Stroke and TIA Notes

8/18/2019 Stroke and TIA Notes

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Stroke and TIA - Summary

• Strokes and transient ischaemic attacks (TIAs) are acute

neurological events, presumed to be vascular in origin, that are

caused by cerebral ischaemia, infarction, or haemorrhage.

• Symptoms and signs develop rapidly, are usually focal, and

include numbness, eakness or paralysis, slurred speech, and

visual disturbances. !eadache is not a typical feature of

ischaemic stroke or TIA.

o "ith stroke, the symptoms and signs persist beyond

#$ hours or cause death ithin #$ hours.

o "ith TIA, the symptoms and signs resolve ithin

#$ hours.

• Strokes can be classi%ed by their main causes as either

ischaemic (&' of cases) or haemorrhagic (' of cases).

• Stroke is the third most common cause of death in the *+.

ost strokes occur in people older than ' years, but they can

occur at any age.

• The complications and conseuences of stroke are numerous

and include neurological problems, depression and an/iety,

speech and communication di0culties, and di0culties ith

activities of daily living.

•

The risk of recurrent vascular events varies considerablyamong individuals and depends on the underlying pathology,

comorbidities, and lifestyle factors.

• anagement of a suspected acute stroke in primary care

includes urgent admission (ithin one hour) to a specialist stroke

unit1

o Antiplatelet treatment should not be started until

haemorrhagic stroke has been ruled out by a brain scan.


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o If the person is eligible for thrombolysis (up to hours

from the start of the symptom), the ambulance control should

be informed so that the person is taken immediately to the

nearest specialist stroke unit for stroke thrombolysis.

• After a stroke, follo up should be arranged ithin eeks of

discharge and then annually to1

o Assess the need for further specialist revie, advice,

information and support.

o Assess social care and health care needs.

o 2heck and optimi3e lifestyle measures, and drug

treatments for secondary prevention of cardiovascular disease.

• anagement of a TIA in primary care includes assessing the

risk of an early stroke using the A425# scoring system.

• If the person is at high risk of an early stroke after a TIA they

should be1

o 6eferred for specialist assessment ithin #$ hours of the

onset of symptoms.

o 7iven an antiplatelet and a statin.

• If the person is at lo risk of an early stroke after a TIA they

should be1

o 6eferred for specialist assessment as soon as possible,

but de%nitely ithin one eek of onset of symptoms.

o 7iven an antiplatelet and a statin.

• After a TIA, follo up should be arranged ithin month (in

primary or secondary care) and then annually in primary care to

check and optimi3e lifestyle measures, and drug treatments for

secondary prevention of cardiovascular disease.


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5e%nition

"hat are strokes and transient ischaemic attacks8

• Stroke is de%ned as a clinical syndrome, caused by cerebral

infarction or haemorrhage, typi%ed by rapidly developing signs of

focal and global disturbance of cerebral functions lasting more

than #$ hours or leading to death.

o Non-disabling stroke is a stroke ith symptoms or

signs that last for more than #$ hours but resolve later, leaving

no permanent disability.

o Disabling stroke is a stroke hich leaves the person

unable to carry out all their usual activities.

o Minor stroke is stroke ith fe mild symptoms on

initial assessment.

o Subarachnoid haemorrhage although it is classi%ed

as a type of stroke, subarachnoid haemorrhage is not usually

included in guidelines on stroke diagnosis and management.

o Stroke with rapid recovery can only be distinguished

from a transient ischaemic attack (TIA) retrospectively and,

apart from guiding investigation to e/clude other conditions, is

of little clinical importance.

• Transient ischaemic attack is de%ned as an acute loss of

cerebral or ocular function ith symptoms lasting less than #$hours caused by an inadeuate cerebral or ocular blood supply as

a result of lo blood 9o, ischaemia, or embolism associated ith

disease of the blood vessels, heart or blood.

o The symptoms and signs of a TIA usually resolve ithin

minutes, or may last a fe hours. Therefore, people ho have

continuing neurological signs hen %rst assessed should be

assumed to have had a stroke.


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2auses and classi%cation

2auses and classi%cation of strokes

Strokes can be classifed by their main causes as either

ischaemic (most common) or haemorrhagic

• !schaemic stroke"

o Ischaemic strokes are caused hen a blood vessel in the

brain is blocked, for e/ample by a blood clot or by the fatty

material from an atherosclerotic plaue. The brain cells in the

part of the brain served by the a:ected blood vessel die of lack

of o/ygen and nutrients.

o There are to main types of ischaemic stroke ;

thrombotic and embolic1

Thrombotic ischaemic stroke ; a blood clot

spontaneously forms in an artery in the brain. This is a

common complication of atherosclerosis.

#mbolic ischaemic stroke ; part of the fatty

material from an atherosclerotic plaue or a clot in a larger

artery or the heart breaks o: and travels donstream until it

is trapped in a narroer artery in the brain.


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Subarachnoid haemorrhagic stroke ; there is

bleeding from a blood vessel beteen the surface of the

brain and the arachnoid tissues that cover the brain.

o Some e/perts do not classify subarachnoid haemorrhage

as stroke because subarachnoid haemorrhages present

di:erently from ischaemic strokes and intracerebral

haemorrhagic strokes, and they reuire particular

management. !oever, both acute strokes and subarachnoid

haemorrhages need emergency admission. So, regardless of

hether subarachnoid haemorrhage is considered stroke, the

primary care management is the same.

• About &' of strokes are ischaemic, and about ' are

haemorrhagic.

2omplications

"hat are the complications and conseuences ofstroke8

• The complications and conse%uences o& stroke include"

o =eurological problems ; balance, movement, tone,

sensation.

o >ain ; neuropathic, shoulder pain and sublu/ation,

musculoskeletal pain.

o 5epression, an/iety, emotionalism, disturbed socialinteraction ; also disinhibition, aggression.

o 2ognitive impairments 1

Attention and concentration.

emory.

5isturbances of spatial aareness ; neglect.

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5isturbance of perception ; visual agnosia.

Apra/ia ; loss of the conceptual ability to

organi3e activities to achieve a goal.

>lanning, organi3ing, initiating, and monitoring

behaviour (i.e. disturbances of e/ecutive functioning).

o Speech and communication di0culties ; aphasia,

dysarthria, apra/ia of speech.

o ?isual impairments and hemianopia .

o 4ladder and boel problems ; urinary incontinence,faecal incontinence, constipation.

o Salloing problems, oral health, malnutrition,

dehydration ; oral health, malnutrition, dehydration.

o Se/ual dysfunction .

o 5i0culties ith activities of daily living ; personal,

social, and vocational.

>rognosis

"hat is the prognosis after a stroke or transientischaemic attack8

• The risk of recurrent vascular events varies considerably

among individuals and depends on the underlying pathology,

comorbidities, and lifestyle factors.

After a TIA1 risk of early stroke

What factors are associated with increased risk of stroke

soon after a TIA?

• >eople ho have had a transient ischaemic attack (TIA) are at

increased risk of having a subseuent stroke in the %rst month of

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the event and up to one year afterards @Intercollegiate Stroke

"orking >arty, ##B1

o A systematic revie and meta-analysis reported that the

pooled risk of stroke ithin # days as C. (D' 2I #. to $.)

and ithin E days '.# (D' 2I C.D to .') @7iles and 6othell,

#EB.

• The early risk of stroke is increased in people ith1

o Increased blood pressure (i.e. sustained above

CFD mm!g).

o !yperlipidaemia.

o 5iabetes mellitus.

o Atrial %brillation and other cardiac arrhythmias.

o Structural cardiac disease.

o 2arotid artery stenosis.

o Gifestyle factors including smoking, e/ercise, eating and

dietary habits, and alcohol consumption.

• 2onsider people at particularly high risk for a subseuent

stroke if they have any of the folloing1

o An A425# score of $ or more ; see Assessing risk of

stroke after TIA.

o Atrial %brillation.

o ore than one TIA in one eek.

o A TIA hile on an anticoagulant.

[National Collaborating Centre for Chronic Conditions, 2008; Intercollegiate Stroke Working Party,

2012]

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After a TIA1 risk (longer term) of 2?5 events

After a TIA, what is the longer-term risk of subsequent

cardiovascular disease events and death?

• 2on%rmed episodes of transient ischaemic attack (TIA)

indicate established cardiovascular disease, ith an increased

risk of future cardiovascular events. Holloing an initial TIA, it has

been estimated that @"arlo and 5avenport, DD Adams et al,

#CB1

o The annual risk of myocardial infarction is #JC, and

C' of people ho have had a TIA ill eventually die of cardiac

disease.

o The combined risk of stroke, myocardial infarction, or

vascular death is about D per year.

o About #J$ of people ho have had a TIA or

ischaemic stroke have asymptomatic coronary heart disease.

• A study of #$$E people enrolled in the 5utch TIA trial (ith a

mean of ' years of age) found that over a mean of years @van"iKk et al, #'B1

o Appro/imately had died.

o Almost '$ had e/perienced at least one ne vascular

event.

o After the %rst C months, the risk of a further vascular

event declined over the ne/t C years, but then increased overthe folloing years. The authors noted that this could be due to

poor compliance ith drugs and less care being taken over

lifestyle issues, as ell as increasing age.

After a stroke1 risks of death and dependency

After a stroke, what is the prognosis for survival and

functional status?

Immediate prognosis

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• Survival" the inpatient death rate for people admitted ith a

stroke as found to be about #$ @=ational Audit L0ce, #'B.

• #arly recurrent stroke" the risk of stroke recurring ithin

C days of an ischaemic stroke as found to depend on the cause

of the stroke1

o About # for stroke caused by large-vessel cervical or

intracranial atherosclerosis ith stenosis.

o About ' for cardioembolic stroke.

o About for lacunar stroke (caused by blockage of a

small non-branching end artery deep in the brain).

o About C for stroke of uncertain cause @>etty et al,

#B.

• 'unctional status" around half of stroke survivors ere left

dependent on others for everyday activities @=ational Audit L0ce,

#'B.

Long-term prognosis

• Survival" a study in >erth, Australia, found that, having

survived C days after a stroke, the risk of dying in the ne/t

years of1

o 6ecurrent stroke as about #'.

o A cardiovascular event (e/cluding stroke) as about

CC @!ardie et al, #CB.

• !mpact o& &unctional status on long-term survival"

o The median survival time for people after an ischaemic

stroke months previously as longer in those ho ere

independent in activities of daily living1

If independent, D.E years (D' 2I &.D to .).

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If dependent, . years (D' 2I '.E to .$) @Slot et

al, #&B.

Lngoing neurological de%cit!o do I assess the cause of a sudden onset ongoingneurological de%cit8

Suspect stroke in anyone presenting with an acute onset

ongoing &ocal neurological defcit that cannot be eplained

byhypoglycaemia or other stroke mimics"

• #specially i& they &ail the '*ST ('ace *rm Speech

Time) test because o&"

o 'acial weakness"

Ask the person to smile or sho their teeth.

The HAST test is failed if there is ne facial

asymmetry such as the mouth or eye droops.

o *rm weakness"

6aise the personMs arms to DN if they are sitting

or $'N if they are lying. Ask the person to maintain the

position hen you let go.

The HAST test is failed if, hen you let go, one arm

falls or drifts don.

o Speech problems"

Involve the person in conversation and determine

hether the speech is slurred or the person has di0culty

%nding the name for commonplace obKects (for e/ample,

cup, table, chair, keys, pen). If they have di0culty seeing,

place the obKects in their hands. If they have a companion,

check hether this is a ne problem.

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The HAST test is failed if there is a ne

une/plained speech problem.

• *lso suspect stroke in people who have an otherwise

uneplained sudden onset o& an ongoing neurological

defcit such as a1

o ?isual %eld defect.

o 5isorder of balance.

o 2oordination disorder.

o *nilateral eakness con%ned to the leg.

o 5isorder of perception.

Scenario1 Suspected acute stroke

Scenario1 Suspected acute stroke due to ongoingneurological de%cit

Age from 16 years onwards

>re-admission management

How should I manage someone presenting with an acute

stroke?

'or people diagnosed with suspected stroke"

• *rrange emergency admission within one hour to a

specialist stroke unit"

o 7reater urgency may be necessary if their clinical

condition is poor (for e/ample, depressed level of

consciousness, progressing symptoms, severe headache).

o If the diagnosis is made by a telephone consultation tell

them to dial DDD for an ambulance.

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o A small number of people ith a severe comorbidity

might not bene%t from admission. If, after discussion ith the

person and their family or carer, a decision is made not to

admit, the reasons for this should be clearly documented.

• 'or people with symptoms starting within the last si

hours"

o


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o 'or atrial fbrillation If in doubt arrange an


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o >resent more than a eek after their last symptoms

have resolved.

anaging high risk of stroke after TIA

How should I manage someone at high risk of stroke

following a transient ischaemic attack?

'or people at high risk o& a stroke &ollowing a transient

ischaemic attack (T!*)"

• 0e&er &or specialist assessment within .1 hours o& the

onset o& symptoms

• 2ive a statin such as simvastatin $ mg.

• 2ive an antiplatelet drug unless they are taking an

anticoagulant drug, hen they should be admitted immediately

ithout giving treatment.

o !& they are not taking an anticoagulant or an

antiplatelet drug immediately give either clopidogrel

344 mg (o5-label use) or aspirin 344mg

5o not delay treatment in people ith

uncontrolled blood pressure.

2onsider prescribing a proton pump inhibitor if the

person is at high risk of gastrointestinal adverse e:ects.

Hor further information on antiplatelet therapy

(including managing adverse e:ects), see the 2+S topic

onAntiplatelet treatment.

o !& they are taking low-dose aspirin regularly

continue the current dose o& aspirin until revieed by a

specialist.

If non-compliance is suspected, give either

clopidogrel C mg or aspirin C mg.

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• *dvise them not to drive until they have been seen by a

specialist (hen de%nitive guidance ill be given).

anaging lo risk of stroke after TIAHow should I manage someone at low risk of a stroke

following a transient ischaemic attack?

'or people at low risk o& a stroke &ollowing a transient

ischaemic attack"

• 0e&er &or specialist assessment as soon as possible

but defnitely within one week o& onset o& symptoms

• 2ive a statin such as simvastatin $ mg daily.

• 2ive an antiplatelet drug

o !& they are not taking an antiplatelet drug

immediately give either clopidogrel (o5-label use) or

aspirin (each as a 344 mg loading dose and 67 mg daily

therea&ter until they have been had been reviewed by a

specialist)

5o not delay initiating aspirin treatment in people

ith uncontrolled blood pressure.

2onsider prescribing a proton pump inhibitor if the

person is at high risk of adverse gastrointestinal e:ects or

e/periences aspirin-induced dyspepsia.

Hor further information on antiplatelet therapy

(including managing adverse e:ects), see the 2+S topic

onAntiplatelet treatment.

o !& they are taking low-dose aspirin regularly

continue the current dose o& aspirin until reviewed by a

specialist

If non-compliance is suspected, give either

clopidogrel or aspirin (each as a C mg loading dose and E'

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mg daily thereafter until they have been had been revieed

by a specialist).

• onsider assessing and managing cardiovascular

disease risk &actors hile aaiting specialist revie. Hor further

information see the 2+S topic on 2?5 risk assessment and

management.

• *dvise them not to drive until they have been seen by a

specialist (hen de%nitive guidance ill be given).

Scenario1 2on%rmed stroke - long-term

care and support

Age from 16 years onwards

Hollo up

When and how should I follow up someone who has had a

stroke?

Following a stroke:

• "here there are no problems reuiring more freuent

assessments, schedule primary care follo up ithin eeks of

discharge, again ithin months of discharge, and then annually

to1

o Assess the need for further specialist revie, advice,

information, support, and rehabilitation ; see 6eferral

guidance.

o Assess social care needs.

o Assess health care needs .

o 2heck and optimi3e lifestyle measures for secondary

prevention of cardiovascular disease.

o 2heck and optimi3e drug treatments for secondaryprevention of cardiovascular disease.

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• >rovide advice about driving after a stroke if appropriate.

• >rovide advice about returning to ork after a stroke if

appropriate.

• Annually check and the record blood pressure and lipid pro%le.

• Arrange annual pre-inter in9uen3a immuni3ations.

Assessing health care needs

How should I assess the health care needs of a person who

has had a stroke?

• "hen people ith a history of stroke consult (for hateverreason), be alert for problems that may reuire ne assessment

and management1

o =eurological problems ; balance, movement, tone,

sensation, poer.

o >ain ; neuropathic, shoulder pain and sublu/ation,

musculoskeletal pain.

o 5epression, an/iety, emotionalism, disturbed social

interaction ; depression, an/iety, emotionalism, disinhibition,

aggression.

o 2ognitive impairments 1

Attention and concentration.

emory.

5isturbances of spatial aareness ; neglect.

5isturbance of perception ; visual agnosia.

Apra/ia ; loss of the conceptual ability to

organi3e activities to achieve a goal.

>lanning, organi3ing, initiating, and monitoringbehaviour (i.e. disturbances of e/ecutive functioning).

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o Speech and communication di0culties ; aphasia,

dysarthria, apra/ia of speech.

o ?isual impairments and hemianopia .

o 4ladder and boel problems ; urinary incontinence,

faecal incontinence, constipation.

o Salloing problems, oral health, malnutrition,

dehydration ; oral health, malnutrition, dehydration, arti%cial

feeding, and the ability to take medication.

o Se/ual dysfunction .

o 5i0culties ith activities of daily living ; personal,

social, and vocational1

There is a separate section on 5riving after a

stroke.

• any of the problems reuire referral to a specialist service.

Specialist services and the problems that they can manage are

summari3ed in the section 6eferral guidance.

eurological problems

• ,alance impairment"

o 4alance training and alking aids should be considered

for people ith balance impairment.

o any people have impaired balance after a stroke. This

is due to a combination of1

6educed limb and trunk motor control.

Altered sensation on one side.

Altered representation in the brain of the body and

posture, often associated ith left visual and spatial neglect.

• 'alls and in8ury prevention"

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o Halls and inKury prevention, and assessment of bone

health, should be part of every stroke rehabilitation plan.

o Training on ho to get up after a fall should be provided

for the person and their carers.

o Hor more information, see the 2+S topic on Halls - risk

assessment.

• 0educed movement weakness clumsiness (motor

control impairment)"

o >eople ith impaired motor control should be referred to

a physiotherapist ith e/perience in neurodisability.

o "eakness on one side (hemiparesis) is probably the

single most disabling factor after a stroke.

• !mpaired tone 9 spasticity and spasms"

o Anyone ith motor eakness after a stroke should be

assessed for spasticity.

There is considerable debate on the de%nition,

physiology, and importance of spasticity.

Hor clinical purposes, consider spasticity to be a

problem if there is increased tone, abnormal posturing, or

involuntary spasms, and if this causes discomfort or limited

activity for the person or di0culty for the carer.

o Spasticity can be treated by1


20/51

Antispastic drugs (for generali3ed spasticity). Hirst

try baclofen, gabapentin, or ti3anidine.

If adeuate control cannot be achieved ith one of

these drugs, refer to a specialist ith e/pertise in managing

spasticity ho can consider trying combinations of these

drugs or other treatments.

o Splinting of the arm and hand should not be used

routinely after stroke.

• !mpaired sensation"

o >eople ith marked sensory loss but good motor

function should be taught ho to take care of the limb and

avoid accidental inKury.

o Touch, position sense, pain and other sensations may be

impaired after a stroke. Its severity is probably associated ith

the e/tent of motor loss.

!ain

• Neuropathic pain"

o Hive percent to # of people e/perience neuropathic

pain after a stroke.

o It can occur together ith spasticity or sensory loss. It is

(in principle) separate from musculoskeletal pain.

o


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o Hor more information on drug treatments for

neuropathic pain, see the 2+S topic on =europathic pain - drug

treatment.

o >eople ith pain that is poorly controlled ithin a fe

eeks should be referred to a specialist in pain management.

• Shoulder pain and subluation"

o >eople ith arm eakness after a stroke should be

asked about shoulder pain from time to time.

o >eople ith shoulder pain and their carers should have

advice on position and handling the eak arm ; overhead arm

slings and shoulder supports should not be used.

o L:er simple analgesics (for e/ample, paracetamol, a

nonsteroidal anti-in9ammatory drug @=SAI5B ith a proton

pump inhibitor @>>IB for gastroprotection) to people ith

shoulder pain ; intra-articular corticosteroids should not be

used.

o 2onsider referring people ith persistent troublesome

shoulder pain for specialist treatments such as shoulder

strapping, high-intensity transcutaneous nerve stimulation, and

functional electrical stimulation.

• Musculoskeletal pain other than shoulder pain"

o After a stroke, immobility and abnormal posture can

cause pain, especially in people ho have osteoarthritis orin9ammatory arthritis.

o eople ith musculoskeletal pain should be assessed to

determine hether the pain can be reduced by improvements

in handling techniues, posture or movement.

o L:er simple analgesics to be taken regularly1

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>aracetamol, up to g four times daily.

An =SAI5 ; together ith a >>I for

gastroprotection. The recommendation to routinely use a >>I

is in line ith =I2< guidelines.

2odeine or similar morphine derivative.

"epression, an#iet$, emotionalism, disturbed social

interaction

• ood disturbance is common after a stroke and presents as

depression, an/iety, or both.

• The severity of mood disturbance is associated ith the

severity of cognitive impairments, motor impairments, and

limitation of activity.

• ood disturbances can e/acerbate other impairments and

limit the recovery of function.

• Depression"

o 5epression is common but often remits as function is

recovered.

o eople ith depression should be screened for an/iety

and emotionalism.

o >eople ith depression su0cient to cause distress or

impede rehabilitation and not responding to primary care

management should be assessed by an e/pert (for e/ample, a

clinical psychologist, appropriately trained stroke physician,

psychiatrist).

o 2ontributory factors (for e/ample, pain, social isolation)

should be addressed.


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o >eople ith minor depression should be1

onitored for progression.

Involved in increased social interaction, increasede/ercise, goal setting, and other psychosocial interventions.

o >eople ith more severe or persistent depression should

be o:ered one or more of1

Antidepressant drug treatment, to be monitored,

and continued for at least months if a bene%t is achieved.

>sychological therapy.

o Hor more information, see the 2+S topic on 5epression.

• *niety"

o An/iety after stroke is often focused on fear of falling

and fear of recurrence.

o


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o Stroke infreuently causes disinhibited or aggressive

behaviour.

o >eople hose style of social interaction after a stroke

causes distress to others should be assessed by a clinical

psychologist, and other specialists (for e/ample, psychiatrist or

speech and language therapist) if necessary.

o anagement may include1

Information and advice for the person, their

family, and others in contact socially or professionally.

Treatment of causal or aggravating factors (for

e/ample, an antidepressant or an antipsychotic).

%ognitive impairments

• 2eneral"

o Almost all people ith cerebrovascular disease have

some degree of cognitive loss.

o


25/51

o >eople ith cognitive impairment should be formally

assessed by a specialist.

o The approach to management should include1

Identi%cation and, if possible, removal of any

causative or aggravating factors (e.g. drugs,

hypothyroidism).

Information and advice for the person and their

family and carers.

Teaching of strategies to compensate for the

impairment (e.g. using notebooks, diaries, audiotapes,

electronic organi3ers, and audio alarms).

• *ttention and concentration"

o 5isturbed alertness is common after stroke, especially in

the initial period of recovery, and ith right cerebral

hemisphere strokes, hen it can be asymmetrical ith the left

side more severely a:ected.

• Memory"

o Almost all people ho have had a stroke e/perience

memory di0culties. About # of people ho survive for

months after a stroke have dementia.

• Disturbances o& spatial awareness 9 neglect"

o 5isturbances of spatial aareness are more common in

people ith right cerebral hemisphere brain damage and

hemianopia. The person acts as if they have reduced

aareness of some part of their environment, usually the left

side.

• Disturbance o& perception 9 visual agnosia"

o

After a stroke, some people have a speci%c di0culty inrecogni3ing obKects (agnosia). Agnosia is usually visual.


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o 4ehaviours due to visual agnosia can be mistakenly

attributed to impaired memory, language, or deliberate

pretence.

• *praia 9 loss o& the conceptual ability to organi:e

activities to achieve a goal"

o >eople ith motor apra/ia have di0culty in carrying out

tasks, such as making a hot drink, despite adeuate sensation

and muscle strength.

o Apra/ia is usually associated ith damage to the left

cerebral hemisphere.

o Any person found to have apra/ia should1

!ave their pro%le of impaired and preserved

action abilities determined using a standardised approach

(for e/ample, Test of *pper Gimb Apra/ia (T*GIA))

!ave the impairment and the impact on function

e/plained to them, their family, and their treating team

4e given therapies andFor taught compensatory

strategies speci%c to the de%cits.

• Disturbances o& eecutive &unctioning"

o M


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&peech and communication di'culties

People with speech difficulties should be referred to a speech and language therapist for assessment

and treatment:

• *phasia 9 impairment o& language"

o Aphasia (also knon as dysphasia) is a speci%c

impairment of language function the ability to form and

understand ords, hether orally or in riting.

o Aphasia is associated ith damage to the dominant

cerebral hemisphere (usually the left). Subtle di0culties ith

communication can occur ith damage to the non-dominant

cerebral hemisphere.

• Dysarthria"

o 5ysarthria occurs hen control over the muscles

responsible for speech is impaired. Speech is slurred.

5ysarthria is often associated ith salloing di0culties

(dysphagia).

• *praia o& speech"

o A small proportion of people ith stroke have speci%c

impairment of the ability to plan and e/ecute the multiple

skilled motor tasks reuired for successful talking this is

apra/ia of speech. It is usually associated ith damage to the

left cerebral hemisphere.

(isual impairments and hemianopia

• Stroke often causes visual problems, such as diplopia (due to

disruption of control of eye movement), nystagmus, blurred

vision, loss of depth perception, visual agnosia (di0culty in

recogni3ing obKects), and visuospatial neglect.

• Goss of part of a visual %eld (hemianopia) is also common.


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• Age-related visual problems may also be present and include

cataract, glaucoma, macular degeneration, and uncorrected

refractive errors.

• eople ith a visual %eld defect should be1

o Informed about the conseuences for driving ; see the

section on 5riving after a stroke.

o Taught compensatory techniues if the defect causes

practical problems ; this may reuire referral.

• Treatment ith prisms should only be considered if the person

is aare that prisms might not have any bene%t for them and if

the treatment is provided and evaluated by an e/pert.

)ladder and bowel problems

• ,owel and bladder impairment"

o 5isturbance of control of e/cretion is common in the

acute phase of a stroke and remains a problem for a signi%cant

minority of people.

• !ncontinence"

o Incontinence is demeaning for the person, is a maKor

stress factor for carers, and greatly increases the risk of skin

pressure ulceration.

o >eople ith urinary or faecal incontinence should only

be discharged home after the person and their carer have been

trained and arrangements for continuing supply of continence

aids and services have been put in place.

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o >eople ith di0culty in salloing should be assessed

by a speech and language therapist, or other appropriately

trained professional. anagement often reuires a

multidisciplinary team.

o All people ho are not salloing should have oral and

dental hygiene maintained (by the person or their carers)

through regular (for e/ample, $-hourly) removal of secretions

and brushing of teeth or dentures.

o >eople ho have been assessed for salloing

problems may need to be reassessed.

• Nutritional problems"

o alnutrition, poor nutrition, and dehydration are

common in people ho have had a stroke1

To identify adults ho are malnourished, at risk of

malnutrition (undernutrition), or obese, the alnutrition

*niversal Screening Tool (*ST) is recommended.

*ST also includes management guidelines hich

can be used to develop a care plan, and is available online

at.bapen.org.uk.

The management of people being arti%cially fed

should be checked.

Lnce nutritional status has been checked,

consider supplementation ith vitamin 5C and calcium ifthere is a risk of de%ciency (particularly if the person is

house bound or are living in a care home).

o Hor problems that need specialist assessment,

treatment, and support in the community, consider referral to a

dietitian or a speech and language therapist.

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&e#ual d$sfunction

• In people ho have had a stroke, se/ual dysfunction is

common for many reasons, including altered sensation, limited

mobility, e:ects of drugs, and changes in mood.

• >eople ho have had a stroke should be asked, at an

appropriate moment, hether they have any concerns about their

se/ual functioning.

• >eople ho reuest help should be1

o 6eassured that se/ual activity is not contraindicated

after a stroke and is e/tremely unlikely to precipitate a further

event.

o Assessed for treatable causes.

o Assessed for the use of a phosphodiesterase type '

inhibitor, such as sildena%l (although these drugs should not be

prescribed for C months after a stroke and until blood pressure

is controlled).

o Advised about ays to overcome practical problems.

o 6eferred to a person ith e/pertise in managing se/ual

dysfunction if problems persist despite primary care

management.

• Hor more information, see the 2+S topic on


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o 5i0culties ith e/tended activities of daily living,

including domestic and community social activities.

o 5i0culties ith vocational activities of daily living,

including productive ork and leisure activities.

• >eople ho have had a stroke should be formally assessed (by

a therapist or nurse) for their safety and independence in all

activities of daily living.

• >eople ho have limitations on any aspect of the activities of

daily living should be referred to an occupational therapist ith

e/perience in neurological disabilities.

• anagement may include1

o Information and advice on coping ith the disabilities.

o Aids, euipment, and home or ork adaptations to

achieve safe activities (and the training needed to use the aids,

euipment, and adaptations).

• There is a separate section on 5riving after a stroke.

Gifestyle advice for secondary prevention

What lifest$le advice should be o*ered following a stroke to

reduce cardiovascular disease risk?

• Advise lifestyle measures that may reduce the risk of stroke

and other cardiovascular disease events, including1

o Stopping smoking.

o Adopting a cardioprotective diet, including reducing salt

intake.

o 6egular e/ercise.

o >rudent use of alcohol ; men should drink no more than

three units per day, and omen no more than to units per

day, ith at least # alcohol-free days per eek.

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o Achieving and maintaining a satisfactory body eight.

• 4ecause lifestyle changes can be a maKor challenge, consider

measures to support behaviour change.

• Hor more information, see the OOGinkOO in the 2+S topic on 2?5

risk assessment and management.

5rug treatments for secondary prevention

What drug treatment should be o*ered following a stroke to

reduce cardiovascular disease risk?

Cardiovascular disease risk will normally be assessed, and treatment initiated in secondary care.

Following discharge for a stroke:

• #nsure optimal management o&"

o *trial fbrillation if present. Hor detailed management

advice see the 2+S topic on Atrial %brillation.

o Diabetes if present. Hor detailed management advice

see the 2+S topic on 5iabetes - type #.

o $ypertension if present. Treatment should be started

prior to discharge from hospital or # eeks after the stroke

(hich ever is the soonest), unless a hypertensive emergency

reuires urgent reduction in blood pressure.

Aim to reduce blood pressure to $FD mm!g or

less, and preferably to CF& mm!g.

Hor people ith bilateral, severe (more than E)stenosis of the internal carotid arteries, a slightly higher

target blood pressure (e.g. systolic blood pressure CJ

' mm!g) may be appropriate.

Hor detailed management advice see the 2+S

topic on !ypertension - not diabetic.

• #nsure an antiplatelet drug has been o5ered unless the

person has an indication for an anticoagulant for e/ample

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because they are in atrial %brillation or they have had a cerebral

venous thrombosis.

o *spirin 344 mg daily &or . weeks is given

immediately a&ter an ischaemic stroke is con%rmed by

brain imaging.

o lopidogrel 67 mg daily is then given long-term if

it can be tolerated and is not contraindicated.

2onsider 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.

Hor further information on ho is at high risk of

gastrointestinal bleeding and prescribing issues on

antiplatelet therapy (including managing gastrointestinal

issues), see the 2+S topic on Antiplatelet treatment.

o If clopidogrel is contraindicated or not tolerated, give a

combination of modi%ed-release dipyridamole (# mg ticedaily) and lo dose aspirin.

o If both clopidogrel and modi%ed-release dipyridamole

are contraindicated or not tolerated, give aspirin alone.

o If both clopidogrel and aspirin are contraindicated or not

tolerated, give modi%ed-release dipyridamole alone.

•

#nsure a statin has been o5ered This is normally started$& hours after an acute stroke.

o Seek specialist advice before initiating a statin in people

ith a history of haemorrhagic stroke, particularly those ith

inadeuately controlled hypertension.

o 6echeck the cholesterol one to three months after

starting treatment and increase treatment if the cholesterol is

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more than $ mmolFG or lo-density lipoprotein (G5G) cholesterol

is more than # mmolFG.

Hor further information see the 2+S topic on Gipid

modi%cation - 2?5 prevention.

Managing atrial fibrillation and diabetes after a stroke

• *trial fbrillation

o The recommendation to manage atrial %brillation is

based on pragmatic 2+S advice. Stroke and thromboembolism

are the main complications of atrial %brillation (AH) @=ational

2ollaborating 2entre for 2hronic 2onditions, #B. >eople ithAH have a %ve-fold greater risk of stroke and thromboembolism

than people ithout AH @=I2


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control or placebo, had any bene%cial e:ect on mortality,

dependency, or stroke recurrence. 4ecause there are also

concerns about possible adverse e:ects ith early reduction in

blood pressure, =I2< recommends starting antihypertensive

treatment in people ith acute stroke only if there is a

hypertensive emergency.

o The recommendation to ait about # eeks before

starting treatment ith an antihypertensive for people ho

have had an acute stroke is based on e/pert opinion from a

revie article @Sudlo, #&B. After an acute stroke blood

pressure tends to fall spontaneously. It is thought that aiting

until blood pressure has stabilised to start an antihypertensiveloers the risk of reducing cerebral perfusion @Sudlo, #&B.

• ,lood pressure targets"

o The recommended blood pressure targets are those

recommended by guidelines published by =I2< and the 62>

I2S"> @=I2

guideline recommends a blood pressure target of

CF& mm!g based on e/pert opinion from the Point 4ritish

!ypertension Society @4!S, #$ Intercollegiate Stroke

"orking >arty, ## B. This blood pressure target is also

advocated by the Point 4ritish Societies guideline @4ritish

2ardiac Society et al, #'B.

A higher target blood pressure (for e/ample,

systolic blood pressure of ' mm!g) for people ith

bilateral severe carotid artery stenosis is recommended by

the 62> I2S"> guidelines @Intercollegiate Stroke "orking>arty, ##B. =o evidence suggests that people ith severe

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stenosis should have a systolic blood pressure more than

' mm!g.

Antiplatelet treatment after a stroke

•


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disease and speci%cally cerebrovascular disease @!eart >rotection

Study 2ollaborative 7roup, ##Amarenco et al, #B.

o In the !eart >rotection Study (!>S), taking simvastatin

$ mg daily (given to people at high risk of cardiovascular

events) resulted in a relative risk reduction of E in vascular

deaths, #E in maKor coronary events and #' in stroke.

o In a second study, atorvastatin & mg daily (given to

people ith a history of TIA or stroke in the preceding

months) resulted in a relative risk reduction of ' in stroke

and C' in maKor coronary events @Amarenco et al, #B.

• /rescribing statins &or people who have had a

haemorrhagic stroke"

o The 62> I2S"> recommended that statins should be

prescribed ith caution, if at all, in people ho have had a

haemorrhagic stroke, particularly if they have inadeuately

controlled hypertension @Intercollegiate Stroke "orking >arty,

##B1

The manufacturer of atorvastatin arns that, for

people ith prior haemorrhagic stroke or lacunar infarct, the

balance of risks and bene%ts of atorvastatin & mg is

uncertain and the potential risk of haemorrhagic stroke

should be considered carefully before initiating treatment

@>%3er Gtd, #E A4>I edicines 2ompendium, #$B.

o Lne meta-analysis found the evidence for statins

causing haemorrhagic stroke to be uncertain @Ga and

6udnicka, #B. 2ohort studies shoed an association hile

randomi3ed trials ere uninformative because the con%dence

intervals on the summary estimate ere too ide. !oever,

the authors concluded that the possible risk is greatly

outeighed by the protective e:ect against thromboembolic

stroke and coronary artery disease.

o Lne study found that the risk of haemorrhagic strokeas increased in people ho ere taking atorvastatin1 ha3ard

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ratio .&, D' 2I .D to #.'D p Q .# @7oldstein et al,

#&B.

o 2+S therefore recommends seeking specialist advice

before prescribing a statin for people ho have had a

haemorrhagic stroke, particularly if they have uncontrolled high

blood pressure.

5riving after a stroke

What should I advise about driving after a stroke?

• *lways consult the latest Driver and =ehicle


40/51

o There is no need to notify the 5?GA unless there is

residual neurological de%cit month after the episode1 for

e/ample, visual %eld defects, cognitive defects, and impaired

limb function.

inor limb eakness alone does not reuire

noti%cation unless the person is restricted to driving certain

types of vehicle or vehicles ith adapted controls.

?ehicle adaptations may be able to overcome

severe physical impairment.

The 5?GA ill need to kno hich, if any, of the

controls reuire modi%cation and ill ask the person to

complete a simple uestionnaire. The driving licence ill

then be coded to re9ect the modi%cations.

• 'or all people (group ! or !! licence) who wish to resume

driving a&ter recovering &rom a stroke"

o They ill need to be assessed for factors that preclude

safe driving. These factors include1

Signi%cant visual %eld defect, or reduction in

visual acuity.

An epileptic sei3ure ithin the past # months (a

sei3ure ithin the %rst #$ hours after the onset of the stroke

is considered to be a provoked sei3ure, not an epileptic

sei3ure).

A disorder of focused attention, especially hemi-

spatial neglect.

o They ill need su0cient muscle control to control their

car (hich may reuire adaptations).

o They ill need su0cient cognitive ability to drive safely

on a busy road. Ln-the-road assessment of ability may be

reuired because assessment in the clinic is inaccurate.


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o Advice on mechanical adaptations can be obtained from

a number of sources, including the 5?GA.

o They can get computer-based driving training and

should consider having driving skills reassessed.

o They should inform their car insurance company before

resuming driving, as failure to do so could result in the

insurance being void.

6eturning to ork after a stroke

What advice should I give about returning to work after a

stroke?

• 'or people that have had a stroke advise that"

o Stroke a:ects everyone in a di:erent ay and it is

di0cult to tell immediately after a stroke ho ill be able to

return to ork or ho uickly this may happen.

o If the person ishes to return to ork (paid or unpaid)

options include1

5iscussing a return to ork ith their 7> or a

member of the stroke care team ho can advise on hether

the person is %t to go back to ork. The person should be

assessed for cognitive functioning, ability to communicate,

and any other practical issues involved in returning to ork.

5iscussing their ork reuirements and options

ith their employer. Hor e/ample, if they ant to ork part-time, full time, or if there is another post available ithin the

organisation that may be more appropriate.

Talking to an employment adviser at a

local Pobcentre >lus (.gov.uk) ho ill be able to give

advice on disability, retraining and transferable skills.

https://www.gov.uk/contact-jobcentre-plushttps://www.gov.uk/contact-jobcentre-plus


42/51


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Take blood pressure measurements.

Assess the risk of pressure sores and prevent their

development.

o * community matron may be the appropriate referral

for people ith high-intensity needs. They can coordinate

inputs from all other agencies.

o * community pharmacist can identify the support

needed to enable the person to manage their on medication

safely.

o * community psychiatric nurse service may be the

appropriate initial referral for people ith depression, mood

sings, and personality changes.

o * continence adviser can assess and treat people ho

have urinary or faecal incontinence.

o * dietitian can provide advice on a healthy diet. This is

especially useful for people ho have di0culty salloing or

are fed arti%cially, are undereight or overeight, or have

diabetes.

o *n occupational therapist can assess, advise, and

provide aids, euipment, or adaptations for people ho have

problems ith everyday activities at home or ork.

o *n orthoptist can give advice about the management

of diplopia, reduced vision, ocular muscle imbalance, visual%eld loss and visual inattention.

o *n orthotist can provide braces hich support and

control eak or paralysed limbs and improve function and

prevent muscles tightening.

o * physiotherapist can assess and treat mobility and

movement problems caused by paralysis, muscle eakness, or

poor balance.


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o * social worker can help to ensure that rehabilitation

plans are meeting the needs of the person, and support the

person and their family through %nancial, relationship or

housing problems.

o * speech and language therapist can assess and

treat people ith1

2ommunication and language di0culties.

Salloing problems or reuiring arti%cial feeding.

Scenario1 2on%rmed TIA - long-term

care and support

Scenario1 2on%rmed transient ischaemic attack - long-term care and support

Age from years onards

Hollo up after TIA

When and how should I follow up someone with a con+rmed

diagnosis of transient ischaemic attack?

Following a transient ischaemic attack (TIA):

• Hollo up ithin month of the event (in primary or

secondary care) and then annually in primary care to1

o 2heck and optimi3e lifestyle measures for secondary


o 2heck and optimi3e drug treatments for secondary


o >rovide advice about driving after a TIA if appropriate.

• Annually check and record blood pressure and lipid pro%le.

http://cks.nice.org.uk/stroke-and-tia#!scenariorecommendation:12http://cks.nice.org.uk/stroke-and-tia#!scenariorecommendation:13http://cks.nice.org.uk/stroke-and-tia#!scenariorecommendation:14http://cks.nice.org.uk/stroke-and-tia#!scenariorecommendation:12http://cks.nice.org.uk/stroke-and-tia#!scenariorecommendation:13http://cks.nice.org.uk/stroke-and-tia#!scenariorecommendation:14


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• Arrange annual pre-inter in9uen3a immuni3ations.

Annual blood pressure and lipid profile

•

The recommendations on the freuency of recording bloodpressure and lipid pro%les are in line ith recommendations in

national guidelines and re9ect the Ruality and Lutcomes

Hrameork of the 7eneral edical Services contract

@Intercollegiate Stroke "orking >arty, ## 4A and =!S

ublic

!ealth


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o >rudent use of alcohol ; men should drink no more than

three units per day, and omen no more than to units per

day, ith at least # alcohol-free days per eek.

o Achieving and maintaining a satisfactory body eight.

• Hor more information, see the OOGinkOO in the 2+S topic on 2?5

risk assessment and management.

• The 62> IS"> found little evidence on lifestyle measures to

prevent the recurrence of a stroke or a transient ischemic attack

(TIA). The 62> IS"> base their recommendations on lifestyle

measures on evidence for the primary prevention on vascular

events.

• 6ecommendations for limiting alcohol consumption are in line

ith advice on sensible drinking from the 5epartment of !ealth.

The recommendation to advise all people to have at least to

alcohol-free days is based on alcohol guidelines from the !ouse of

2ommons Science and Technology 2ommittee @!ouse of

2ommons, #B.

5rug treatments for secondary prevention

What drug treatments should be o*ered a person following

a transient ischaemic attack to reduce cardiovascular

disease risk?

Cardiovascular disease risk will normally be assessed, and treatment initiated in secondary care.

Following discharge for a transient ischaemic attack (TIA):

• #nsure optimal management o&"

o *trial fbrillation if present. Hor detailed management

advice see the 2+S topic on Atrial %brillation.

o Diabetes if present. Hor detailed management advice

see the 2+S topic on 5iabetes - type #.

o $ypertension if present. Treatment should be initiated

immediately after the diagnosis of TIA has been con%rmed by a

specialist.

http://cks.nice.org.uk/topic-under-reviewhttp://cks.nice.org.uk/cvd-risk-assessment-and-managementhttp://cks.nice.org.uk/cvd-risk-assessment-and-managementhttp://cks.nice.org.uk/stroke-and-tia#!references/-352372http://cks.nice.org.uk/stroke-and-tia#!references/-352372http://cks.nice.org.uk/atrial-fibrillationhttp://cks.nice.org.uk/diabetes-type-2http://cks.nice.org.uk/topic-under-reviewhttp://cks.nice.org.uk/cvd-risk-assessment-and-managementhttp://cks.nice.org.uk/cvd-risk-assessment-and-managementhttp://cks.nice.org.uk/stroke-and-tia#!references/-352372http://cks.nice.org.uk/stroke-and-tia#!references/-352372http://cks.nice.org.uk/atrial-fibrillationhttp://cks.nice.org.uk/diabetes-type-2


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Aim to reduce blood pressure to $FD mm!g or

less, and preferably to CF& mm!g.

Hor people ith bilateral, severe (more than E)

stenosis of the internal carotid arteries, a slightly higher

target blood pressure (e.g. systolic blood pressure CJ

' mm!g) may be appropriate.

Hor detailed management advice see the 2+S

topic on !ypertension - not diabetic.

• #nsure an antiplatelet drug has been o5ered long-term

unless they have an indication for an anticoagulant for e/ample

because they are in atrial %brillation or they have had a cerebral

venous thrombosis.

o lopidogrel (67 mg daily) is the preferred long-term

antiplatelet.

2onsider prescribing a proton pump inhibitor to

reduce the risk of gastrointestinal bleeding in people at high

risk of gastrointestinal bleeding or to relieve aspirin-induceddyspepsia.

Hor further information ho is at high risk of

gastrointestinal bleeding and prescribing issues on

antiplatelet therapy (including managing gastrointestinal

issues), see the 2+S topic on Antiplatelet treatment.

o If clopidogrel is contraindicated or not tolerated, give a

combination of modi%ed-release dipyridamole (# mg ticedaily) and lo dose aspirin.

o If both clopidogrel and modi%ed-release dipyridamole

are contraindicated or not tolerated, give aspirin alone.

o If both clopidogrel and aspirin are contraindicated or not

tolerated, give modi%ed-release dipyridamole alone.

http://cks.nice.org.uk/hypertension-not-diabetichttp://cks.nice.org.uk/antiplatelet-treatment#!scenarioclarification:1http://cks.nice.org.uk/antiplatelet-treatmenthttp://cks.nice.org.uk/hypertension-not-diabetichttp://cks.nice.org.uk/antiplatelet-treatment#!scenarioclarification:1http://cks.nice.org.uk/antiplatelet-treatment


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• #nsure a statin has been o5ered as soon as possible after

a TIA.

o 6echeck the cholesterol one to three months after

starting treatment and increase treatment if the cholesterol is

more than $ mmolFG or lo-density lipoprotein (G5G) cholesterol

is more than # mmolFG.

Hor further information see the 2+S topic on Gipid

modi%cation - 2?5 prevention.

Managing atrial fibrillation and diabetes after a TIA

• *trial fbrillation

o The recommendation to manage atrial %brillation is

based on pragmatic 2+S advice. Stroke and thromboembolism

are the main complications of atrial %brillation (AH) @=ational

2ollaborating 2entre for 2hronic 2onditions, #B. >eople ith

AH have a %ve-fold greater risk of stroke and thromboembolism

than people ithout AH @=I2


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• ;hen to start antihypertensive treatment

o The recommendation to start antihypertensives

immediately after the diagnosis of a TIA is in line ith guidance

issued by =I2< @=ational 2ollaborating 2entre for 2hronic

2onditions, #&B and the 62> I2S"> @Intercollegiate Stroke

"orking >arty, ##B. A delay in starting antihypertensives is

recommended for people ho have had a stroke because there

are concerns about possible adverse e:ects ith early

reduction in blood pressure. !oever this is not the case in TIA

and it is reasonable to start antihypertensives promptly for

these people @Sudlo, #&B.

• ,lood pressure targets"

o The recommended blood pressure targets are those

recommended by guidelines published by =I2< and the 62>

I2S"> @=I2

guideline recommends a blood pressure target of

CF& mm!g based on e/pert opinion from the Point 4ritish

!ypertension Society @4!S, #$ Intercollegiate Stroke

"orking >arty, ## B. This blood pressure target is also

advocated by the Point 4ritish Societies guideline @4ritish

2ardiac Society et al, #'B.

A higher target blood pressure (for e/ample,

systolic blood pressure of ' mm!g) for people ith

bilateral severe carotid artery stenosis is recommended by

the 62> I2S"> guidelines @Intercollegiate Stroke "orking

>arty, ##B. =o evidence suggests that people ith severe

stenosis should have a systolic blood pressure more than' mm!g.

http://cks.nice.org.uk/stroke-and-tia#!references/-352372http://cks.nice.org.uk/stroke-and-tia#!references/-352372http://cks.nice.org.uk/stroke-and-tia#!references/-352372http://cks.nice.org.uk/stroke-and-tia#!references/-352372http://cks.nice.org.uk/stroke-and-tia#!references/-352372http://cks.nice.org.uk/stroke-and-tia#!references/-352372http://cks.nice.org.uk/stroke-and-tia#!references/-352372http://cks.nice.org.uk/stroke-and-tia#!references/-352372http://cks.nice.org.uk/stroke-and-tia#!references/-352372http://cks.nice.org.uk/stroke-and-tia#!references/-352372http://cks.nice.org.uk/stroke-and-tia#!references/-352372http://cks.nice.org.uk/stroke-and-tia#!references/-352372http://cks.nice.org.uk/stroke-and-tia#!references/-352372http://cks.nice.org.uk/stroke-and-tia#!references/-352372http://cks.nice.org.uk/stroke-and-tia#!references/-352372http://cks.nice.org.uk/stroke-and-tia#!references/-352372http://cks.nice.org.uk/stroke-and-tia#!references/-352372http://cks.nice.org.uk/stroke-and-tia#!references/-352372http://cks.nice.org.uk/stroke-and-tia#!references/-352372http://cks.nice.org.uk/stroke-and-tia#!references/-352372http://cks.nice.org.uk/stroke-and-tia#!references/-352372http://cks.nice.org.uk/stroke-and-tia#!references/-352372http://cks.nice.org.uk/stroke-and-tia#!references/-352372http://cks.nice.org.uk/stroke-and-tia#!references/-352372http://cks.nice.org.uk/stroke-and-tia#!references/-352372http://cks.nice.org.uk/stroke-and-tia#!references/-352372http://cks.nice.org.uk/stroke-and-tia#!references/-352372http://cks.nice.org.uk/stroke-and-tia#!references/-352372http://cks.nice.org.uk/stroke-and-tia#!references/-352372http://cks.nice.org.uk/stroke-and-tia#!references/-352372


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Antiplatelet treatment after a TIA

• arty, ##B found that lipid-loering therapy ith

statins as bene%cial for people ith cardiovascular disease and

speci%cally cerebrovascular disease @!eart >rotection Study

2ollaborative 7roup, ## Amarenco et al, #B.

o In the !eart >rotection Study (!>S), taking simvastatin

$ mg daily (given to people at high risk of cardiovascular

events) resulted in a relative risk reduction of E in vascular

deaths, #E in maKor coronary events and #' in stroke @!eart

>rotection Study 2ollaborative 7roup, ##B.

o In a second study atorvastatin & mg daily (given to

people ith a history of TIA or stroke in the preceding

months) resulted in a relative risk reduction of ' in strokeand C' in maKor coronary events ith treatment @Amarenco

et al, #B.The recommendation to start treatment ith a

statin after a TIA is based on guidelines issued by =I2< and the

62> I2S"> @=I2


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5riving after a TIA

What should I advise about driving after transient ischaemic

attack?

Always consult the latest Driver and Vehicle Licensing Agency (DVLA) regulations to ensurethat your advice is accurate and up to date — see the 'At a Glance' booklet available on

the DVLA website.

• 'or people with a group !! licence 9 &or large goods

vehicles or passenger carrying vehicles 9 who have had a

transient ischaemic attack (T!*)"

o They must notify the 5?GA, ho ill not allo them to

drive under this licence for at least # months.

o They can be considered for re-licensing after this period

provided that they have no other signi%cant risk factors.

6e-licensing ill also be subKect to satisfactory

medical reports, including e/ercise electrocardiography.

"here there is imaging evidence of essentially

normal carotid arteries 7roup II licensing may be alloedithout the need for functional cardiac assessment.

• 'or people with a group ! licence 9 an ordinary driving

licence &or car or motorcycle 9 who have had a T!*"

o They must not drive for at least $ eeks.

o >eople ho have multiple TIAs over a short period

should notify the 5?GA of this the 5?GA ill reuire at leastC months free of further attacks before alloing driving to be

resumed.

o They should inform their car insurance company before

resuming driving, as failure to do so could result in the

insurance being void.
https://www.gov.uk/government/publications/at-a-glancehttps://www.gov.uk/government/publications/at-a-glancehttps://www.gov.uk/government/organisations/driver-and-vehicle-licensing-agencyhttps://www.gov.uk/government/organisations/driver-and-vehicle-licensing-agencyhttps://www.gov.uk/government/publications/at-a-glancehttps://www.gov.uk/government/organisations/driver-and-vehicle-licensing-agency

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Stroke and TIA Notes

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