• Scenario: Suspected acute stroke: covers the management in primary care of people who present with symptoms suggestive of an acute stroke. Because transient ischaemic attack (TIA) cannot be confidently diagnosed unless the symptoms have resolved within 24 hours, people with ongoing neurological symptoms and signs suggestive of acute stroke or TIA should be treated as if they have stroke.
• Scenario: Transient ischaemic attack: covers the management in primary care of people who present with a history of neurological symptoms that have resolved within 24 hours and suggest TIA.
• Scenario: Long-term care and support: covers the principles of secondary prevention of cardiovascular disease. It also covers the complications and consequences of stroke. Although the management of complications of stroke will usually be started in secondary care and continued by specialists, new problems can present in primary care. This section summarizes the primary care assessment and management of these problems, which will often be referral to the appropriate specialist.

• This section covers the management of people presenting with ongoing neurological symptoms and signs that suggest an acute stroke or transient ischaemic attack (TIA).
• In this situation, it is not possible to differentiate between a stroke and a TIA, as TIA is a retrospective diagnosis that is made when symptoms have resolved. All people with current stroke symptoms should therefore be managed as if they have stroke.

• Urgently admit all people with suspected acute stroke:
• Particular urgency is necessary for people who might be suitable for thrombolysis or whose clinical condition is poor (e.g. depressed level of consciousness, progressing symptoms, severe headache).
• A small number of people have severe comorbidity and might not benefit from admission. If, after discussion with the person and their family or carer, a decision is made not to admit, the reasons for this should be clearly documented.
• Do not start antiplatelet treatment until haemorrhagic stroke has been ruled out by a brain scan.

In depth

• Aspirin (300 mg daily) should be started immediately, unless it is contraindicated or not tolerated, and continued at this dose until reviewed in secondary care:
• Do not delay initiating aspirin treatment in people with uncontrolled blood pressure.
• Consider gastroprotection (e.g. a proton pump inhibitor) if the person is at high risk of adverse gastrointestinal effects or experiences aspirin-induced dyspepsia.
• Consider clopidogrel (75 mg daily — unlicensed use) only if the person is allergic or cannot tolerate aspirin.
• Both aspirin and clopidogrel are contraindicated in people with active gastrointestinal bleeding or ulceration.
• For further information on antiplatelet therapy (including managing gastrointestinal issues), see the CKS topic on Antiplatelet treatment.
• For people who are already prescribed low-dose aspirin:
• Continue the current dose of aspirin until reviewed in secondary care.
• If non-compliance is suspected, start aspirin 300 mg daily immediately (see above).
• Check for unrecognized risk factors for transient ischaemic attack, such as atrial fibrillation.
• For people who have a transient ischaemic attack while on warfarin:
• Admit immediately for an urgent brain scan to exclude haemorrhagic stroke.
• Other measures for secondary prevention should be introduced as soon as the diagnosis is confirmed.

In depth

Use the ABCD² scoring system to help assess the risk of stroke early after a transient ischaemic attack:

• A — age: 60 years of age or more, 1 point.
• B — blood pressure at presentation: 140/90 mmHg or greater, 1 point.
• C — clinical features: unilateral weakness, 2 points; speech disturbance without weakness, 1 point.
• D — duration of symptoms: 60 minutes or longer, 2 points; 10–59 minutes, 1 point.
• D — presence of diabetes: 1 point.
• Points from the individual items are added to give the ABCD² score.
• People with a score of 4 or more are regarded as being at high risk of an early stroke.

In depth

• Consider admission if:
• The person has atrial fibrillation — they are at higher risk for early stroke.
• Refer immediately (the target is to be seen by a specialist and investigated within 24 hours of the start of symptoms) if:
• The person's ABCD2 score is 4 or more — they are at higher risk for early stroke.
• The person has had two or more transient ischaemic attacks (TIAs) within 1 week — they are at higher risk for early stroke.
• The person is on anticoagulation treatment — brain imaging is required to exclude intracranial bleeding.
• Consider immediate referral if:
• The person has recurrent TIAs more than 1 week apart — they are at higher risk for early stroke.
• Refer urgently (the target is to be seen by a specialist and investigated within 1 week of the onset of symptoms) if:
• The person presents sufficiently early and is at lower risk of an early stroke, that is has both:
• An ABCD2 score of 3 or less.
• No other TIAs within the past week.

In depth

Follow local arrangements on which tests should be done in primary care:

• For people with a transient ischaemic attack and at low risk for early stroke, consider arranging the following tests to be done before they are seen in secondary care:
• Blood tests:
• Full blood count.
• Urea and electrolytes.
• Glucose.
• Lipid profile.
• Liver function tests.
• Thyroid-stimulating hormone (TSH).
• Electrocardiography if there are signs of atrial fibrillation, such as an irregular pulse.

In depth

• Provide information about the mechanisms and causes of transient ischaemic attacks (TIAs).
• Advise on the need for people with a TIA to have immediate antithrombotic treatment to reduce the risk of having a stroke within the next few days or weeks. For most people, the appropriate treatment is aspirin.
• Explain to people that they need specialist assessment and treatment and that they need to be seen urgently, within 24 hours, if the imminent risk for a stroke is high:
• The assessment is to clarify the diagnosis (and revise it if necessary), determine the cause of the TIA, and decide what further investigations and treatments are needed.
• Everyone will need blood tests and electrocardiography (ECG). Many people will need a brain scan and/or a scan of their carotid arteries. Some people will need other tests, for example chest radiography, echocardiography, or ambulatory ECG monitoring.
• People with atrial fibrillation or artificial heart valves will usually need anticoagulation (if they not are already on it).
• Advise that, after the specialist assessment and treatment, they can reduce their risk of future stroke and other cardiovascular events by adopting a healthier lifestyle and taking drugs to reduce certain risk factors. For details, see Prevention.
• Advise on driving restrictions:
• The person should not drive until they have been assessed by a specialist (when definitive guidance will be given).
• Driving is not permitted until at least 1 month after a TIA.
• Return to driving should be discussed with the GP or stroke team.
• People who have had a TIA and hold a heavy goods vehicle licence must contact the Driver and Vehicle Licensing Agency.
• For more details, see Driving after a stroke or TIA.
• Additional information and advice is available from the Stroke Association:
• Stroke Information Service, The Stroke Association, 240 City Road, London EC1V 2PR
• Online: www.stroke.org.uk
• Helpline: 0845 3033 100 (calls charged at local rate, open Monday to Friday, 9 a.m. to 5 p.m.)

In depth

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