and staff trained in their use.(Required) B Patients with acute stroke should have their clinical status monitored closely, including: level of consciousness; blood glucose; blood pressure; oxygen saturation; hydration and nutrition; temperature; cardiac rhythm and rate.(Required) C Patients with acute stroke should only receive supplemental oxygen if their oxygen saturation is below 95% and there is no contraindication.(Required) D Patients with acute stroke should have their hydration assessed using a standardised approach within four hours of arrival at hospital, and should be reviewed regularly and managed so that normal hydration is maintained.(Required) E Patients with acute stroke should have their swallowing screened, using a validated screening tool, by a trained healthcare professional within four hours of arrival at hospital and before being given any oral food, fluid or medication.(Required) F Until a safe swallowing method is established, patients with dysphagia after acute stroke should: be immediately considered for alternative fluids; have a comprehensive specialist assessment of their swallowing; be considered for nasogastric tube feeding within 24 hours; be referred to a dietitian for specialist nutritional assessment, advice and monitoring; receive adequate hydration, nutrition and medication by alternative means; be referred to a pharmacist to review the formulation and administration of medication.(Required) G Patients with swallowing difficulties after acute stroke should only be given food, fluids and medications in a form that can be swallowed without aspiration.(Required) H Patients with acute stroke should be treated to maintain a blood glucose concentration between 5 and 15 mmol/L with close monitoring to avoid hypoglycaemia.(Required) I Patients with acute ischaemic stroke should only receive blood pressure-lowering treatment if there is an indication for emergency treatment, such as: systolic blood pressure above 185 mmHg or diastolic blood pressure above 110 mmHg when the patient is otherwise eligible for treatment with thrombolysis; hypertensive encephalopathy; hypertensive nephropathy; hypertensive cardiac failure or myocardial infarction; aortic dissection; pre-eclampsia or eclampsia.(Required) J Patients with acute stroke admitted on antihypertensive medication should resume oral treatment once they are medically stable and as soon as they can swallow medication safely.(Required) K Patients with acute ischaemic stroke should receive high-intensity statin treatment with atorvastatin 20-80 mg daily as soon as they can swallow medication safely.(Required) L Patients with primary intracerebral haemorrhage should only be started on statin treatment based on their cardiovascular disease risk and not for secondary prevention of intracerebral haemorrhage.(Required)
3.11 Positioning A Patients with acute stroke should have an initial specialist assessment for positioning as soon as possible and within 4 hours of arrival at hospital.(Required) B Patients admitted to hospital with acute stroke should be allowed to adopt either a sitting-up or lying-flat head position in the first 24 hours, according to comfort. Stroke units should not have a policy or practice that favours either head position.(Required) C Healthcare professionals responsible for the initial assessment of patients with acute stroke should be trained in how to position patients appropriately, taking into account the degree of their physical impairment after stroke.(Required) D When lying or sitting, patients with acute stroke should be positioned to minimise the risk of aspiration and other respiratory complications, shoulder pain and subluxation, contractures and skin pressure ulceration.(Required)
3.12 Early mobilisation A Patients with difficulty moving after stroke should be assessed as soon as possible within the first 24 hours of onset by an appropriately trained healthcare professional to determine the most appropriate and safe methods of transfer and mobilisation.(Required) B Patients with difficulty moving early after stroke who are medically stable should be offered frequent, short daily mobilisations (sitting out of bed, standing or walking) by appropriately trained staff with access to appropriate equipment, typically beginning between 24 and 48 hours of stroke onset. Mobilisation within 24 hours of onset should only be for patients who require little or no assistance to mobilise.(Required)
3.13 Deep vein thrombosis and pulmonary embolism A Patients with immobility after acute stroke should be offered intermittent pneumatic compression within 3 days of admission to hospital for the prevention of deep vein thrombosis. Treatment should be continuous for 30 days or until the patient is mobile or discharged, whichever is sooner.(Required) B Patients with immobility after acute stroke should not be routinely given low molecular weight heparin or graduated compression stockings (either full-length or below-knee) for the prevention of deep vein thrombosis.(Required) C Patients with ischaemic stroke and symptomatic deep vein thrombosis or pulmonary embolism should receive anticoagulant treatment provided there are no contraindications.(Required) D Patients with intracerebral haemorrhage and symptomatic deep vein thrombosis or pulmonary embolism should receive treatment with a vena caval filter.(Required)
SECTION 4: REHABILITATION AND RECOVERY
4.1 Rehabilitation potential A People with stroke should be considered to have the potential to benefit from rehabilitation at any point after their stroke.(Required) B People with stroke and their carers should be involved in a collaborative process with healthcare professionals to agree rehabilitation options, guided by the person’s own needs, goals and preferences.(Required) C The multidisciplinary team should consider all available rehabilitation options and recommend the service that is most likely to enable the person with stroke to meet their goals and needs. For those people for whom standard rehabilitation services (such as early supported discharge, or community stroke teams) may not be appropriate, collaborative local decision making should ensure that a stroke-skilled multidisciplinary team works with the person with stroke and their family towards achievable and meaningful goals, which may be in conjunction with other statutory or voluntary provision; People with stroke involving the spinal cord should be referred to specialist spinal injuries service for advice and support and/or to provide rehabilitation.(Required) D Stroke rehabilitation should be needs-led and not time-limited, and available to those people with stroke for whom: ongoing needs have been identified by the person with stroke, their carer(s) or the multidisciplinary team across all areas of stroke recovery, e.g. functional abilities, mental health, cognitive function, psychological well-being, education regarding stroke, social participation, management of complications and care needs; and their needs remain related to the stroke and/or are best met by the skills of the stroke team.(Required) E Clinicians should facilitate shared decision making and communicate the likelihood of the individual achieving their goals in an informed, compassionate, and individualised manner.(Required) F From an early stage in rehabilitation, clinicians should prepare people with stroke and their carer(s) that discharge from the service will occur and ensure an adequate transition plan is created collaboratively. Discharge information should include how to re-access services if required.(Required) G Statistically derived tools which predict future functional capacity should be considered to guide expectations of treatment or to predict risk: Tools should only be applied in the population and phase of stroke within which the tool was developed; Clinicians need to be trained to understand the limitations of tools, and how to use the tools effectively.(Required) H The multidisciplinary team should complete weekly reviews whilst providing rehabilitation in any setting, considering the needs, goals and progress of the person with stroke, and their treatment and discharge plans. The choice of rehabilitation pathway should be regularly reviewed to ensure rehabilitation continues to best meet the person’s needs.(Required) I For people with stroke who are no longer receiving stroke rehabilitation at 6 months, a primary focus of the 6 month review should be to identify and redirect those with ongoing needs and/or goals back into stroke services. Reviews should be holistic in nature and be completed by a stroke specialist with appropriate skills and expertise.(Required) J People with stroke should receive a holistic annual review conducted by a professional with a broad range of skills and knowledge across physical, psychological and social domains. Those for whom new or ongoing stroke rehabilitation goals can be identified and agreed should be referred to stroke services for further rehabilitation.(Required)
4.2 Rehabilitation approach – intensity of therapy (motor recovery and function) A People with stroke should be actively involved in their rehabilitation through: having their feelings, wishes and expectations for recovery understood and acknowledged; participating in the process of goal setting unless they choose not to, or are unable to because of the severity of their cognitive or linguistic impairments; being given help to understand the process of goal setting, and to define and articulate their personal goals.(Required) B People with stroke should be helped to identify goals that: are meaningful and relevant to them; are challenging but achievable; aim to achieve both short-term (days/weeks) and long-term (weeks/months) objectives; are documented, with specific, time-bound and measurable outcomes; have achievement measured and evaluated in a consistent way; include family/carers where this is appropriate; are used to guide and inform therapy and treatment.(Required) C People with stroke should be supported and involved in a self-management approach to their rehabilitation goals.(Required)
4.4 Self-management A People with stroke should be offered self-management support based on self-efficacy, aimed at the knowledge and skills needed to manage life after stroke, with particular attention given to this at reviews and transfers of care.(Required) B People with stroke whose motivation and engagement in rehabilitation appears reduced should be assessed for changes in self-esteem, self-efficacy or identity and mood.(Required) C People with significant changes in self-esteem, self-efficacy or identity after stroke should be offered information, support and advice and considered for one or more of the following psychological interventions: increased social interaction; increased exercise; other psychosocial interventions, such as psychosocial education groups.(Required)
4.5 Remotely delivered therapy and telerehabilitation A People with stroke should be offered training and resources to support them to carry out appropriately targeted self-directed therapy practice in addition to their standard rehabilitation, in accordance with the individual’s goals and preferences. Self directed therapy should be monitored and reviewed regularly.(Required) B People with stroke who are able to follow regimes independently or with the support of a carer should be considered for self-directed rehabilitation to increase practice in addition to standard rehabilitation; for example, patients undergoing constraint-induced movement therapy, electrical stimulation or computerised speech and language therapy.(Required) C For people undergoing rehabilitation after stroke, the use of competition (with self or others) may be considered to give people motivation to practise self-directed rehabilitation.(Required)
4.6 Self-directed therapy A People with stroke should be offered training and resources to support them to carry out appropriately targeted self-directed therapy practice in addition to their standard rehabilitation, in accordance with the individual’s goals and preferences. Self directed therapy should be monitored and reviewed regularly.(Required) B People with stroke who are able to follow regimes independently or with the support of a carer should be considered for self-directed rehabilitation to increase practice in addition to standard rehabilitation; for example, patients undergoing constraint-induced movement therapy, electrical stimulation or computerised speech and language therapy.(Required) C For people undergoing rehabilitation after stroke, the use of competition (with self or others) may be considered to give people motivation to practise self-directed rehabilitation.(Required)
4.8 Independence in daily living A People with stroke should be formally assessed for their safety and independence in all relevant personal activities of daily living by a clinician with the appropriate expertise, and the findings should be recorded using a standardised assessment tool.(Required) B People with limitations of personal activities of daily living after stroke should: be referred to an occupational therapist with knowledge and skills in neurological rehabilitation. Assessment should include consideration of the impact of hidden deficits affecting function including neglect, executive dysfunction and visual impairments; be assessed by an occupational therapist within 24 hours of admission to a stroke unit; be offered treatment for identified problems (e.g. feeding, work) by the occupational therapist, in discussion with other members of the specialist multidisciplinary team.(Required) C People with stroke should be offered, as needed, specific treatments that include: dressing practice for people with residual problems with dressing; as many opportunities as appropriate to practise self-care as possible; assessment, provision and training in the use of equipment and adaptations that increase safe independence; training their family/carers in how to help them.(Required)
4.9 Hydration and nutrition A Patients with acute stroke should have their hydration assessed using a standardised approach within four hours of arrival at hospital, and should be reviewed regularly and managed so that hydration is maintained.(Required) B Patients with acute stroke should be screened for the risk of malnutrition on admission and at least weekly thereafter. Screening should be conducted by trained staff using a structured, standardised, validated tool.(Required) C Patients with acute stroke who are at low risk of malnutrition on admission, and are able to meet their nutritional needs orally, should not routinely receive oral nutritional supplements.(Required) D Patients with acute stroke who are at risk of malnutrition or who require tube feeding or dietary modification should be referred to a dietitian for specialist nutritional assessment, advice and monitoring.(Required) E Patients with stroke who are at risk of malnutrition should be offered nutritional support. This may include oral nutritional supplements, specialist dietary advice and/or tube feeding in accordance with their expressed wishes or, if the patient lacks mental capacity, in their best interests.(Required) F Patients with stroke who are unable to maintain adequate nutrition and hydration orally should be: referred to a dietitian for specialist nutritional assessment, advice and monitoring; be assessed for nasogastric tube feeding within 24 hours of admission; assessed for a nasal bridle if the nasogastric tube needs frequent replacement, using locally agreed protocols; assessed for gastrostomy feeding if they are unable to tolerate a nasogastric tube with nasal bridle.(Required) G People with stroke who require food or fluid of a modified consistency should: be referred to a dietitian for specialist nutritional assessment, advice and monitoring; have the texture of modified food or fluids prescribed using internationally agreed descriptors; be referred to a pharmacist to review the formulation and administration of medication.(Required) H People with stroke should be considered for gastrostomy feeding if they: need but are unable to tolerate nasogastric tube feeding, including a trial with a nasal bridle if appropriate and other measures such as taping the tube or increased supervision; are unable to swallow adequate food and fluids orally by four weeks from the onset of stroke and gastrostomy feeding is considered to be required long-term; reach the point where shared decision making by the person with stroke, their family/carers, and the multidisciplinary team has agreed that artificial nutrition is appropriate due to the high long-term risk of malnutrition.(Required) I People with difficulties self-feeding after stroke should be assessed and provided with the appropriate equipment and assistance including physical help and encouragement, environmental considerations, and postural support to promote independent and safe feeding.(Required) J People with stroke discharged from stroke services with continuing problems meeting their nutritional needs should have a documented care plan to ensure their dietary intake and nutritional status are monitored at a frequency appropriate to their needs and which identifies who will be responsible for ongoing monitoring (such as district nurses or family/carers).(Required) K People with stroke receiving end-of-life (palliative) care should not have burdensome restrictions on oral food and fluid intake, if those restrictions would exacerbate suffering.(Required) L The carers and family of those with a gastrostomy tube should receive training, equipment and ongoing support from a specialist team, e.g. a home enteral feeding team.(Required)
4.10 Mouth care A People with stroke, especially those who have difficulty swallowing or who are tube fed, should have mouth care at least three times a day (particularly after mealtimes), which includes removal of food debris and excess secretions, and application of lip balm.(Required) B People with stroke, including those who have full or partial dentition and/or wear dentures and especially those who have difficulty swallowing or who are tube fed, should have mechanical removal of plaque at least twice a day by the brushing of teeth and cleaning of gums and tongue with a low foaming, fluoride-containing toothpaste. Chlorhexidine dental gel may be prescribed short term and requires regular review. A powered toothbrush should be considered.(Required) C People with stroke who have dentures should have their dentures: put in during the day, using a fixative if required; cleaned regularly using a denture cleansing agent or soap and water; checked, and the individual referred to a dental professional if ill-fitting or replacement is required. Any remaining teeth should be cleaned with a toothbrush and fluoride-containing toothpaste.(Required) D Staff delivering mouth care in hospital or in a care home or domiciliary setting should receive training on mouth care, which should include: assessment of oral hygiene; selection and use of appropriate oral hygiene equipment and cleaning agents; provision of mouth care routines; awareness and recognition of swallowing difficulties.(Required) E People with stroke and their family/carers should receive information and training in mouth care and maintaining good oral hygiene before transfer of their care from hospital. This information should be clearly communicated within and across care settings, e.g. within a care plan which includes regular dental reviews.(Required)
4.11 Continence A Stroke unit staff should be trained in the use of standardised assessment and management protocols for urinary and faecal incontinence and constipation in people with stroke.(Required) B People with stroke should not have an indwelling (urethral) catheter inserted unless indicated to relieve urinary retention or when fluid balance is critical.(Required) C People with stroke who have continued loss of bladder and/or bowel control 2 weeks after onset should be reassessed to identify the cause of incontinence, and be involved in deriving a treatment plan (with their family/carers if appropriate). The treatment plan should include: treatment of any identified cause of incontinence; training for the person with stroke and/or their family/carers in the management of incontinence; referral for specialist treatments and behavioural adaptations if the person is able to participate; adequate arrangements for the continued supply of continence aids and services.(Required) D People with stroke with continued loss of urinary continence should be offered behavioural interventions and adaptations prior to considering pharmaceutical and long-term catheter options, such as: timed toileting; prompted voiding; review of caffeine intake; bladder retraining; pelvic floor exercises; external equipment.(Required) E People with stroke with constipation should be offered: advice on diet, fluid intake and exercise; a regulated routine of toileting; a prescribed medication review to minimise use of constipating medication; oral laxatives; a structured bowel management programme which includes nurse-led bowel care interventions; education and information for the person with stroke and their family/carers; rectal laxatives if severe problems persist.(Required) F People with continued continence problems on transfer of care from hospital should receive follow-up with specialist continence services in the community.(Required)
4.12 Extended activities of daily living A People whose activities have been limited by stroke should be: assessed by an occupational therapist with expertise in neurological disability; trained in how to achieve activities safely and given as many opportunities to practise as reasonable under supervision, provided that the activities are potentially achievable; provided with and trained in how to use any adaptations or equipment needed to perform activities safely.(Required) B People with stroke who cannot undertake a necessary activity safely should be offered alternative means of achieving the goal to ensure safety and well-being.(Required)
4.13 Sex A People with stroke should be asked, soon after discharge and at their 6-month and annual reviews, whether they have any concerns about sex. Partners should also have an opportunity to raise any problems.(Required) B People with sexual dysfunction after stroke who want further help should be: assessed for treatable causes including a medication review; reassured that sexual activity is not contraindicated after stroke and is extremely unlikely to precipitate a further stroke; assessed for erectile dysfunction and the use of a phosphodiesterase type 5 inhibitor (e.g. sildenafil); advised against the use of a phosphodiesterase type 5 inhibitor for 3 months after stroke and/or until blood pressure is controlled; referred to a professional with expertise in psychosexual problems if sexual dysfunction persists.(Required)
4.14 Driving A People who have had an acute stroke or TIA should be asked about driving before they leave the hospital or specialist outpatient clinic.(Required) B People with stroke who wish to drive should: be advised of the exclusion period from driving and their responsibility to notify the DVLA, DVA or NDLS if they have any persisting disability which may affect their eligibility; be asked about or examined for any absolute bars to driving e.g. epileptic seizure (excluding seizure within 24 hours of stroke onset), significant visual field defects, reduced visual acuity or double vision; be offered an assessment of the impairments that may affect their eligibility, including their cognitive, visual and physical abilities; receive a written record of the findings and conclusions, copied to their general practitioner.(Required) C People with persisting cognitive, language or motor disability after stroke who wish to return to driving should be referred for on-road screening and evaluation.(Required) D People who wish to drive after a stroke should be informed about eligibility for disabled concessions (e.g. Motability, the Blue Badge scheme).(Required)
4.15 Return to work A People with stroke should be asked about their work at the earliest opportunity, irrespective of whether they plan to return. This will enable staff to have a better understanding of their role before having a stroke, and offer the person an opportunity to discuss their thoughts and feelings.(Required) B People who need or wish to return to any type of work after stroke should: be provided with information regarding rights, financial support and vocational rehabilitation. This should include information regarding driving, where appropriate (e.g. in the work role or travelling to work); be supported to understand the consequences of their stroke in relation to work; be supported by an appropriate professional with an understanding of the person’s work-related needs to discuss with their employer their return to work, at a time that is appropriate, taking account of their job role and the support available. Timing should be mutually agreed between the person with stroke, the employer and the professional delivering vocational rehabilitation. This should include human resources where appropriate; be supported to identify their work requirements with their employer, with input from occupational health, where available; be assessed on relevant work-related skills and competencies to establish their potential for return; participate in discussions and decision making regarding the most suitable time and way to return to work, including the nature and amount of work; be referred to statutory employment support (e.g. Jobcentre Plus, Intreo) or vocational rehabilitation (VR), as appropriate to their needs. VR may be provided by publicly funded organisations (such as the NHS), the independent sector (including services funded through the UK’s Department for Work and Pensions such as Access to Work) or the voluntary sector (including support from stroke key workers); signposted if required to seek advice from their employer’s human resources department (or equivalent), trade union and/or seek specific legal advice.(Required) C Services supporting people with stroke to return to work should ensure that: there is a co-ordinator (or co-ordinating team or joint cross-agency working) responsible for liaison and support with planning and negotiating return to work with all those involved (including co-workers and managers, where applicable) and who ensures all involved are aware of their roles, responsibilities, and relevant legislation; employers are provided with information and education regarding the individual needs of the person following stroke such as communication needs or fatigue; workplaces offer flexibility (e.g. workplace accommodation) to enable people with stroke to adapt their return to work, in line with the requirements of the Equality Act (2010) in the UK and Employment Equality Acts (1998-2015) in Ireland.(Required) D Vocational rehabilitation programmes for people returning to work after stroke should include: assessment of potential barriers and facilitators to returning to work, based on the work role and demands from both the employee’s and employer’s perspectives; an action plan for how barriers may be overcome; interventions as required by the individual, which may include vocational counselling and coaching, emotional support, adaptation of the working environment, strategies to compensate for functional limitations (e.g. communication, cognition, mobility and arm function), and fatigue management; collaboration between the person with stroke, their employer and healthcare professional in planning, facilitating and monitoring their return to work.(Required) E Healthcare professionals who work with people following stroke should have knowledge and skills about supporting them to return to work, appropriate to the nature and level of service they provide.(Required) F Authorised healthcare professionals should provide a statement of fitness to work (e.g. ‘fit note’) to support people to return to work, including recommended alterations to work patterns, tasks undertaken or environment.(Required)
4.17 Motor impairment A People with stroke should be assessed for weakness and cardiovascular fitness using a standardised approach, and have the impairment explained to them and their family/carers. Assessment and outcome measures used should encompass the range of effects of exercise including weakness, cardiovascular fitness and activities.(Required) B People with weakness after stroke sufficient to limit their activities should be assessed within 24 hours of admission by a therapist with knowledge and skills in neurological rehabilitation.(Required) C Clinicians should screen for, prescribe and monitor exercise programmes for people with stroke, e.g. using a 6 minute walk test or shuttle test. Programmes should be individualised to the person’s goals and preferences. Screening equipment (such as treadmills, ECG and blood pressure monitors) should be available, and clinicians should liaise with other services that offer exercise-based rehabilitation (e.g. cardiac or pulmonary rehabilitation) with regard to integrating screening and exercise resources.(Required) D People with weakness after stroke should be taught task-specific, repetitive, intensive exercises or activities to increase their strength. Exercise and repetitive task practice should be the principal rehabilitation approaches, in preference to other therapy approaches including Bobath..(Required) E People with stroke should be offered cardiorespiratory training or mixed training once they are medically stable, regardless of age, time since stroke and severity of impairment. Facilities and equipment to support high-intensity (greater than 70% peak heart rate) cardiorespiratory fitness training (such as bodyweight support treadmills and/or static/recumbent cycles) should be available; The dose of training should be at least 30-40 minutes, 3 to 5 times a week for 10-20 weeks; Programmes of mixed training (medium intensity cardiorespiratory [40%-60% of heart rate reserve] and strength training [50-70% of one-repetition maximum]) such as circuit training classes should also be available at least 3 days per week for 20 weeks; Exercise aimed at increasing heart rate should be used for those with more severe weakness, such as using arm cycles or seated exercise groups; The choice of programme should be guided by patients’ goals and preferences and delivery of the programme individualised to their level of impairment and goals.(Required) F People with respiratory impairment and at risk of pneumonia after stroke should be considered for respiratory muscle training using a threshold resistance trainer or flow-oriented resistance trainer. Training should be carried out for at least 20 minutes per day, 3 days per week for 3 weeks; The relevant clinicians (nurses, speech and language therapists, physiotherapists and support staff) should be trained in how to use the training equipment.(Required) G People with stroke who are unable to exercise against gravity independently should be considered for adjuncts to exercise (such as neuromuscular or functional electrical stimulation), to support participation in exercise training.(Required) H People with stroke should be supported with measures to maximise exercise adherence such as: measures to build confidence and self-efficacy (such as the use of social networking apps or physical activity platforms); ensuring patients and family/carers know the benefits of exercise and why they are doing it, including how the exercises given relate to their individual needs; incorporation of exercise into documented goal setting; individualisation of exercise programme to suit their abilities and goals; use of technology (e.g. apps, videos, phone check-ins); ongoing coaching to support written exercise instructions; the involvement of family and carers with exercise.(Required) I Clinicians should not use risk assessment protocols that limit training for fear of cardiovascular or other adverse events except where screening has identified intensive exercise is contraindicated for an individual.(Required)
4.18 Arm function A People with some upper limb movement at any time after stroke should be offered repetitive task practice as the principal rehabilitation approach, in preference to other therapy approaches including Bobath. Practice should be characterised by a high number of repetitions of movements that are task-specific and functional, both within and outside of therapy sessions (self-directed). Repetitive task practice: may be bilateral or unilateral depending on the task and level of impairment; should be employed regardless of the presence of cognitive impairment such as neglect or inattention; may be enhanced by using trunk restraint and priming techniques.(Required) B People with stroke who have at least 20 degrees of active wrist extension and 10 degrees of active finger extension in the affected hand should be considered for constraint-induced movement therapy.(Required) C People with wrist and finger weakness which limits function after stroke should be considered for functional electrical stimulation applied to the wrist and finger extensors, as an adjunct to conventional therapy. Stimulation protocols should be individualised to the person’s presentation and tolerance, and the person with stroke, their family/carers and clinicians in all settings should be trained in the safe application and use of electrical stimulation devices.(Required) D People with stroke without movement in the affected arm or hand (and clinicians, families and carers) should be trained in how to care for the limb in order to avoid complications (e.g. loss of joint range, pain). They should be monitored for any change and repetitive task practice should be offered if active movement is detected.(Required) E People with stroke may be considered for mirror therapy to improve arm function following stroke as an adjunct to usual therapy.(Required) F People with stroke who are able and motivated to participate in the mental practice of an activity should be offered training and encouraged to use it to improve arm function, as an adjunct to usual therapy.(Required) G People with arm weakness after stroke, who are able and motivated to follow regimes independently or with the support of a carer, should be considered for self-directed upper limb rehabilitation to increase practice in addition to usual therapy, e.g. patients undergoing constraint-induced movement therapy or functional electrical stimulation.(Required) H People with mild-moderate arm weakness after stroke may be considered for transcutaneous vagus nerve stimulation in addition to usual therapy. Implanted vagus nerve stimulation should only be used in the context of a clinical trial.(Required) I People with reduced arm function after a stroke may be considered for robot-assisted movement therapy to improve motor recovery of the arm as an adjunct to usual therapy, preferably in the context of a clinical trial.(Required)
4.19 Ataxia A People with posterior circulation stroke should be assessed for ataxia using a standardised approach, and have the impairment explained to them, their family/carers and the multidisciplinary team.(Required) B People with ataxia after stroke sufficient to limit their activities should be assessed by a therapist with knowledge and skills in neurological rehabilitation.(Required) C People with ataxia after stroke should be taught task-specific, repetitive, intensive exercises or activities to increase strength and function.(Required) D People with ataxia after stroke should be considered for compensatory techniques to aid functional independence and safety, such as proximal stabilisation, and provision of equipment (small aids).(Required)
4.20 Balance A People with impaired balance after a stroke should receive a structured multi-factorial assessment including investigation of other causes such as medication, and issues with vision, weakness, dual tasking and the peripheral vestibular system. The assessment should include impacts on daily activities, safety and independence. Onward specialist referral for vestibular rehabilitation should be considered for those people with peripheral vestibular problems.(Required) B People with impaired balance at any level (sitting, standing, stepping, walking) at any time after stroke should receive repetitive task practice in the form of progressive balance training such as trunk control exercises, treadmill training, circuit and functional training, fitness training, and strengthening exercises.(Required) C People with impaired balance after stroke should be offered repetitive task practice and balance training as the principal rehabilitation approach, in preference to other therapy approaches including Bobath.(Required) D People with limitations of dorsiflexion or ankle instability causing balance limitations after stroke should be considered for ankle-foot orthoses and/or functional electrical stimulation. The person with stroke, their family/carers and clinicians in all settings should be trained in the safe use and application of orthoses and electrical stimulation devices.(Required) E People with limitations of their standing balance or confidence after stroke should be offered walking aids to improve their stability.(Required) F People with difficulties with sitting balance after stroke should receive an assessment of postural and seating needs. Equipment should be available and provided for patients with identified seating and postural needs regardless of setting.(Required)
4.21 Falls and fear of falling A People with stroke should be offered a falls risk assessment and management as part of their stroke rehabilitation, including training for them and their family/carers in how to get up after a fall. Assessment should include physical, sensory, psychological, pharmacological and environmental factors.(Required) B People with stroke should be offered an assessment of fear of falling as part of their falls risk assessment and receive psychological support if identified.(Required) C People at high risk of falls after stroke should be offered a standardised assessment of fragility fracture risk as part of their stroke rehabilitation.(Required) D People with stroke with symptoms of vitamin D deficiency, or those who are considered to be at high risk (e.g. housebound) should be offered calcium and vitamin D supplements.(Required) E People at high risk of falls after stroke should be advised to participate in physical activity/exercise which incorporates balance and co-ordination at least twice per week.(Required) F People with stroke and limitations of dorsiflexion or ankle instability causing impaired balance and risk or fear of falling should be considered for referral to orthotics for an ankle-foot orthosis and/or functional electrical stimulation. The person with stroke, their family/carers and clinicians in all settings should be trained in the safe use and application of orthoses and electrical stimulation devices.(Required)
4.22 Walking A People with limited mobility after stroke should be assessed for, provided with and trained to use appropriate mobility aids, including a wheelchair, to enable safe independent mobility.(Required) B People with stroke, including those who use wheelchairs or have poor mobility, should be advised to participate in exercise with the aim of improving aerobic fitness and muscle strength unless there are contraindications.(Required) C People with impaired mobility after stroke should be offered repetitive task practice as the principal rehabilitation approach, in preference to other therapy approaches including Bobath.(Required) D People who cannot walk independently after stroke should be considered for electromechanical-assisted gait training including body weight support.(Required) E People with stroke who are able to walk (albeit with the assistance of other people or assistive devices) and who wish to improve their mobility at any stage after stroke should be offered access to equipment to enable intensive walking training such as treadmills or electromechanical gait trainers. To achieve this, training needs to be at 60-85% heart rate reserve (by adjustment of inclination or speed) for at least 40 minutes, three times a week for 10 weeks.(Required) F People with stroke with limited ankle/foot stability or limited dorsiflexion (‘foot drop’) that impedes mobility or confidence should be offered an ankle-foot orthosis (using a lightweight, flexible orthosis in the first instance) or functional electrical stimulation to improve walking and balance, including referral to orthotics if required. Any orthosis or electrical stimulation device should be evaluated and individually fitted before long-term use. The person with stroke, their family/carers and clinicians in all settings should be trained in the safe application and use of orthoses and electrical stimulation devices. People using an orthosis after stroke should be educated about the risk of pressure damage from their orthosis, especially if sensory loss is present in addition to weakness. Services should provide timely access for orthotic repairs and adaptations.(Required) G Stroke services should have local protocols and agreements in place to ensure specialist assessment, evaluation and follow-up is available for long-term functional electrical stimulation use.(Required) H People with stroke who are mobile should be assessed for real-world walking such as road crossing, walking on uneven ground, over distances and inclines. This should include assessment of the impact of dual tasking, neglect, vision and confidence in busy environments.(Required) I Stroke services should consider building links with voluntary sector and recreational fitness facilities such as gyms or leisure centres or providing equipment in outpatient departments to enable community-dwelling people with stroke to access treadmills and other relevant fitness equipment.(Required) J Clinicians should not use risk assessment protocols that limit training for fear of cardiovascular or other adverse events, given the good safety record of repetitive gait training however it is delivered.(Required)
4.23.1 Neuropathic pain (central post-stroke pain) A People with central post-stroke pain should be initially treated with amitriptyline, gabapentin or pregabalin: amitriptyline starting at 10 mg per day, with gradual titration as tolerated, but no higher than 75 mg per day (higher doses could be considered in consultation with a specialist pain service); gabapentin starting at 300 mg twice daily with titration as tolerated to a maximum of 3.6 g per day; pregabalin starting at 150 mg per day (in two divided doses; a lower starting dose may be appropriate for some people), with titration as tolerated but no higher than 600 mg per day in two divided doses.(Required) B People with central post-stroke pain who do not achieve satisfactory pain reduction with initial pharmacological treatment at the maximum tolerated dose should be considered for treatment with another medication of or in combination with the original medication: if initial treatment was with amitriptyline switch to or combine with pregabalin; if initial treatment was with gabapentin switch to pregabalin; if initial treatment was with pregabalin switch to or combine with amitriptyline.(Required) C People with central post-stroke pain should be regularly reviewed including physical and psychological well-being, adverse effects, the impact on lifestyle, sleep, activities and participation, and the continued need for pharmacological treatment. If there is sufficient improvement, treatment should be continued and gradual reductions in the dose over time should be considered if improvement is sustained.(Required)
4.23.2 Musculoskeletal pain A People with functional loss in their arm after stroke should have the risk of shoulder pain reduced by: careful positioning of the arm, with the weight of the limb supported, including the use of wheelchair arm rests; ensuring that healthcare staff and family/carers handle the affected arm correctly, avoiding mechanical stress and excessive range of movement; avoiding the use of overhead arm slings/ shoulder supports and pulleys.(Required) B People with arm weakness after stroke should be asked regularly about shoulder pain.(Required) C People who develop shoulder pain after stroke should: be assessed for causes and these should be managed accordingly, including musculoskeletal issues, subluxation and spasticity; have the severity monitored and recorded regularly, using a validated pain assessment tool; have preventative measures put in place; be offered regular simple analgesia.(Required) D People with shoulder pain after stroke should only be offered intra-articular steroid injections if they also have inflammatory arthritis.(Required) E People with inferior shoulder subluxation within 6 months of hemiplegic stroke should be considered for neuromuscular electrical stimulation, unless contraindicated. The stimulation protocol should be individualised to the person’s presentation and tolerance. The person with stroke, their family/carers and clinicians in all settings should be trained in the safe application and use of electrical stimulation devices.(Required) F People with persistent shoulder pain after stroke should be considered for other interventions such as orthotic provision, spasticity management, or suprascapular nerve block, including specialist referral if required.(Required)
4.24 Spasticity and contractures A People with motor weakness after stroke should be assessed for spasticity as a cause of pain, as a factor limiting activities or care, and as a risk factor for the development of contractures.(Required) B People with stroke should be supported to set and monitor specific goals for interventions for spasticity using appropriate clinical measures for ease of care, pain and/or range of movement.(Required) C People with spasticity after stroke should be monitored to determine the extent of the problem and the effect of simple measures to reduce spasticity e.g. positioning, passive movement, active movement (with monitoring of the range of movement and alteration in function) and/or pain control.(Required) People with persistent or progressive focal spasticity after stroke affecting one or two areas for whom a therapeutic goal can be identified (e.g. ease of care, pain) should be offered intramuscular botulinum toxin. This should be within a specialist multidisciplinary team and be accompanied by rehabilitation therapy and/or splinting or casting for up to 12 weeks after the injections. Goal attainment should be assessed 3-4 months after the injections and further treatment planned according to response.(Required) People with generalised or diffuse spasticity after stroke should be offered treatment with skeletal muscle relaxants (e.g. baclofen, tizanidine) and monitored for adverse effects, in particular sedation and increased weakness. Combinations of antispasticity medication should only be initiated by healthcare professionals with specific expertise in managing spasticity.(Required) F People with stroke should only receive intrathecal baclofen, intraneural phenol or similar interventions in the context of a specialist multidisciplinary spasticity service.(Required) G People with stroke with increased tone that is reducing passive or active movement around a joint should have the range of passive joint movement assessed. They should only be offered splinting or casting following individualised assessment and with monitoring by appropriately skilled staff.(Required) H People with stroke should not be routinely offered splinting for the arm and hand.(Required) I People with spasticity in the upper or lower limbs after stroke should not be treated with electrical stimulation to reduce spasticity.(Required) J People with spasticity in their wrist or fingers who have been treated with botulinum toxin may be considered for electrical stimulation (cyclical/neuromuscular electrical stimulation) after the injection to maintain range of movement and/or to provide regular stretching as an adjunct to splinting or when splinting is not tolerated.(Required) K People with stroke at high risk of contracture should be monitored to identify problematic spasticity and provided with interventions to prevent skin damage, or significant difficulties with hygiene, dressing, pain or positioning.(Required)
4.25 Fatigue A Healthcare professionals should anticipate post-stroke fatigue, and ask people with stroke (or their family/ carers) if they experience fatigue and how it impacts on their life.(Required) B Healthcare professionals should use a validated measure in their assessment of post-stroke fatigue, with a clear rationale for its selection, and should also consider physical and psychological fatigue, personality style, context demands and coping styles.(Required) C People with stroke should be assessed and periodically reviewed for post-stroke fatigue, including for factors that might precipitate or exacerbate fatigue (e.g. depression and anxiety, sleep disorders, pain) and these factors should be addressed accordingly. Appropriate time points for review are at discharge from hospital and then at regular intervals, including at 6 months and annually thereafter.(Required) D People with stroke should be provided with information and education regarding fatigue being a common post-stroke problem, and with reassurance and support as early as possible, including how to prevent and manage it, and signposting to peer support and voluntary sector organisations. Information should be provided in appropriate and accessible formats.(Required) E People with post-stroke fatigue should be involved in decision making about strategies to prevent and manage it that are tailored to their individual needs, goals and circumstances.(Required) F People with post-stroke fatigue should be referred to appropriately skilled and experienced clinicians as required, and should be considered for the following approaches, whilst being aware that no single measure will be effective for everyone: building acceptance and adjustment to post-stroke fatigue and recognising the need to manage it; education on post-stroke fatigue for the person with stroke, and their family/ and carers; using a diary to record activities and fatigue; predicting situations that may precipitate or exacerbate fatigue; pacing and prioritising activities; relaxation and meditation; rest; setting small goals and gradually expanding activities; changing diet and/or exercise (applied with caution and tailored to individual needs); seeking peer support and/or professional advice; coping methods including compensatory techniques, equipment and environmental adaptations.(Required) G Healthcare professionals working with people affected by post-stroke fatigue should be provided with education and training on post-stroke fatigue, including its multi-factorial nature and impact, potential causes and triggers, validated assessment tools and the importance of involving people affected by post-stroke fatigue in designing strategies to prevent and manage it.(Required) H Healthcare professionals working with people with post-stroke fatigue should consider the impact of fatigue on their day-to-day ability to engage with assessment and rehabilitation, and tailor the scheduling and length of such activities accordingly.(Required) I Service planners and managers should consider people with stroke whose ability to engage in rehabilitation is affected by post-stroke fatigue, and provide access to alternative solutions to ensure that they are still able to benefit from personalised rehabilitation input as required.(Required)
4.26 Swallowing A Patients with acute stroke should have their swallowing screened, using a validated screening tool, by a trained healthcare professional within four hours of arrival at hospital and before being given any oral food, fluid or medication.(Required) B Until a safe swallowing method is established, patients with swallowing difficulty after acute stroke should: be immediately considered for alternative fluids; have a comprehensive specialist assessment of their swallowing completed by a specialist in dysphagia management within 24 hours of admission; be considered for nasogastric tube feeding within 24 hours; be referred to a dietitian for specialist nutritional assessment, advice and ongoing monitoring; receive adequate hydration, nutrition and medication by alternative means; be referred to a pharmacist to review medication formulation.(Required) C Patients with swallowing difficulty in the acute phase of stroke should only be given food, fluids and medications in a form that minimizes the risk of aspiration.(Required) D People with stroke who require modified food or fluid consistency should have these provided in line with internationally agreed descriptors e.g. International Dysphagia Diet Standardisation Initiative (IDDSI).(Required) E Patients with stroke with suspected aspiration or who require tube feeding or dietary modification should be considered for instrumental assessment (videofluoroscopy or fibre-optic endoscopic evaluation of swallowing [FEES])(Required) F Patients with stroke who require instrumental assessment of swallowing (videofluoroscopy or fibre-optic endoscopic evaluation of swallowing [FEES]) should only receive this: in conjunction with a specialist in dysphagia management; in order to investigate the nature and causes of swallowing difficulties; to facilitate shared decision making and direct an active treatment/rehabilitation programme for swallowing difficulties.(Required) G Patients with swallowing difficulty after stroke should be considered for compensatory measures and adaptations to oral intake aimed at reducing the risks of aspiration and choking, improving swallowing efficiency and optimising nutrition and hydration. This should be based on a thorough assessment of dysphagia and may include: texture modification of food and fluids; sensory modification, such as altering the volume, taste and temperature of foods or carbonation of fluids; compensatory measures such as postural changes (e.g. chin tuck) or swallowing manoeuvres (e.g. supraglottic swallow).(Required) H People with swallowing difficulty after stroke should be considered for swallowing rehabilitation by a specialist in dysphagia management. This should be based on a thorough assessment of dysphagia, such as by a speech and language therapist, to decide on the most appropriate behavioural intervention, and may include a variety of muscle strengthening and/or skill training exercises.(Required) I People with dysphagia after stroke may be considered for neuromuscular electrical stimulation as an adjunct to behavioural rehabilitation where the device is available and it can be delivered by a trained healthcare professional.(Required) J Patients with tracheostomy and severe dysphagia after stroke may be considered for pharyngeal electrical stimulation to aid decannulation where the device is available and it can be delivered by a trained healthcare professional.(Required) K People with difficulties feeding themselves after stroke should be assessed and provided with the appropriate equipment and assistance (including physical help and verbal encouragement) to promote independent and safe feeding.(Required) L People with swallowing difficulty after stroke should be provided with written guidance for all staff and carers to follow when feeding them or providing fluids.(Required) M People with stroke should be considered for gastrostomy feeding if they: need, but are unable to tolerate, nasogastric tube feeding, even after a trial with a nasal bridle if appropriate and other measures such as taping the tube or increased supervision; are unable to swallow adequate food and fluids orally by four weeks from the onset of stroke and gastrostomy feeding is considered to be required long-term; reach the point where shared decision making by the person with stroke, their family/carers, and the multidisciplinary team has agreed that artificial nutrition is appropriate due to the high long-term risk of malnutrition.(Required) N For people with dysphagia after stroke the option to eat and drink orally despite acknowledged risks should be considered. This decision-making process should be person-centred and taken together with the person with stroke, their family/carers and the multidisciplinary team. It should include a swallowing assessment and steps to minimise risk.(Required) O People with stroke who are discharged from specialist treatment with continuing problems with swallowing food or fluids safely should be trained, or have family/carers trained, in the management of their swallowing and be regularly reassessed.(Required) P People with stroke receiving end-of-life (palliative) care should not have burdensome restrictions on oral food or fluids if those restrictions would exacerbate suffering. In particular, following assessment this may involve a decision, taken together with the person with stroke, their family/carers and the multidisciplinary team, to allow oral food or fluids despite risks including aspiration and choking.(Required)
4.28 Psychological effects of stroke – general A Healthcare professionals screening people for cognitive problems after stroke should establish a baseline of their cognitive abilities prior to the stroke by taking a collateral history from family/carers and clinical records.(Required) B People with stroke should be routinely screened for delirium. Multidisciplinary teams should be aware of delirium throughout the person’s inpatient stay, and an unexpected change in cognition should prompt a further assessment for delirium.(Required) C People with stroke should be screened for cognitive problems as soon as it is medically appropriate and they are able to participate in a brief interaction, usually within the initial days after onset of stroke.(Required) D Registered healthcare professionals who undertake cognitive screening of people with stroke should have the necessary knowledge and skills to appropriately select a screening tool for the identified purpose; to appropriately administer cognitive screening tools; and to interpret the findings taking account of the person’s pre-stroke cognition, perception of cognition, functional abilities and other relevant factors such as mood.(Required) E People with cognitive impairment after stroke, identified by screening, should have further assessment, including functional assessment and cognitive or neuropsychological assessment where indicated, to inform treatment planning, patient and family education and discharge planning.(Required)
4.29 Cognitive screening A Healthcare professionals screening people for cognitive problems after stroke should establish a baseline of their cognitive abilities prior to the stroke by taking a collateral history from family/carers and clinical records.(Required) B People with stroke should be routinely screened for delirium. Multidisciplinary teams should be aware of delirium throughout the person’s inpatient stay, and an unexpected change in cognition should prompt a further assessment for delirium.(Required) C People with stroke should be screened for cognitive problems as soon as it is medically appropriate and they are able to participate in a brief interaction, usually within the initial days after onset of stroke.(Required) D Registered healthcare professionals who undertake cognitive screening of people with stroke should have the necessary knowledge and skills to appropriately select a screening tool for the identified purpose; to appropriately administer cognitive screening tools; and to interpret the findings taking account of the person’s pre-stroke cognition, perception of cognition, functional abilities and other relevant factors such as mood.(Required) E People with cognitive impairment after stroke, identified by screening, should have further assessment, including functional assessment and cognitive or neuropsychological assessment where indicated, to inform treatment planning, patient and family education and discharge planning.(Required)
4.30 Cognitive assessment A People with cognitive problems after stroke should receive an in-depth cognitive assessment, including functional performance, using standardised and validated tools to determine the nature of their cognitive difficulties and to detect uncommon or subtle changes for which screening tests may lack sensitivity.(Required) B Community stroke teams (including clinical psychology/neuropsychology) should be available to accept referrals for further cognitive assessment, identification of rehabilitation goals and assessment and management of risk, including when it is inappropriate for this to be conducted in the acute hospital setting. This should include contributing to mental capacity or safeguarding decisions and the assessment and management of people returning to cognitively demanding roles such as work or driving.(Required) C Standardised cognitive assessments should be carried out by specialised assessors (e.g. occupational therapists with relevant knowledge and skills, or stroke clinical psychologists/neuropsychologists) with appropriate training and awareness of the properties and limitations of the various tests(Required) D People with stroke returning to cognitively demanding roles such as managing instrumental activities of daily living (e.g. finances, driving or work) should have detailed cognitive assessments performed by an appropriately skilled assessor.(Required) E People with stroke who are unable to tolerate or adequately engage in standardised cognitive assessment should be assessed using appropriate functional tasks within a structured approach.(Required)
4.31 Apraxia A People with difficulty executing tasks after stroke despite adequate limb movement should be assessed for the presence of apraxia using standardised measures.(Required) B People with apraxia after stroke should: have their profile of impaired and preserved abilities determined using a standardised approach; have the impairment and the impact on function explained to them, their family/carers, and the multidisciplinary team; be offered therapy and trained in compensatory techniques specific to the deficits identified, ideally in the context of a clinical trial.(Required)
4.32 Attention and concentration A People who appear easily distracted or unable to concentrate after stroke should have their attentional abilities assessed using standardised measures.(Required) B People with impaired attention after stroke should have cognitive demands reduced by: having shorter treatment sessions; taking planned rests; reducing background distractions; avoiding activities when tired.(Required) C People with impaired attention after stroke should: have the impairment explained to them, their family/carers and the multidisciplinary team; be offered an attentional intervention (e.g. time pressure management, attention process training, environmental manipulation), ideally in the context of a clinical trial; be given as many opportunities to practise their activities as reasonable under supervision.(Required)
4.33 Memory A People with stroke who report memory problems and those considered to have problems with learning and remembering should have their memory assessed using standardised measures.(Required) B People with memory impairment after stroke causing difficulties with rehabilitation should: have the impairment explained to them, their family/carers and the multidisciplinary team; be assessed for treatable or contributing factors (e.g. delirium, hypothyroidism); have their profile of impaired and preserved memory abilities determined, including the impact of other cognitive deficits e.g. attention; have nursing and therapy sessions altered to capitalise on preserved abilities; be trained in approaches that help them to encode, store and retrieve new information e.g. spaced retrieval (increasing time intervals between review of information) or deep encoding of material (emphasising semantic features); be trained in compensatory techniques to reduce their prospective memory problems (e.g. use of electronic reminders or written checklists); receive therapy in an environment as similar as possible to their usual environment.(Required)
4.34 Executive function A When making decisions with and on behalf of people with stroke, healthcare professionals should adhere to the principles defined in the relevant legislation (England and Wales: Mental Capacity Act 2005; Scotland: Adults with Incapacity (Scotland) Act 2000; Northern Ireland: Mental Capacity Act (Northern Ireland) 2016; Ireland: Assisted Decision-Making (Capacity) Act 2015), especially with regard to determining mental capacity and making decisions in the best interests of a person who lacks mental capacity.(Required) B The specialist multidisciplinary team should be involved in making decisions about mental capacity, and should provide information and advice to the person with stroke (when appropriate) and their family/carers.(Required)
4.36 Perception A People who appear to have perceptual difficulties after stroke should have a perceptual assessment using standardised measures.(Required) B People with agnosia after stroke should: have the impairment explained to them, their family/carers and the multidisciplinary team; have their environment assessed and adapted to reduce potential risks and promote independence; be offered a perceptual intervention, such as functional training, sensory stimulation, strategy training and/or task repetition, ideally in the context of a clinical trial.(Required)
4.37 Neglect A People with stroke affecting the non-dominant cerebral hemisphere should be considered at risk of impaired awareness on the contralateral side and should be assessed for this using standardised measures.(Required) B When assessing problems with spatial awareness in people with stroke, clinicians should use a standardised test battery in preference to a single subtest, and the effect on functional tasks such as dressing and mobility should be included.(Required) C People with impaired awareness to one side after stroke should: have the impairment explained to them, their family/carers and the multidisciplinary team; be trained in compensatory strategies to reduce the impact on their activities; be given cues to draw attention to the affected side during therapy and nursing activities; be monitored to ensure that they do not eat too little through missing food on one side of the plate; be offered interventions aimed at reducing the functional impact of the reduced awareness (e.g. visual scanning training, limb activation, sensory stimulation, eye patching, prism wearing, prism adaptation training, mirror therapy, galvanic vestibular stimulation, transcranial magnetic stimulation), ideally in the context of a clinical trial.(Required)
4.39 Anxiety, depression and psychological distress A Healthcare professionals should be aware of the psychological needs of people with stroke and their family/carers, and routinely provide education, advice, and emotional support for them. Multidisciplinary teams should embed measures that promote physical and mental well-being within the wider rehabilitation package, and collaborate with other statutory and voluntary services to deliver them, such as: increased social interaction; meaningful activities to support rebuilding of self-confidence and self-esteem; increased exercise; mind-body interventions such as relaxation, mindfulness, Tai Chi and yoga; other psychosocial interventions such as psychological education groups.(Required) B People with stroke should be routinely screened for anxiety and depression using standardised tools, the results of which should be used alongside other sources of information to inform clinical formulation of treatment and support needs.(Required) C People with stroke with one mood disorder (e.g. depression) should be assessed for others (e.g. anxiety).(Required) D When assessing, diagnosing or treating people with mood disorders after stroke, clinicians should take account of other relevant factors such as prior psychological history, type of stroke and other features such as cognitive or language deficits and fatigue.(Required) E People with mood disorders after stroke who are assessed to have suicidal ideas or intent, or who have a previous history of suicidal ideas or intent, should be referred for assessment and risk management by a psychiatric team and have a risk management plan put in place immediately.(Required) F People with depression or anxiety after stroke, and those assessed to be at risk, should be considered by the multidisciplinary team for non-pharmacological approaches, education and a reasonable period of watchful waiting where appropriate.(Required) G People with stroke should be offered one-to-one motivational interviewing or problem-solving therapy, adapted as necessary for people with aphasia or cognitive impairment, as part of a multidisciplinary rehabilitation approach to prevent depression.(Required) H People with stroke at significant risk of anxiety or depression should be offered psychological therapies (motivational interviewing, cognitive behavioural therapy, problem-solving therapy or acceptance and commitment therapy) provided they have sufficient cognitive and language skills to engage with the therapy.(Required) I People with stroke should not be routinely offered SSRIs for the prevention of depression, but SSRIs may be considered when other preventative approaches are not appropriate (e.g. in people with severe cognitive or language impairment) or when the risk of depression is high (e.g. in people with a previous history of depression). The balance of risk and benefit from SSRIs should take account of the potential for increased adverse effects (seizures and hip fracture).(Required) J People with depression after stroke should be offered psychological interventions (motivational interviewing, cognitive behavioural therapy or problem-solving therapy) adapted as necessary for use with people with aphasia or cognitive impairment and/or an SSRI.(Required) K People with depression after stroke may be considered for non-invasive brain stimulation in the context of a clinical trial.(Required) L People with aphasia and low mood after stroke should be considered for individual behavioural therapy.(Required) M People with anxiety after stroke may be considered for medication therapy, after discussion between clinician and the person about adverse events and alternative treatment approaches including psychological interventions.(Required) N People with depression or anxiety after stroke who are treated with antidepressant medication should be monitored for effectiveness and adverse effects within the first 6 weeks. If there has been a benefit people should be treated for at least four months beyond initial recovery. If the person’s mood has not improved after 6 weeks, medication adherence should be checked before considering a dose increase, a change to another antidepressant or an alternative non-pharmacological treatment.(Required) O People with persistent moderate to severe emotional disturbance after stroke who have not responded to high-intensity psychological intervention or pharmacological treatment should receive collaborative care, which should include long-term follow-up and involve liaison between the GP, stroke team and secondary care mental health services with supervision from a senior mental health professional.(Required) P Where people with depression or anxiety after stroke are being treated within primary care mental health services (such as Improving Access to Psychological Therapies [IAPT]) or secondary care mental health services, advice, consultation and training should be available from the stroke service. Guidance for the management of people with significant language and cognitive impairment should be agreed between services and joint working offered where appropriate.(Required) Q People with severe, persistent, or atypical symptoms of emotional disturbance after stroke, and those with complex presentations where emotional disturbance, cognitive and language deficits co-exist, should receive specialist assessment and treatment from a clinical psychologist/neuropsychologist to facilitate formulation and treatment planning within the multidisciplinary team.(Required) R Healthcare professionals who undertake mood assessment of people with stroke should have the knowledge and skills to select a screening tool appropriate for the purpose; to administer assessment tools appropriately; and to interpret the findings taking into account the person’s pre-stroke psychological history, perception of mood, and other relevant contextual factors such as medical state, fatigue, and sleep.(Required) S Stroke-skilled clinical psychology/neuropsychology should be available to multidisciplinary team members involved in the assessment and formulation of psychological problems after stroke, to help facilitate an understanding of these problems for people with stroke, to facilitate appropriate treatment approaches, and to provide training, clinical supervision, advice and support.(Required)
4.40 Apathy A For people with stroke who show diminished motivation, reduced goal-directed behaviour or decreased emotional responsiveness that is persistent and affects engagement with rehabilitation or functional recovery, apathy should be considered alongside other cognitive and mood disorders.(Required) B People with apathy after stroke should have a review of rehabilitation goals to ensure they reflect the person’s values, preferences and priorities. The person’s confidence to complete rehabilitation activities and plans should also be considered as an additional need requiring support.(Required) C People with apathy after stroke should be managed by a multidisciplinary approach in line with the stepped care and matched care models of psychological care. Assessment and treatment from a clinical psychologist/neuropsychologist should be available, particularly when the presentation is complex, persistent or is resistant to approaches trialled by the multidisciplinary team, to support assessment, clinical formulation and rehabilitation planning.(Required) D People with apathy after stroke should have the impairment and the impact on function explained to them, their family/carers, and the multidisciplinary team.(Required) E Members of the stroke multidisciplinary team should receive training in psychological care including apathy, at levels appropriate to the stepped care and matched care models.(Required)
4.41 Emotionalism A People with stroke who persistently cry or laugh in unexpected situations or are upset by their fluctuating emotional state should be assessed by a specialist member of the multidisciplinary team trained in the assessment of emotionalism.(Required) B People diagnosed with emotionalism after stroke should be appropriately distracted from the provoking stimulus when they show increased emotional behaviour.(Required) C People with severe or persistent emotionalism after stroke should be given antidepressant medication, monitoring effectiveness by the frequency of crying. They should be monitored for adverse effects and treated for at least four months beyond initial recovery. If the person’s emotionalism has not improved after 2-4 weeks, medication adherence should be checked before considering a dose increase or a change to another antidepressant.(Required)
4.43 Aphasia A People should be assessed early after stroke for communication difficulties by a speech and language therapist to diagnose the problem, devise and implement a treatment programme and explain the nature and implications to the person, their family/carers and the multidisciplinary team.(Required) B People with aphasia after stroke should be given the opportunity to improve their language and communication abilities as frequently and for as long as they continue to make meaningful gains, under supervision from a speech and language therapist.(Required) C People with aphasia after stroke should be offered access to appropriate practice-based digital therapies. Adherence to and engagement with these digital therapies will likely be improved if supported by a carer or healthcare professional. Telerehabilitation programmes should: be personalised to the individual’s goals and preferences; be used when it is considered to be a beneficial option to promote recovery and should not be used as an alternative to in-person rehabilitation; be monitored and adapted by the therapist according to progress towards goals; be supplemented with face-to-face reviews and include the facility for contact with the therapist as required.(Required) D People with communication difficulties after stroke should: be assessed and offered access to a range of communication aids, prescribed according to the person’s needs, goals, and preferences; be assessed for their ability to use assistive technology and have programmes and equipment adjusted accordingly; be trained and supported in the use of the appropriate technology.(Required) E People with communication difficulties after stroke should be offered access to social and participatory activities such as conversation partners, peer support groups, and return to work programmes as appropriate.(Required) F People with aphasia after stroke whose first language is not English should be assessed and provided with information about aphasia and offered therapy and communication practice in their preferred language. Referral to appropriate services such as interpreters should be made promptly to facilitate early assessment and treatment.(Required) G Intensive speech and language therapy such as comprehensive aphasia programmes may be considered from 3 months after stroke for those who can tolerate high-intensity therapy.(Required) H People with aphasia after stroke should be monitored and assessed for depression and other mood disorders using validated tools. Accessible information should be provided and psychological interventions tailored to the person’s needs.(Required) I The carers and family of a person with communication difficulties after stroke, and health and social care staff, should receive information and training from a speech and language therapist to improve their communication skills and enable them to optimise engagement in the person’s rehabilitation, and promote autonomy and social participation.(Required) J People with persistent communication difficulties after stroke, that limit their social activities, should be offered information about local or national groups for people with aphasia and referred as appropriate.(Required)
4.44 Dysarthria A People with unclear or unintelligible speech after stroke should be assessed by a speech and language therapist to diagnose the problem and to explain the nature and implications to the person, their family/carers and the multidisciplinary team.(Required) B People with dysarthria after stroke which limits communication should: be trained in techniques to improve the clarity of their speech; be assessed for compensatory and augmentative communication techniques (e.g. letter board, communication aids) if speech remains unintelligible.(Required) C The communication partners (e.g. family/carers, staff) of a person with severe dysarthria after stroke should be trained in how to assist the person in their communication.(Required)
4.45 Apraxia of speech A People with marked difficulty articulating words after stroke should be assessed for apraxia of speech and treated to maximise articulation of key words to improve speech intelligibility.(Required) B People with severe communication difficulties but good cognitive and language function after stroke should be assessed and provided with alternative or augmentative communication techniques or aids to supplement or compensate for limited speech.(Required)
4.47 Sensation A People with stroke should be screened for altered sensation and if present, assessed for sensory impairments using standardised measures.(Required) B People with sensory loss after stroke should be trained in how to avoid injury to the affected body parts.(Required)
4.48 Vision A People with stroke should be screened for visual changes by a professional with appropriate knowledge and skills, using a standardised approach.(Required) B People with stroke should be: assessed for visual acuity whilst wearing their usual glasses or contact lenses to check their ability to read newspaper text and see distant objects clearly; examined for the presence of visual field deficit (e.g. hemianopia) and eye movement disorders (e.g. strabismus and motility deficit); assessed using adapted visual tests for those with communication impairment.(Required) C People with altered vision, visual field defects or eye movement disorders after stroke should receive information, support and advice from an orthoptist and/or an ophthalmologist.(Required) D People reporting visual disturbance following stroke should be assessed by an occupational therapist to assess its impact on their ability to carry out functional tasks independently, their confidence and safety.(Required) E People with visual loss due to retinal artery occlusion should be jointly managed by an ophthalmologist and a stroke physician.(Required) F Multidisciplinary treatment programmes should be developed with an orthoptist and should include restorative and compensatory approaches to maximise safety and independence, in accordance with the person’s presentation, goals and preferences. For people with visual field loss due to stroke, compensation training such as visual scanning or visual search training should be considered.(Required) G People with visual deficits following stroke should be advised about driving restrictions and receive accessible written information regarding the process of assessment and decision making.(Required)
SECTION 5: LONG TERM MANAGEMENT & SECONDARY PREVENTION
5.1 A comprehensive and personalised approach A People with stroke or TIA should receive a comprehensive and personalised strategy for vascular prevention including medication and lifestyle factors, which should be implemented as soon as possible and should continue long-term.(Required) B People with stroke or TIA should receive information, advice and treatment for stroke, TIA and vascular risk factors which is: given first in the hospital or clinic setting; reinforced by all health professionals involved in their care; provided in an appropriate format.(Required) D People with stroke or TIA who are receiving medication for secondary prevention should: receive information about the reason for the medication, how and when to take it and common side effects; receive verbal and written information about their medicines in an appropriate format; be offered compliance aids such as large-print labels, non-childproof tops and dosette boxes according to their level of manual dexterity, cognitive impairment, personal preference and compatibility with safety in the home; be aware of how to obtain further supplies of medication; have their medication regularly reviewed; have their capacity to take full responsibility for self-medication assessed (including cognition, manual dexterity and ability to swallow) by the multidisciplinary team as part of their rehabilitation prior to the transfer of their care out of hospital.(Required)
5.2 Identifying risk factors A People with stroke or TIA for whom secondary prevention is appropriate should be investigated for risk factors as soon as possible within 1 week of onset.(Required) B Provided they are eligible for any resultant intervention, people with stroke or TIA should be investigated for the following risk factors: ipsilateral carotid artery stenosis; atrial fibrillation; structural cardiac disease.(Required) C People with evidence of non-symptomatic cerebral infarction on brain imaging (silent cerebral ischaemia) should have an individualised assessment of their vascular risk and secondary prevention.(Required)
5.3 Carotid artery stenosis A Following stroke or TIA, the degree of carotid artery stenosis should be reported using the North American Symptomatic Carotid Endarterectomy Trial (NASCET) method.(Required) B People with non-disabling carotid artery territory stroke or TIA should be considered for carotid revascularisation, and if they agree with intervention: they should have carotid imaging (duplex ultrasound, MR or CT angiography) performed urgently to assess the degree of stenosis; if the initial test identifies a relevant severe stenosis (greater than or equal to 50%), a second or repeat non-invasive imaging investigation should be performed to confirm the degree of stenosis. This confirmatory test should be carried out urgently to avoid delaying any intervention.(Required) C People with non-disabling carotid artery territory stroke or TIA should be considered for carotid revascularisation if the symptomatic internal carotid artery has a stenosis of greater than or equal to 50%. The decision to offer carotid revascularisation should be: based on individualised risk estimates taking account of factors such as the time from the event, gender, age and the type of qualifying event; supported by risk tables or web-based risk calculators (e.g. the Oxford University Stroke Prevention Research Unit calculator(Required) D People with non-disabling carotid artery territory stroke or TIA and a carotid stenosis of less than 50% should not be offered revascularisation of the carotid artery.(Required) E Carotid endarterectomy for people with symptomatic carotid stenosis should be: the treatment of choice, particularly for people who are 70 years of age and over or for whom the intervention is planned within seven days of stroke or TIA; performed in people who are neurologically stable and who are fit for surgery using either local or general anaesthetic according to the person’s preference; performed as soon as possible and within 1 week of first presentation; deferred for 72 hours in people treated with intravenous thrombolysis; only undertaken by a specialist surgeon in a vascular centre where the outcomes of carotid surgery are routinely audited.(Required) F Carotid angioplasty and stenting should be considered for people with symptomatic carotid stenosis who are: unsuitable for open surgery (e.g. high carotid bifurcation, symptomatic re-stenosis following endarterectomy, radiotherapy-associated carotid stenosis); or less than 70 years of age and who have a preference for carotid artery stenting. The procedure should only be undertaken by an experienced operator in a vascular centre where the outcomes of carotid stenting are routinely audited.(Required) G People who have undergone carotid revascularisation should be reviewed post-operatively by a stroke physician to optimise medical aspects of vascular secondary prevention.(Required) H Patients with atrial fibrillation and symptomatic internal carotid artery stenosis should be managed for both conditions unless there are contraindications.(Required)
5.4 Blood pressure A People with stroke or TIA should have their blood pressure checked, and treatment should be initiated or increased as tolerated to consistently achieve a clinic systolic blood pressure below 130 mmHg, equivalent to a home systolic blood pressure below 125 mmHg. The exception is for people with severe bilateral carotid artery stenosis, for whom a systolic blood pressure target of 140–150 mmHg is appropriate. Concern about potential adverse effects should not impede the initiation of treatment that prevents stroke, major cardiovascular events or mortality.(Required) B For people with stroke or TIA aged 55 or over, or of African or Caribbean origin at any age, antihypertensive treatment should be initiated with a long-acting dihydropyridine calcium-channel blocker or a thiazide-like diuretic. If target blood pressure is not achieved, an angiotensin converting enzyme inhibitor or angiotensin II receptor blocker should be added.(Required) C For people with stroke or TIA not of African or Caribbean origin and younger than 55 years, antihypertensive treatment should be initiated with an angiotensin converting enzyme inhibitor or an angiotensin II receptor blocker.(Required) D People with stroke or TIA should have blood pressure-lowering treatment initiated prior to the transfer of care out of hospital or at 2 weeks, whichever is the soonest, or at the first clinic visit for people not admitted.(Required) E People with stroke or TIA should have their blood pressure-lowering treatment monitored frequently in primary care and increased to achieve target blood pressure as quickly and safely as tolerated. People whose blood pressure remains above target despite treatment should be checked for medication adherence at each visit before escalation of treatment, and people who do not achieve their target blood pressure despite escalated treatment should be referred for a specialist opinion. Once blood pressure is controlled to target, people taking antihypertensive treatment should be reviewed at least annually.(Required) F In people with stroke being treated with antihypertensive agents to reduce recurrent stroke risk, management guided by home or ambulatory BP monitoring should be considered, in order to improve treatment compliance and BP control.(Required) G People with stroke using home BP monitoring should use a validated device with an appropriate measurement cuff and a standardised method. They (or where appropriate, their family/carer) should receive education on how to use the device, the implications of readings for management, and be provided with ongoing support, particularly if they have anxiety or cognitive and physical disability after stroke.(Required)
5.5 Lipid modification A People with ischaemic stroke or TIA should be offered personalised advice and support on lifestyle factors to reduce cardiovascular risk, including diet, physical activity, weight reduction, alcohol moderation and smoking cessation.(Required) B People with ischaemic stroke or TIA should be offered treatment with a statin unless contraindicated or investigation of their stroke or TIA confirms no evidence of atherosclerosis. Treatment should: begin with a high-intensity statin such as atorvastatin 80 mg daily. A lower dose should be used if there is the potential for medication interactions or a high risk of adverse effects; be with an alternative statin at the maximum tolerated dose if a high-intensity statin is unsuitable or not tolerated.(Required) C Lipid-lowering treatment for people with ischaemic stroke or TIA and evidence of atherosclerosis should aim to reduce fasting LDL-cholesterol to below 1.8 mmol/L (equivalent to a non-HDL-cholesterol of below 2.5 mmol/L in a non-fasting sample). If this is not achieved at first review at 4-6 weeks, the prescriber should: discuss adherence and tolerability; optimise dietary and lifestyle measures through personalised advice and support; consider increasing to a higher dose of statin if this was not prescribed from the outset; consider adding ezetimibe 10 mg daily; consider the use of additional agents such as injectables (inclisiran or monoclonal antibodies to PCSK9) or bempedoic acid (for statin-intolerant people taking ezetimibe monotherapy); continue to escalate lipid-lowering therapy (in combination if necessary) at regular intervals in order to reduce LDL-cholesterol to below 1.8 mmol/L.(Required) D People with ischaemic stroke or TIA in whom investigation confirms no evidence of atherosclerosis should be assessed for lipid-lowering therapy on the basis of their overall cardiovascular risk.(Required) E People with intracerebral haemorrhage should be assessed for lipid-lowering therapy on the basis of their overall cardiovascular risk and the underlying cause of the haemorrhage.(Required) F In people with ischaemic stroke or TIA below 60 years of age with very high cholesterol (below 30 years with total cholesterol above 7.5 mmol/L or 30 years or older with total cholesterol concentration above 9.0 mmol/L) consider a diagnosis of familial hypercholesterolaemia.(Required) G In people with ischaemic stroke or TIA of presumed atherosclerotic cause below 60 years of age, consider the measurement of lipoprotein(a) and specialist referral if raised above 200 nmol/L.(Required)
5.6 Antiplatelet treatment A For long-term prevention of vascular events in people with ischaemic stroke or TIA without paroxysmal or permanent atrial fibrillation: clopidogrel 75 mg daily should be the standard antithrombotic treatment; aspirin 75 mg daily should be used for those who are unable to tolerate clopidogrel; if a patient has a recurrent cardiovascular event on clopidogrel, clopidogrel resistance may be considered. The combination of aspirin and clopidogrel is not recommended for long-term prevention of vascular events unless there is another indication e.g. acute coronary syndrome, recent coronary stent.(Required) B People with ischaemic stroke with acute haemorrhagic transformation should be treated with long-term antiplatelet or anticoagulant therapy unless the prescriber considers that the risks outweigh the benefits.(Required) C Patients who have a spontaneous (non-traumatic) intracerebral haemorrhage (ICH) whilst taking an antithrombotic (antiplatelet or anticoagulant) medication for the prevention of occlusive vascular events may be considered for restarting antiplatelet treatment beyond 24 hours after ICH symptom onset.(Required) D Clinicians should consider the baseline risks of recurrent ICH and occlusive vascular events when making a decision about antiplatelet use after ICH outside randomised controlled trials.(Required) E Wherever possible, patients with spontaneous (non-traumatic) ICH and a co-existent indication for antithrombotic medication treatment should be encouraged to participate in randomised controlled trials of antithrombotic therapy.(Required)
5.7 Anticoagulation A For people with ischaemic stroke or TIA and paroxysmal, persistent or permanent atrial fibrillation (AF: valvular or non-valvular) or atrial flutter, oral anticoagulation should be the standard long-term treatment for stroke prevention. Anticoagulant treatment: should not be given if brain imaging has identified significant haemorrhage; should not be commenced in people with severe hypertension (clinic blood pressure of 180/120 or higher), which should be treated first; may be considered for patients with moderate-to-severe stroke from 5-14 days after onset. Wherever possible these patients should be offered participation in a trial of the timing of initiation of anticoagulation after stroke. Aspirin 300 mg daily should be used in the meantime; should be considered for patients with mild stroke earlier than 5 days if the prescriber considers the benefits to outweigh the risk of early intracranial haemorrhage. Aspirin 300 mg daily should be used in the meantime; should be initiated within 14 days of onset of stroke in all those considered appropriate for secondary prevention; should be initiated immediately after a TIA once brain imaging has excluded haemorrhage, using an agent with a rapid onset (e.g. DOAC in non-valvular AF or subcutaneous low molecular weight heparin while initiating a VKA for those with valvular AF); should include measures to reduce bleeding risk, using a validated tool to identify modifiable risk factors.(Required) B First-line treatment for people with ischaemic stroke or TIA due to non valvular AF should be anticoagulation with a DOAC.(Required) C People with ischaemic stroke or TIA in sinus rhythm should not receive anticoagulation unless there is another indication.(Required) D People with ischaemic stroke or TIA due to valvular/rheumatic AF or with mechanical heart valve replacement, and those with contraindications or intolerance to DOAC treatment, should receive anticoagulation with adjusted-dose warfarin (target INR 2.5, range 2.0 to 3.0) with a target time in the therapeutic range of greater than 72%.(Required) E For people with cardioembolic TIA or stroke for whom treatment with anticoagulation is considered inappropriate because of a high risk of bleeding: antiplatelet treatment should not be used as an alternative when there are absolute contraindications to anticoagulation (e.g. undiagnosed bleeding); measures should be taken to reduce bleeding risk, using a validated tool to identify modifiable risk factors. If after intervention for relevant risk factors the bleeding risk is considered too high for anticoagulation, antiplatelet treatment should not be routinely used as an alternative; a left atrial appendage occlusion device may be considered as an alternative, provided the short-term peri-procedural use of antiplatelet therapy is an acceptable risk.(Required) F People with cardioembolic TIA or stroke for whom treatment with anticoagulation is considered inappropriate for reasons other than the risk of bleeding may be considered for antiplatelet treatment to reduce the risk of recurrent vaso-occlusive disease.(Required) G People who initially present with recurrent TIA or stroke should receive the same antithrombotic treatment as those who have had a single event. More intensive antiplatelet therapy or anticoagulation treatment should only be given as part of a clinical trial or in exceptional clinical circumstances.(Required)
5.9 Paroxysmal atrial fibrillation A Patients with ischaemic stroke or TIA not already diagnosed with atrial fibrillation or flutter should undergo an initial period of cardiac monitoring for a minimum of 24 hours if they are appropriate for anticoagulation.(Required) B Patients with ischaemic stroke or TIA, in whom no other cause of stroke has been found after comprehensive neurovascular investigation (stroke of undetermined aetiology or ‘cryptogenic’ stroke) and in whom a cardioembolic cause is suspected, should be considered for more prolonged sequential or continuous cardiac rhythm monitoring with an external patch, wearable recorder or implantable loop recorder if they are appropriate for anticoagulation.(Required)
5.10 Patent foramen ovale A People with ischaemic stroke or TIA and a PFO should receive optimal secondary prevention treatment, including antiplatelet therapy, treatment for high blood pressure, lipid-lowering therapy and lifestyle modification. Anticoagulation is not recommended unless there is another recognised indication.(Required) B Selected people below the age of 60 with ischaemic stroke or TIA of otherwise undetermined aetiology, in association with a PFO and a right-to-left shunt or an atrial septal aneurysm, should be considered for endovascular PFO device closure within six months of the index event to prevent recurrent stroke. This decision should be made after careful consideration of the benefits and risks by a multidisciplinary team including the patient’s physician and the cardiologist performing the procedure. The balance of risk and benefit from the procedure, including the risk of atrial fibrillation and other recognised peri-procedural complications should be fully considered and explained to the person with stroke.(Required) C People older than 60 years with ischaemic stroke or TIA of otherwise undetermined aetiology and a PFO should preferably be offered closure in the context of a clinical trial or prospective registry.(Required)
5.11 Other cardioembolism A People with stroke or TIA should be investigated with transthoracic echocardiography if the detection of a structural cardiac abnormality would prompt a change of management and if they have: clinical or ECG findings suggestive of structural cardiac disease that would require assessment in its own right, or unexplained stroke or TIA, especially if other brain imaging features suggestive of cardioembolism are present.(Required)
5.12 Vertebral artery disease A People with ischaemic stroke or TIA and symptomatic vertebral artery stenosis should receive optimal secondary prevention including antithrombotic therapy, blood pressure treatment, lipid-lowering therapy and lifestyle modification. Angioplasty and stenting of the vertebral artery should only be offered in the context of a clinical trial.(Required)
5.13 Intracranial artery stenosis A People with ischaemic stroke or TIA due to severe symptomatic intracranial stenosis should be offered dual antiplatelet therapy with aspirin and clopidogrel for the first three months in addition to optimal secondary prevention including blood pressure treatment, lipid-lowering therapy and lifestyle modification. Endovascular or surgical intervention should only be offered in the context of a clinical trial.(Required)
5.14.1 Oral contraception A Premenopausal women with stroke and TIA should not be offered the combined oral contraceptive pill. Alternative hormonal (progestogen-only) and non-hormonal contraceptive methods should be considered instead.(Required)
5.14.2 Hormone replacement therapy A Post-menopausal women with ischaemic stroke or TIA who wish to start or continue hormone replacement therapy should receive advice based on the overall balance of risk and benefit, taking account of the woman’s preferences.(Required) B Post-menopausal women with ischaemic stroke or TIA should not be offered hormone replacement therapy for secondary vascular prevention.(Required)
5.15 Obstructive sleep apnoea A People with stroke or TIA should be screened for obstructive sleep apnoea with a valid clinical screening tool. People who screen positive who are suspected of having sleep apnoea should be referred for specialist respiratory/sleep medicine assessment.(Required)
5.16 Antiphospholipid syndrome A People with ischaemic stroke or TIA in whom other conditions such as atrial fibrillation and large or small vessel atherosclerotic disease have been excluded should be investigated for antiphospholipid syndrome (with IgG and IgM anticardiolipin ELISA and lupus anticoagulant), particularly if the person: is under 50 years of age; has any autoimmune rheumatic disease, particularly systemic lupus erythematosus; has a history of one or more venous thromboses; has a history of recurrent first trimester pregnancy loss or at least one late pregnancy loss (second or third trimester).(Required) B People with antiphospholipid syndrome who have an ischaemic stroke or TIA: should be managed acutely in the same way as people without antiphospholipid syndrome; should have decisions on long-term secondary prevention made on an individual basis in conjunction with appropriate specialists including haematology and/or rheumatology.(Required)
5.17 Insulin resistance A People with stroke or TIA should not receive pioglitazone for secondary vascular prevention.(Required)
5.18 Fabry disease A Young people with stroke or TIA should be investigated for Fabry disease if they have suggestive clinical features such as acroparesthesias, angiokeratomas, sweating abnormalities, corneal opacities, unexplained renal insufficiency or a family history suggesting the condition.(Required) B People with stroke or TIA and a diagnosis of Fabry disease should receive optimal secondary prevention and be referred to specialist genetic and metabolic services for advice on other aspects of care including the provision of enzyme replacement therapy.(Required)
5.19 Cerebral Amyloid Angiopathy A Patients with lobar ICH associated with probable CAA should be considered for blood pressure lowering to below a long-term target of 130/80 mmHg. Wherever possible patients should be offered participation in a randomised trial of blood pressure-lowering treatment.(Required) B Patients with lobar ICH associated with probable CAA may be considered for antiplatelet therapy for the secondary prevention of vaso-occlusive events, but wherever possible patients should be offered participation in a randomised trial. If participation in a randomised trial is not possible then clinicians should make an individualised decision based on estimates of the future risks of recurrent ICH and vaso-occlusive events.(Required) C Patients with lobar ICH associated with probable CAA and AF may be considered for oral anticoagulation for stroke prevention, but wherever possible patients should be offered participation in a randomised trial. If participation in a randomised trial is not possible then clinicians should make an individualised decision based on estimates of the future risks of recurrent ICH and vaso-occlusive events.(Required) D Patients with lobar ICH associated with probable CAA and AF may be considered for a left atrial appendage occlusion (LAAO) device, but wherever possible patients should be offered participation in a randomised trial. If participation in a randomised trial is not possible then LAAO may be considered based on an estimation of the future risks of recurrent ICH and vaso-occlusive events.(Required)
5.20 CADASIL A People with clinical and radiological features that are suggestive of CADASIL should only be offered genetic testing after appropriate counselling and discussion. Predictive testing in other family members should be performed by a specialist clinical genetics service after appropriate counselling.(Required) B People with CADASIL should be considered for intensive cardiovascular risk factor management, particularly with respect to blood pressure management (target to below 130/80 mmHg) and smoking cessation advice. They should also be considered for active management of other risk factors including lipid lowering treatment (including with statins), and diabetes mellitus, and offered lifestyle advice (including regarding obesity and exercise).(Required) C People with CADASIL and ischaemic stroke or TIA may be considered for antiplatelet therapy; cerebral microbleeds are not a contraindication.(Required)
5.21 Cerebral microbleeds A In patients with ischaemic stroke or TIA requiring antiplatelet or anticoagulant treatment, the presence of cerebral microbleeds (regardless of number or distribution) need not preclude antithrombotic medication use.(Required) B In patients with recent ischaemic stroke or TIA treated with antithrombotic (i.e. antiplatelet or anticoagulant) medication, the use of a validated risk score (such as the MICON-ICH score) may be considered for predicting the risk of symptomatic intracranial haemorrhage to allow the mitigation of bleeding risk, including assertive management of modifiable factors (e.g. hypertension, alcohol intake and review of concurrent medication).(Required)
5.23 Physical activity A People with stroke or TIA should participate in physical activity for fitness unless there are contraindications. Exercise prescription should be individualised, and reflect treatment goals and activity recommendations.(Required) B People with stroke or TIA should aim to be active every day and minimise the amount of time spent sitting for long periods.(Required) C People with stroke should be offered cardiorespiratory training or mixed training regardless of age, time since having the stroke, and severity of impairment. Facilities and equipment to support high-intensity (greater than 70% peak heart rate) cardiorespiratory fitness training (such as bodyweight support treadmills, or static or recumbent cycles) should be available; The dose of training should be at least 30-40 minutes, 3 to 5 times a week for 10-20 weeks; Programmes of mixed training (medium intensity cardiorespiratory [40%-60% of heart rate reserve] and strength training [50-70% of one-repetition maximum]) such as circuit training classes should also be available at least 3 days per week for 20 weeks; The choice of programme should be guided by patients’ goals and preferences and delivery of the programme individualised to their level of impairment and goals.(Required) D People with stroke or TIA who are at risk of falls should engage in additional physical activity which incorporates balance and co-ordination, at least twice per week.(Required) E Physical activity programmes for people with stroke or TIA should be tailored to the individual after appropriate assessment, starting with low-intensity physical activity and gradually increasing to moderate levels.(Required) F Physical activity programmes for people with stroke or TIA may be delivered by therapists, fitness instructors or other appropriately trained people, supported by interagency working where possible. When delivered outside statutory health services, physical fitness training should be delivered by professionals with appropriate education and training in stroke and exercise (e.g. Chartered Institute for the Management of Sport and Physical Activity [CIMSPA]-endorsed exercise professionals or clinical exercise physiologists).(Required) G Stroke rehabilitation services should build links with community-based exercise facilities (such as support groups, gyms, leisure centres or exercise referral schemes) to support people with stroke to transition to ongoing physical activity on completion of an exercise programme.(Required) H Stroke services should consider working with other established rehabilitation services, such cardiac or pulmonary rehabilitation, to develop exercise-based programmes and ensure access to equipment and screening protocols.(Required)
5.24 Smoking cessation A People with stroke or TIA who smoke should be advised to stop immediately. Smoking cessation should be promoted in an individualised prevention plan using interventions which may include pharmacotherapy, psychosocial support and referral to statutory stop smoking services.(Required)
5.25 Nutrition (secondary prevention) A People with stroke or TIA should be advised to eat an optimum diet that includes: five or more portions of fruit and vegetables per day from a variety of sources; two portions of oily fish per week (salmon, trout, herring, pilchards, sardines, fresh tuna).(Required) B People with stroke or TIA should be advised to reduce and replace saturated fats in their diet with polyunsaturated or monounsaturated fats by: using low-fat dairy products; replacing butter, ghee and lard with products based on vegetable and plant oils; limiting red meat intake, especially fatty cuts and processed meat(Required) C People with stroke or TIA who are overweight or obese should be offered advice and support to aid weight loss including adopting a healthy diet, limiting alcohol intake to 2 units a day or less and taking regular exercise. Targeting weight reduction in isolation is not recommended.(Required) D People with stroke or TIA should be advised to reduce their salt intake by: not adding salt to food at the table; using little or no salt in cooking; avoiding high-salt foods, e.g. processed meat such as ham and salami, cheese, stock cubes, pre-prepared soups and savoury snacks such as crisps and salted nuts.(Required) E People with stroke or TIA who drink alcohol should be advised to limit their intake to 14 units a week, spread over at least three days.(Required) F Unless advised to do so for other medical conditions, people with stroke or TIA should not routinely supplement their diet with: B vitamins or folate; vitamins A, C, E or selenium; calcium with or without vitamin D.(Required)
5.27 Further rehabilitation A People with stroke, including those living in a care home, should be offered a structured, holistic review of their individual needs by a healthcare professional with appropriate knowledge and skills, using an appropriate mode of communication (e.g. face-to-face, by telephone or online). This review should cover physical, neuropsychological and social needs, seek to identify what matters most to the person, and be undertaken at 6 months after stroke, or earlier if requested by the person with stroke. At this 6-month review, the reviewer should discuss with the person with stroke who would be best placed to undertake the next review at 1 year post-stroke (or at another point in time, depending on the person’s needs), as well as the agreed mode of communication. This review should be offered annually thereafter (or at another point in time, if requested by the person with stroke), for as long as a need for ongoing review continues and on request thereafter.(Required) B People with stroke who have further needs identified at a 6-month or subsequent review should be considered for intervention or referral for health or social care assessment if: new health or social care needs are identified; existing health or social care needs have escalated; further rehabilitation goals related to specific physical, psychological, vocational, family or social needs can be identified and agreed; risk factors or co-morbidities are identified that would lead to deterioration if no action were taken.(Required) C People with stroke who have further needs identified at a 6-month or subsequent review that do not require health or social care input should be provided with information about or referred to other appropriate services to address their needs (e.g. community-based support groups provided by voluntary or statutory services). Healthcare professionals should discuss with the person if they could facilitate the transition with their agreement (e.g. by providing relevant information to the service, or by a scheduling a joint session).(Required) D Healthcare professionals providing 6-month or subsequent reviews of people with stroke should maintain an up-to-date overview of appropriate health and social care services, and other service providers (e.g. community support groups and local councils) to facilitate transitions to other services as required.(Required) E People with stroke should be provided with the contact details of a named healthcare professional (e.g. a stroke co-ordinator or key worker) who can provide further information, support and advice, as and when needed.(Required) F People with stroke should be supported to develop their own self-management plan, based on their individual needs, goals, preferences and circumstances.(Required) G People with stroke who are unable to undertake their own self-management should be referred in a timely manner to appropriate health, social care, or other voluntary or statutory services depending on their needs.(Required)
5.28 Social integration and participation A As part of their self-management plan, people with stroke should be supported to identify social and leisure activities that they wish to participate in, taking into account their cognitive and practical skills. Healthcare professionals should: advise the person with stroke and their family/carers about the benefits of participating in social and leisure activities; identify and help them to overcome any barriers to participation (e.g. low self-confidence or lack of transport).(Required) B People with stroke should be provided with information and referral to statutory and voluntary community organisations that can support the person in social participation.(Required) C People with stroke whose social behaviour is causing distress to themselves or others should be assessed by an appropriately trained healthcare professional to determine the underlying cause and advise on management. Following the assessment: the nature of the problem and its cause should be explained to family/carers, other people in social contact and the rehabilitation team; the person should be helped to learn the best way to interact without causing distress; those involved in social interactions should be trained in how to respond to inappropriate or distressing behaviour; psychosocial management approaches should be considered; antipsychotic medicines may be indicated if other causes have been excluded and the person is at risk of harm to themselves or others. The balance of risk and benefit from antipsychotic medication should be carefully considered. Treatment should be started with a low dose and increased slowly according to symptoms, and should be short-term (e.g. one week) or intermittent and withdrawn slowly(Required) Please comment further on any areas of compliance you feel the network should be aware of e.g. could be part of a QI project or discussed at a network group etc
Section Break 