National Clinical Guideline for Stroke

Overview

This summary of the updated 2023 stroke guideline covers prehospital care, long-term management, and secondary prevention strategies, such as blood pressure control, lipid modification, and improved nutrition.

This summary is intended for primary care practitioners. For recommendations on acute care, refer to the secondary care summary. For recommendations on organisation of stroke services and rehabilitation and recovery, refer to the full guideline.

This guideline was produced by the Intercollegiate Stroke Working Party and SIGN, and is endorsed for use in clinical practice by the Royal College of Physicians of London and the Royal College of Physicians of Ireland.

Reflecting on your Learnings

Reflection is important for continuous learning and development, and a critical part of the revalidation process for UK healthcare professionals. Click here to access the Guidelines Reflection Record.

Organisation of Stroke Services

Transfer to Acute Stroke Services

• Community health services and ambulance services (including call handlers and primary care reception staff) should be trained to recognise people with symptoms indicating an acute stroke as an emergency requiring transfer to a hyperacute stroke centre with pre-alert notification to the stroke team 
• People with an acute neurological presentation suspected to be a stroke should be admitted directly to a hyperacute stroke unit that cares predominantly for patients with stroke, with access to a designated thrombectomy centre 24 hours a day, 7 days a week for consideration of mechanical thrombectomy. 

Organisation of Inpatient Stroke Services

• People with the sudden onset of focal neurological symptoms seen by community-based clinicians (for example, ambulance paramedics) should be screened for hypoglycaemia with a capillary blood glucose test, and for stroke or transient ischaemic attack (TIA) using a validated tool. Those people with persisting neurological symptoms who screen positive using a validated tool should be transferred to a hyperacute stroke unit as soon as possible with pre-alert notification to the admitting stroke team 
• People with suspected acute stroke (including people already in hospital) should be admitted directly to a hyperacute stroke unit and be assessed for emergency stroke treatments by a specialist clinician without delay. Refer to the secondary care summary for further information.

For recommendations on transfers of care from hospital to home—community stroke rehabilitation, refer to the full guideline.

For recommendations on acute care, refer to the full guideline. 

Management of TIA and Minor Stroke—Assessment and Diagnosis

• Patients with acute focal neurological symptoms that resolve completely within 24 hours of onset (i.e. suspected TIA) should be given aspirin 300 mg immediately unless contraindicated and assessed urgently within 24 hours by a stroke specialist clinician in a neurovascular clinic or an acute stroke unit
• Healthcare professionals should not use assessment tools such as the ABCD2 score to stratify risk of TIA, inform urgency of referral, or subsequent treatment options.

For more details on the management of acute stroke, refer to the secondary care summary.

Activity and Participation

Hydration and Nutrition

• Patients with stroke who are at risk of malnutrition should be offered nutritional support
• This may include oral nutritional supplements, specialist dietary advice, and/or tube feeding in accordance with their expressed wishes or, if the patient lacks mental capacity, in their best interests 
• Patients with stroke who are unable to maintain adequate nutrition and hydration orally should be referred to a dietitian for specialist nutritional assessment, advice, and monitoring
• People with stroke who require food or fluid of a modified consistency should:
  • be referred to a dietitian for specialist nutritional assessment, advice, and monitoring 
  • have the texture of modified food or fluids prescribed using internationally agreed descriptors 
  • be referred to a pharmacist to review the formulation and administration of medication 
• People with difficulties self-feeding after stroke should be assessed and provided with the appropriate equipment and assistance including physical help and encouragement, environmental considerations, and postural support to promote independent and safe feeding. 

Continence

• People with stroke with continued loss of urinary continence should be offered behavioural interventions and adaptations prior to considering pharmaceutical and long-term catheter options, such as:
  • timed toileting 
  • prompted voiding 
  • review of caffeine intake 
  • bladder retraining 
  • pelvic floor exercises 
  • external equipment 
• People with stroke with constipation should be offered:
  • advice on diet, fluid intake, and exercise 
  • a regulated routine of toileting 
  • a prescribed medication review to minimise use of constipating medication 
  • oral laxatives 
  • a structured bowel management programme which includes nurse-led bowel care interventions 
  • education and information for the person with stroke and their family/carers 
  • rectal laxatives if severe problems persist 
• People with continued continence problems on transfer of care from hospital should receive follow up with specialist continence services in the community. 

Driving

• People with stroke who wish to drive should:
  • be advised of the exclusion period from driving and their responsibility to notify the Driver & Vehicle Licensing Agency, Driver & Vehicle Agency, or National Driver Licence Service if they have any persisting disability which may affect their eligibility 
  • be asked about or examined for any absolute bars to driving for example, epileptic seizure (excluding seizure within 24 hours of stroke onset), significant visual field defects, reduced visual acuity, or double vision 
  • be offered an assessment of the impairments that may affect their eligibility, including their cognitive, visual, and physical abilities 
  • receive a written record of the findings and conclusions, copied to their general practitioner 
• People with persisting cognitive, language, or motor disability after stroke who wish to return to driving should be referred for on-road screening and evaluation 
• People who wish to drive after a stroke should be informed about eligibility for disabled concessions (for example, Motability, the Blue Badge scheme). 

Return to Work

• People with stroke should be asked about their work at the earliest opportunity, irrespective of whether they plan to return. This will enable staff to have a better understanding of their role before having a stroke, and offer the person an opportunity to discuss their thoughts and feelings 
• People who need or wish to return to any type of work after stroke should:
  • be provided with information regarding rights, financial support, and vocational rehabilitation. This should include information regarding driving, where appropriate (for example, in the work role or travelling to work) 
  • be supported to understand the consequences of their stroke in relation to work
• Healthcare professionals who work with people following stroke should have knowledge and skills about supporting them to return to work, appropriate to the nature and level of service they provide 
• Authorised healthcare professionals should provide a statement of fitness to work (for example, ‘fit note’ to support people to return to work, including recommended alterations to work patterns, tasks undertaken, or environment). 

Motor Recovery and Physical Effects of Stroke 

Falls and Fear of Falling

• People with stroke should be offered a falls risk assessment and management as part of their stroke rehabilitation, including training for them and their family/carers in how to get up after a fall. Assessment should include physical, sensory, psychological, pharmacological, and environmental factors 
• People with stroke should be offered an assessment of fear of falling as part of their falls risk assessment and receive psychological support if identified 
• People at high risk of falls after stroke should be offered a standardised assessment of fragility fracture risk as part of their stroke rehabilitation 
• People with stroke with symptoms of vitamin D deficiency, or those who are considered to be at high risk (for example, housebound) should be offered calcium and vitamin D supplements
• People at high risk of falls after stroke should be advised to participate in physical activity/exercise which incorporates balance and co-ordination at least twice per week
• People with stroke and limitations of dorsiflexion or ankle instability causing impaired balance and risk or fear of falling should be considered for referral to orthotics for an ankle–foot orthosis and/or functional electrical stimulation. The person with stroke, their family/carers, and clinicians in all settings should be trained in the safe use and application of orthoses and electrical stimulation devices. 

Walking

• People with limited mobility after stroke should be assessed for, provided with, and trained to use appropriate mobility aids, including a wheelchair, to enable safe independent mobility 
• People with stroke, including those who use wheelchairs or have poor mobility, should be advised to participate in exercise with the aim of improving aerobic fitness and muscle strength unless there are contraindications 
• People with impaired mobility after stroke should be offered repetitive task practice as the principal rehabilitation approach, in preference to other therapy approaches including Bobath therapy
• People who cannot walk independently after stroke should be considered for electromechanical-assisted gait training including body weight support. 

Musculoskeletal Pain

• People with musculoskeletal pain after stroke should be assessed to ensure that movement, posture, and moving and handling techniques are optimised to reduce pain
• People who continue to experience musculoskeletal pain should be offered pharmacological treatment with simple analgesic medication. Paracetamol, topical nonsteroidal anti-inflammatory drugs, or transcutaneous electrical nerve stimulation should be offered before considering the addition of opioid analgesics. 

Fatigue

• Healthcare professionals should anticipate post-stroke fatigue, and ask people with stroke (or their family/carers) if they experience fatigue and how it impacts on their life 
• Healthcare professionals should use a validated measure in their assessment of post-stroke fatigue, with a clear rationale for its selection, and should also consider physical and psychological fatigue, personality style, context demands, and coping styles 
• People with stroke should be assessed and periodically reviewed for post-stroke fatigue, including for factors that might precipitate or exacerbate fatigue (for example, depression and anxiety, sleep disorders, pain), and these factors should be addressed accordingly. Appropriate time points for review are at discharge from hospital and then at regular intervals, including at 6 months and annually thereafter 
• People with stroke should be provided with information and education regarding fatigue being a common post-stroke problem, and with reassurance and support as early as possible, including how to prevent and manage it, and signposting to peer support and voluntary sector organisations. Information should be provided in appropriate and accessible formats 
• People with post-stroke fatigue should be involved in decision making about strategies to prevent and manage it that are tailored to their individual needs, goals, and circumstances
• People with post-stroke fatigue should be referred to appropriately skilled and experienced clinicians as required, and should be considered for the following approaches, whilst being aware that no single measure will be effective for everyone:
  • building acceptance and adjustment to post-stroke fatigue and recognising the need to manage it 
  • education on post-stroke fatigue for the person with stroke, and their family/carers 
  • using a diary to record activities and fatigue 
  • predicting situations that may precipitate or exacerbate fatigue 
  • pacing and prioritising activities 
  • relaxation and meditation 
  • rest 
  • setting small goals and gradually expanding activities 
  • changing diet and/or exercise (applied with caution and tailored to individual needs) 
  • seeking peer support and/or professional advice 
  • coping methods including compensatory techniques, equipment, and environmental adaptations 
• Healthcare professionals working with people affected by post-stroke fatigue should be provided with education and training on post-stroke fatigue, including its multi-factorial nature and impact, potential causes and triggers, validated assessment tools, and the importance of involving people affected by post-stroke fatigue in designing strategies to prevent and manage it 
• Healthcare professionals working with people with post-stroke fatigue should consider the impact of fatigue on their day-to-day ability to engage with assessment and rehabilitation, and tailor the scheduling and length of such activities accordingly.

For recommendations on swallowing, refer to the full guideline.

Anxiety, Depression, and Psychological Distress

• Healthcare professionals should be aware of the psychological needs of people with stroke and their family/carers, and routinely provide education, advice, and emotional support for them. Multidisciplinary teams should embed measures that promote physical and mental wellbeing within the wider rehabilitation package, and collaborate with other statutory and voluntary services to deliver them, such as:
  • increased social interaction 
  • meaningful activities to support rebuilding of self-confidence and self-esteem 
  • increased exercise 
  • mind–body interventions such as relaxation, mindfulness, Tai chi, and yoga 
  • other psychosocial interventions such as psychological education groups 
• People with stroke should be routinely screened for anxiety and depression using standardised tools, the results of which should be used alongside other sources of information to inform clinical formulation of treatment and support needs 
• People with stroke should not be routinely offered selective serotonin reuptake inhibitors (SSRIs) for the prevention of depression, but SSRIs may be considered when other preventative approaches are not appropriate (for example, in people with severe cognitive or language impairment) or when the risk of depression is high (for example, in people with a previous history of depression). The balance of risk and benefit from SSRIs should take account of the potential for increased adverse effects (seizures and hip fracture) 
• People with persistent moderate to severe emotional disturbance after stroke who have not responded to high-intensity psychological intervention or pharmacological treatment should receive collaborative care, which should include long-term follow-up and involve liaison between the GP, stroke team, and secondary care mental health services with supervision from a senior mental health professional 
• Where people with depression or anxiety after stroke are being treated within primary care mental health services (such as Improving Access to Psychological Therapies) or secondary care mental health services, advice, consultation, and training should be available from the stroke service. Guidance for the management of people with significant language and cognitive impairment should be agreed between services and joint working offered where appropriate. 

Long-Term Management and Secondary Prevention 

A Comprehensive and Personalised Approach

• People with stroke or TIA should receive a comprehensive and personalised strategy for vascular prevention including medication and lifestyle factors, which should be implemented as soon as possible and should continue long term 
• People with stroke or TIA should receive information, advice, and treatment for stroke, TIA, and vascular risk factors which is:
  • given first in the hospital or clinic setting 
  • reinforced by all health professionals involved in their care 
  • provided in an appropriate format 
• People with stroke or TIA should have their risk factors and secondary prevention reviewed and monitored at least once a year in primary care 
• People with stroke or TIA who are receiving medication for secondary prevention should:
  • receive information about the reason for the medication, how and when to take it, and common side effects 
  • receive verbal and written information about their medicines in an appropriate format 
  • be offered compliance aids such as large-print labels, non-childproof tops, and dosette boxes according to their level of manual dexterity, cognitive impairment, personal preference, and compatibility with safety in the home 
  • be aware of how to obtain further supplies of medication 
  • have their medication regularly reviewed 
  • have their capacity to take full responsibility for self-medication assessed (including cognition, manual dexterity, and ability to swallow) by the multidisciplinary team as part of their rehabilitation prior to the transfer of their care out of hospital. 

Blood Pressure

• People with stroke or TIA should have their blood pressure (BP) checked, and treatment should be initiated or increased as tolerated to consistently achieve a clinic systolic BP below 130 mmHg, equivalent to a home systolic BP below 125 mmHg. The exception is for people with severe bilateral carotid artery stenosis, for whom a systolic BP target of 140–150 mmHg is appropriate. Concern about potential adverse effects should not impede the initiation of treatment that prevents stroke, major cardiovascular events, or mortality 
• For people with stroke or TIA aged 55 or over, or of African or Caribbean origin at any age, antihypertensive treatment should be initiated with a long-acting dihydropyridine calcium-channel blocker or a thiazide-like diuretic. If target BP is not achieved, an angiotensin-converting enzyme inhibitor or angiotensin II receptor blocker should be added 
• For people with stroke or TIA not of African or Caribbean origin and younger than 55 years, antihypertensive treatment should be initiated with an angiotensin-converting enzyme inhibitor or an angiotensin II receptor blocker 
• People with stroke or TIA should have BP-lowering treatment initiated prior to the transfer of care out of hospital or at 2 weeks, whichever is the soonest, or at the first clinic visit for people not admitted 
• People with stroke or TIA should have their BP-lowering treatment monitored frequently in primary care and increased to achieve target BP as quickly and safely as tolerated. People whose BP remains above target despite treatment should be checked for medication adherence at each visit before escalation of treatment, and people who do not achieve their target BP despite escalated treatment should be referred for a specialist opinion. Once BP is controlled to target, people taking antihypertensive treatment should be reviewed at least annually 
• In people with stroke being treated with antihypertensive agents to reduce recurrent stroke risk, management guided by home or ambulatory BP monitoring should be considered, in order to improve treatment compliance and BP control 
• People with stroke using home BP monitoring should use a validated device with an appropriate measurement cuff and a standardised method. They (or where appropriate, their family/carer) should receive education on how to use the device, the implications of readings for management, and be provided with ongoing support, particularly if they have anxiety or cognitive and physical disability after stroke. 

Lipid Modification

• People with ischaemic stroke or TIA should be offered personalised advice and support on lifestyle factors to reduce cardiovascular risk, including diet, physical activity, weight reduction, alcohol moderation, and smoking cessation 
• People with ischaemic stroke or TIA should be offered treatment with a statin unless contraindicated or investigation of their stroke or TIA confirms no evidence of atherosclerosis. Treatment should:
  • begin with a high-intensity statin such as atorvastatin 80 mg daily. A lower dose should be used if there is the potential for medication interactions or a high risk of adverse effects 
  • be with an alternative statin at the maximum tolerated dose if a high-intensity statin is unsuitable or not tolerated 
• Lipid-lowering treatment for people with ischaemic stroke or TIA and evidence of atherosclerosis should aim to reduce fasting LDL-cholesterol to below 1.8 mmol/L (equivalent to a non-HDL-cholesterol of below 2.5 mmol/L in a non-fasting sample). If this is not achieved at first review at 4–6 weeks, the prescriber should:
  • discuss adherence and tolerability 
  • optimise dietary and lifestyle measures through personalised advice and support 
  • consider increasing to a higher dose of statin if this was not prescribed from the outset 
  • consider adding ezetimibe 10 mg daily 
  • consider the use of additional agents such as injectables (inclisiran or monoclonal antibodies to proprotein convertase subtilisin/kexin type 9) or bempedoic acid (for statin-intolerant people taking ezetimibe monotherapy) 
  • continue to escalate lipid-lowering therapy (in combination if necessary) at regular intervals in order to reduce LDL-cholesterol to below 1.8 mmol/L 
• People with ischaemic stroke or TIA in whom investigation confirms no evidence of atherosclerosis should be assessed for lipid-lowering therapy on the basis of their overall cardiovascular risk 
• People with intracerebral haemorrhage should be assessed for lipid-lowering therapy on the basis of their overall cardiovascular risk and the underlying cause of the haemorrhage
• In people with ischaemic stroke or TIA below 60 years of age with very high cholesterol (below 30 years with total cholesterol above 7.5 mmol/L or 30 years or older with total cholesterol concentration above 9.0 mmol/L) consider a diagnosis of familial hypercholesterolaemia 
• In people with ischaemic stroke or TIA of presumed atherosclerotic cause below 60 years of age, consider the measurement of lipoprotein(a) and specialist referral if raised above 200 nmol/L. 

Antiplatelet Treatment

• For long-term prevention of vascular events in people with ischaemic stroke or TIA without paroxysmal or permanent atrial fibrillation (AF):
  • clopidogrel 75 mg daily should be the standard antithrombotic treatment 
  • aspirin 75 mg daily should be used for those who are unable to tolerate clopidogrel 
  • if a patient has a recurrent cardiovascular event on clopidogrel, clopidogrel resistance may be considered
• The combination of aspirin and clopidogrel is not recommended for long-term prevention of vascular events unless there is another indication, for example, acute coronary syndrome, recent coronary stent
• For more details on antiplatelet treatment, please refer to the secondary care summary.

Anticoagulation

• For people with ischaemic stroke or TIA and paroxysmal, persistent, or permanent atrial fibrillation AF (valvular or non-valvular) or atrial flutter, oral anticoagulation should be the standard long-term treatment for stroke prevention. For further information, please refer to the secondary care summary 
• People with cardioembolic TIA or stroke for whom treatment with anticoagulation is considered inappropriate for reasons other than the risk of bleeding may be considered for antiplatelet treatment to reduce the risk of recurrent vaso-occlusive disease. 

Physical Activity

• People with stroke or TIA should participate in physical activity for fitness unless there are contraindications. Exercise prescription should be individualised, and reflect treatment goals and activity recommendations 
• People with stroke or TIA should aim to be active every day and minimise the amount of time spent sitting for long periods
• People with stroke should be offered cardiorespiratory training or mixed training regardless of age, time since having the stroke, and severity of impairment
  • facilities and equipment to support high-intensity (greater than 70% peak heart rate) cardiorespiratory fitness training (such as bodyweight support treadmills, or static or recumbent cycles) should be available 
  • the dose of training should be at least 30–40 minutes, three to five times a week for 10–20 weeks 
  • programmes of mixed training (medium intensity cardiorespiratory [40–60% of heart rate reserve] and strength training [50–70% of one-repetition maximum]) such as circuit training classes should also be available at least 3 days per week for 20 weeks 
  • the choice of programme should be guided by patients’ goals and preferences and delivery of the programme individualised to their level of impairment and goals
• People with stroke or TIA who are at risk of falls should engage in additional physical activity which incorporates balance and co-ordination, at least twice per week 
• Physical activity programmes for people with stroke or TIA should be tailored to the individual after appropriate assessment, starting with low-intensity physical activity and gradually increasing to moderate levels. 

Smoking Cessation

• People with stroke or TIA who smoke should be advised to stop immediately. Smoking cessation should be promoted in an individualised prevention plan using interventions which may include pharmacotherapy, psychosocial support, and referral to statutory stop smoking services. 

Nutrition (Secondary Prevention)

• People with stroke or TIA should be advised to eat an optimum diet that includes:
  • five or more portions of fruit and vegetables per day from a variety of sources 
  • two portions of oily fish per week (salmon, trout, herring, pilchards, sardines, fresh tuna) 
• People with stroke or TIA should be advised to reduce and replace saturated fats in their diet with polyunsaturated or monounsaturated fats by:
  • using low-fat dairy products 
  • replacing butter, ghee, and lard with products based on vegetable and plant oils 
  • limiting red meat intake, especially fatty cuts and processed meat 
• People with stroke or TIA who are overweight or obese should be offered advice and support to aid weight loss including adopting a healthy diet, limiting alcohol intake to 2 units a day or less, and taking regular exercise. Targeting weight reduction in isolation is not recommended 
• People with stroke or TIA should be advised to reduce their salt intake by:
  • not adding salt to food at the table
  • using little or no salt in cooking 
  • avoiding high-salt foods, for example, processed meat such as ham and salami, cheese, stock cubes, pre-prepared soups, and savoury snacks such as crisps and salted nuts 
• People with stroke or TIA who drink alcohol should be advised to limit their intake to 14 units a week, spread over at least 3 days 
• Unless advised to do so for other medical conditions, people with stroke or TIA should not routinely supplement their diet with:
  • B vitamins or folate 
  • vitamins A, C, E, or selenium 
  • calcium with or without vitamin D. 

Further Rehabilitation

• People with stroke, including those living in a care home, should be offered a structured, holistic review of their individual needs by a healthcare professional with appropriate knowledge and skills, using an appropriate mode of communication (for example, face to face, by telephone, or online)
  • this review should cover physical, neuropsychological, and social needs, seek to identify what matters most to the person, and be undertaken at 6 months after stroke, or earlier if requested by the person with stroke
  • at this 6-month review, the reviewer should discuss with the person with stroke who would be best placed to undertake the next review at 1 year post-stroke (or at another point in time, depending on the person’s needs), as well as the agreed mode of communication
  • this review should be offered annually thereafter (or at another point in time, if requested by the person with stroke), for as long as a need for ongoing review continues and on request thereafter 
• People with stroke should be provided with the contact details of a named healthcare professional (for example, a stroke co-ordinator or key worker) who can provide further information, support, and advice, as and when needed 
• People with stroke should be supported to develop their own self-management plan, based on their individual needs, goals, preferences, and circumstances 
• People with stroke who are unable to undertake their own self-management should be referred in a timely manner to appropriate health, social care, or other voluntary or statutory services depending on their needs.