Planned follow up:

• Local arrangements should make it clear how this is decided and where the person will be followed up.
• Follow-up arrangements and frequency depend on individual clinical needs and response to treatment. Where there are no problems requiring more frequent assessments:
• People who have had a stroke:
• Schedule primary care follow up (together with the carers) within 6 weeks of discharge, again within 6 months of discharge, and then annually.
• People who have had a transient ischaemic attack (TIA) or minor stroke:
• Follow up within 1 month of the event (in primary or secondary care) and then annually in primary care.

Management:

• Assess the need for further specialist review, advice, information, support, and rehabilitation — see Referral guidance.
• Assess social care needs.
• Assess health care needs — see Assessment.
• Check and optimize lifestyle measures and drug treatments for secondary prevention:
• Check and record annually blood pressure and lipid profile.
• Arrange for annual pre-winter influenza immunizations.

In depth

• When people with a history of stroke consult (for whatever reason), be alert for problems that may require new assessment and management:
• Neurological problems — balance, movement, tone, sensation, power.
• Pain — neuropathic, shoulder pain and subluxation, musculoskeletal pain.
• Mood and social interaction problems — depression, anxiety, emotionalism, disinhibition, aggression.
• Cognitive impairments:
• Attention and concentration.
• Memory.
• Disturbances of spatial awareness — neglect.
• Disturbance of perception — visual agnosia.
• Apraxia — loss of the conceptual ability to organize activities to achieve a goal.
• Planning, organizing, initiating, and monitoring behaviour (i.e. disturbances of executive functioning).
• Speech and communication difficulties — aphasia, dysarthria, apraxia of speech.
• Visual impairments and hemianopia.
• Bladder and bowel problems — urinary incontinence, faecal incontinence, constipation.
• Swallowing and nutrition problems — oral health, malnutrition, dehydration, artificial feeding.
• Sexual dysfunction.
• Difficulties with activities of daily living — personal, social, and vocational:
• There is a separate section on Driving after a stroke or TIA.

In depth

• Advise lifestyle measures that reduce the risk of stroke and other cardiovascular disease events, including:
• Stopping smoking.
• Adopting a cardioprotective diet, including reducing salt intake.
• Regular exercise.
• Prudent use of alcohol.
• Achieving and maintaining a satisfactory body weight.
• Because lifestyle changes can be a major challenge, consider measures to support behaviour change.
• For more information, see the section on Advice on lifestyle interventions in the CKS topic on CVD risk assessment and management.

• Antithrombotic, antihypertensive, and lipid modifying treatments are recommended, and will need to be started by the GP if this has not already been done in secondary care.
• For full management details, see the CKS topics on:
• Antiplatelet treatment, or Atrial fibrillation for people with this condition.
• Hypertension - not diabetic.
• Lipid modification - CVD prevention.
• Diabetes type 2, for people with this condition.
• All people should be followed up 1 month after the event, either in primary or secondary care, so that medication and other interventions to modify risk factors (for example diabetes, hypertension, hyperlipidaemia, or ischaemic heart disease) can be assessed [DH, 2007].

For the management of acute stroke or TIA, see Acute stroke/TIA.

For the management of someone presenting with a suspected completed TIA , see TIA, completed.

Secondary prevention of TIA

• For people who have had a TIA, long-term antiplatelet treatment should usually be started in primary care as soon as the diagnosis is confirmed.
• A combination of modified-release dipyridamole (200 mg twice daily) and aspirin (50 mg to 300 mg daily) is recommended.
• Consider also prescribing a proton pump inhibitor to reduce the risk of gastrointestinal bleeding in people at high risk of gastrointestinal bleeding or to relieve aspirin-induced dyspepsia.
• If aspirin is contraindicated or not tolerated, give modified-release dipyridamole alone.
• Clopidogrel (75 mg daily) alone is an alternative (off-label use).
• If modified-release dipyridamole is not tolerated, give aspirin alone.
• For further information on antiplatelet therapy (including managing gastrointestinal issues), see the CKS topic on Antiplatelet treatment.

Secondary prevention of ischaemic stroke

• For people who have had an ischaemic stroke, high-dose aspirin is usually continued for about 2 weeks after the event, and then low–dose long–term antiplatelet treatment is started.
• Clopidogrel (75 mg daily) is the preferred antiplatelet for secondary prevention of ischaemic stroke.
• If clopidogrel is contraindicated or not tolerated, give a combination of modified-release dipyridamole (200 mg twice daily) and aspirin (50 mg to 300 mg daily).
• Consider also prescribing a proton pump inhibitor to reduce the risk of gastrointestinal bleeding in people at high risk of gastrointestinal bleeding or to relieve aspirin-induced dyspepsia.
• If both clopidogrel and modified-release dipyridamole are contraindicated or not tolerated, give aspirin alone.
• If both clopidogrel and aspirin are contraindicated or not tolerated, give modified-release dipyridamole alone.
• For further information on antiplatelet therapy (including managing gastrointestinal issues), see the CKS topic on Antiplatelet treatment.

Recurrent stroke or TIA

• People who have recurrent strokes or TIAs should not be given more intensive antiplatelet treatment or anticoagulation unless there are exceptional circumstances or as part of a clinical trial. Seek specialist advice regarding management of these people.

People with persistent or paroxysmal atrial fibrillation or with cerebral venous sinus thrombosis

• Anticoagulation is recommended for people with persistent or paroxysmal atrial fibrillation, and is usually recommended for people with cerebral venous sinus thrombosis.
• Anticoagulation is normally initiated in secondary care, and should not be started until intracerebral haemorrhage has been excluded by brain imaging.
• For more information on managing anticoagulation in people with atrial fibrillation, see the CKS topic on Atrial fibrillation and the CKS topic on Anticoagulation - oral.

In depth

• All people with stroke or transient ischaemic attack (TIA) should have their blood pressure checked and be offered antihypertensive treatment in line with national guidelines:
• For people with a TIA: consider starting antihypertensive treatment as soon as possible.
• For people with an acute stroke: treatment will usually be initiated in secondary care about 2 weeks after the event (unless a hypertensive emergency requires urgent reduction in blood pressure).
• Optimal target blood pressure:
• For people with established cardiovascular disease: aim to reduce blood pressure to 140/90 mmHg or less, and preferably to 130/80 mmHg.
• For people with bilateral, severe (more than 70%) stenosis of the internal carotid arteries: a slightly higher target blood pressure (e.g. systolic blood pressure 150 mmHg) may be appropriate.
• For information and prescription details, see the CKS topic on Hypertension - not diabetic for people without Type 2 diabetes; otherwise, see the CKS topic on Diabetes type 2.

In depth

The following recommendations apply to most people. They do not apply to people with lipid disorders such as familial hypercholesterolaemia:

• A statin should be started:
• As soon as possible for people with a transient ischaemic attack (TIA).
• 48 hours after the event for people with an acute stroke.
• People with an acute stroke or TIA who are already receiving statins should continue their statin treatment.
• Seek specialist advice before initiating a statin in people with a history of haemorrhagic stroke, particularly those with inadequately controlled hypertension.
• Before starting treatment:
• Consider whether treatment is appropriate, taking into account comorbidities and life expectancy.
• Perform baseline blood tests (for more information, see the section on Tests before drug treatment in the CKS topic on Lipid modification - CVD prevention).
• Investigate for (and if found, manage) any conditions, such as diabetes, that are suggested by the baseline tests.
• If dyslipidaemia is present, investigate for, and manage, secondary causes.
• Consider higher-intensity statin therapy if the total cholesterol level does not decrease to below 4 mmol/L or the low-density lipoprotein cholesterol level does not decrease to below 2 mmol/L.
• Optimize, as far as possible, the management of comorbidities and implementation of lifestyle interventions.
• For more information (including options when simvastatin is not suitable), see the CKS topic on Lipid modification - CVD prevention and the appropriate sections in the CKS topic on Diabetes type 2.

In depth

• Always consult the latest Driver and Vehicle Licensing Agency (DVLA) regulations to ensure that your advice is accurate and up to date — see the 'At a Glance' booklet available on the DVLA website.
• For people with a group II licence — for large goods vehicles or passenger carrying vehicles — who have had a stroke or TIA:
• They must notify the DVLA, who will not allow them to drive under this licence for at least 12 months.
• They can be considered for re-licensing after this period provided that they have no residual impairment likely to affect safe driving and no other significant risk factors.
• Re-licensing will also be subject to satisfactory medical reports, including exercise electrocardiography.
• Where there is imaging evidence of essentially normal carotid arteries Group 2 licensing may be allowed without the need for functional cardiac assessment.
• For people with a group I licence — an ordinary driving licence for car or motorcycle — who have had a stroke or TIA:
• They must not drive for at least 4 weeks.
• They may resume driving after this period if clinical recovery is satisfactory.
• There is no need to notify the DVLA unless there is residual neurological deficit 1 month after the episode: for example, visual field defects, cognitive defects, and impaired limb function.
• Minor limb weakness alone does not require notification unless the person is restricted to driving certain types of vehicle or vehicles with adapted controls.
• Vehicle adaptations may be able to overcome severe physical impairment.
• The DVLA will need to know which, if any, of the controls require modification and will ask the person to complete a simple questionnaire. The driving licence will then be coded to reflect the modifications.
• People who have multiple TIAs over a short period should notify the DVLA of this; the DVLA will require at least 3 months free of further attacks before allowing driving to be resumed.
• For all people (group I or II licence) who wish to resume driving after recovering from a stroke or TIA:
• They will need to be assessed for factors that preclude safe driving. These factors include:
• Significant visual field defect, or reduction in visual acuity.
• An epileptic seizure within the past 12 months (a seizure within the first 24 hours after the onset of the stroke is considered to be a provoked seizure, not an epileptic seizure).
• A disorder of focused attention, especially hemi-spatial neglect.
• They will need sufficient muscle control to control their car (which may require adaptations).
• They will need sufficient cognitive ability to drive safely on a busy road. On-the-road assessment of ability may be required because assessment in the clinic is inaccurate.
• Advice on mechanical adaptations can be obtained from a number of sources, including the DVLA.
• They can get computer-based driving training and should consider having driving skills reassessed.
• They should inform their car insurance company before resuming driving, as failure to do so could result in the insurance being void.

In depth

• The GP is responsible for the general medical care of people who have had a stroke and been discharged from hospital. They should ensure that problems related to stroke are detected early and, when necessary, referred to the appropriate community health service, local social services, voluntary services, and specialists in secondary care.
• Only general guidelines for referral can be given for referral to specialist services because the service organization and provision of stroke aftercare vary with locality:
• Information on local specialist stroke rehabilitation and support services in the community should be available from the primary care trust.
• Community services include a community stroke team, a community stroke coordinator, communication groups, stroke support groups, and stroke exercise groups.
• Secondary care services used by people who have had a stroke are diverse and may include gastrostomy clinics, spasticity clinics, and pain clinics.
• The following is an incomplete list of specialist services to which referral may be useful for people who have had a stroke:
• A chiropodist can assess the need for, and provide, foot care for people who have problems caused by paralysis and lack of movement.
• A community or district nurse can make regular home visits, for example to:
• Arrange for equipment, such as a wheelchair, commode, or hoist, to be provided through social services.
• Take blood pressure measurements.
• A community matron may be the appropriate referral for people with high-intensity needs. They can coordinate inputs from all other agencies.
• A community psychiatric nurse service may be the appropriate initial referral for people with depression, mood swings, and personality changes.
• A continence adviser can assess and treat people who have urinary or faecal incontinence.
• A dietitian can provide advice on a healthy diet. This is especially useful for people who have difficulty swallowing or are fed artificially, are underweight or overweight, or have diabetes.
• For people who have problems with everyday activities at home or work, an occupational therapist can assess, advise, and provide aids, equipment, or adaptations.
• An orthotist can provide braces which support and control weak or paralysed limbs and improve function and prevent muscles tightening.
• A physiotherapist can assess and treat mobility and movement problems caused by paralysis, muscle weakness, or poor balance.
• A speech and language therapist can assess and treat people with:
• Communication and language difficulties.
• Swallowing problems or requiring artificial feeding.

In depth