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, weakness or paralysis, slurred speech, and

visual disturbances. Headache is not a typical feature of
ischaemic stroke or TIA.
o

With stroke, the symptoms and signs persist beyond

24 hours or cause death within 24 hours.

With TIA, the symptoms and signs resolve within

24 hours.
Strokes can be classified by their main causes as either

ischaemic (85% of cases) or haemorrhagic (15% of cases).

Stroke is the third most common cause of death in the UK.

Most strokes occur in people older than 65 years, but they can
occur at any age.
The complications and consequences of stroke are numerous

and include neurological problems, depression and anxiety,

speech and communication difficulties, and difficulties with
activities of daily living.
The risk of recurrent vascular events varies considerably

among individuals and depends on the underlying pathology,

comorbidities, and lifestyle factors.
Management of a suspected acute stroke in primary care

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

unit:
o

Antiplatelet treatment should not be started until

haemorrhagic stroke has been ruled out by a brain scan.

If the person is eligible for thrombolysis (up to 6 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, follow up should be arranged within 6 weeks of

discharge and then annually to:

o

Assess the need for further specialist review, advice,

information and support.

Assess social care and health care needs.

Check and optimize lifestyle measures, and drug

treatments for secondary prevention of cardiovascular disease.
Management of a TIA in primary care includes assessing the

risk of an early stroke using the ABCD2 scoring system.

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

should be:
o

Referred for specialist assessment within 24 hours of the

onset of symptoms.

Given an antiplatelet and a statin.

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

should be:
o

Referred for specialist assessment as soon as possible,

but definitely within one week of onset of symptoms.

Given an antiplatelet and a statin.

After a TIA, follow up should be arranged within 1 month (in

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

check and optimize lifestyle measures, and drug treatments for
secondary prevention of cardiovascular disease.

Definition
What are strokes and transient ischaemic attacks?
Stroke is defined as a clinical syndrome, caused by cerebral

infarction or haemorrhage, typified by rapidly developing signs of

focal and global disturbance of cerebral functions lasting more
than 24 hours or leading to death.
o

Non-disabling stroke is a stroke with symptoms or

signs that last for more than 24 hours but resolve later, leaving
no permanent disability.

Disabling stroke is a stroke which leaves the person

unable to carry out all their usual activities.

Minor stroke is stroke with few mild symptoms on

initial assessment.

Subarachnoid haemorrhage although it is classified

as a type of stroke, subarachnoid haemorrhage is not usually
included in guidelines on stroke diagnosis and management.

Stroke with rapid recovery can only be distinguished

from a transient ischaemic attack (TIA) retrospectively and,
apart from guiding investigation to exclude other conditions, is
of little clinical importance.
Transient ischaemic attack is defined as an acute loss of

cerebral or ocular function with symptoms lasting less than 24

hours caused by an inadequate cerebral or ocular blood supply as
a result of low blood flow, ischaemia, or embolism associated with
disease of the blood vessels, heart or blood.
o

The symptoms and signs of a TIA usually resolve within

minutes, or may last a few hours. Therefore, people who have
continuing neurological signs when first assessed should be
assumed to have had a stroke.

Causes and classification

Causes and classification of strokes
Strokes can be classified by their main causes as either
ischaemic (most common) or haemorrhagic.
Ischaemic stroke:

Ischaemic strokes are caused when a blood vessel in the

brain is blocked, for example by a blood clot or by the fatty

material from an atherosclerotic plaque. The brain cells in the
part of the brain served by the affected blood vessel die of lack
of oxygen and nutrients.
There are two main types of ischaemic stroke

thrombotic and embolic:

Thrombotic ischaemic stroke a blood clot

spontaneously forms in an artery in the brain. This is a
common complication of atherosclerosis.

Embolic ischaemic stroke part of the fatty

material from an atherosclerotic plaque or a clot in a larger
artery or the heart breaks off and travels downstream until it
is trapped in a narrower artery in the brain. Embolic strokes
are common complications of atrial fibrillation and
atherosclerosis of the carotid arteries.
Haemorrhagic stroke:

There are two main types of haemorrhagic stroke

intracerebral and subarachnoid:

Intracerebral haemorrhagic stroke there is

bleeding from a blood vessel within the brain. High blood
pressure is the main cause of intracerebral haemorrhagic
stroke.

Subarachnoid haemorrhagic stroke there is

bleeding from a blood vessel between the surface of the

brain and the arachnoid tissues that cover the brain.
Some experts do not classify subarachnoid haemorrhage

as stroke because subarachnoid haemorrhages present

differently from ischaemic strokes and intracerebral
haemorrhagic strokes, and they require particular
management. However, both acute strokes and subarachnoid
haemorrhages need emergency admission. So, regardless of
whether subarachnoid haemorrhage is considered stroke, the
primary care management is the same.
About 85% of strokes are ischaemic, and about 15% are

haemorrhagic.

Complications
What are the complications and consequences of
stroke?
The complications and consequences of stroke include:

Neurological problems balance, movement, tone,

sensation.
Pain neuropathic, shoulder pain and subluxation,

musculoskeletal pain.
Depression, anxiety, emotionalism, disturbed social

interaction also 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).

o

Speech and communication difficulties aphasia,

dysarthria, apraxia of speech.

Visual impairments and hemianopia .

Bladder and bowel problems urinary incontinence,

faecal incontinence, constipation.

Swallowing problems, oral health, malnutrition,

dehydration oral health, malnutrition, dehydration.

Sexual dysfunction .

Difficulties with activities of daily living personal,

social, and vocational.

Prognosis
What is the prognosis after a stroke or transient
ischaemic attack?

The risk of recurrent vascular events varies considerably

among individuals and depends on the underlying pathology,
comorbidities, and lifestyle factors.

After a TIA: risk of early stroke

What factors are associated with increased risk of stroke
soon after a TIA?

People who have had a transient ischaemic attack (TIA) are at

increased risk of having a subsequent stroke in the first month of

the event and up to one year afterwards [Intercollegiate Stroke

Working Party, 2012]:
o

A systematic review and meta-analysis reported that the

pooled risk of stroke within 2 days was 3.1% (95% CI 2.0 to 4.1)
and within 7 days 5.2% (95% CI 3.9 to 6.5) [Giles and Rothwell,
2007].
The early risk of stroke is increased in people with:

Increased blood pressure (i.e. sustained above

130/90 mmHg).

Hyperlipidaemia.

Diabetes mellitus.

Atrial fibrillation and other cardiac arrhythmias.

Structural cardiac disease.

Carotid artery stenosis.

Lifestyle factors including smoking, exercise, eating and

dietary habits, and alcohol consumption.
Consider people at particularly high risk for a subsequent

stroke if they have any of the following:

o

An ABCD2 score of 4 or more see Assessing risk of

stroke after TIA.

Atrial fibrillation.

More than one TIA in one week.

A TIA while on an anticoagulant.

[NationalCollaboratingCentreforChronicConditions,2008;IntercollegiateStrokeWorkingParty,
2012]

After a TIA: risk (longer term) of CVD events

After a TIA, what is the longer-term risk of subsequent
cardiovascular disease events and death?
Confirmed episodes of transient ischaemic attack (TIA)

indicate established cardiovascular disease, with an increased

risk of future cardiovascular events. Following an initial TIA, it has
been estimated that [Warlow and Davenport, 1996; Adams et al,
2003]:
The annual risk of myocardial infarction is 23%, and

35% of people who have had a TIA will eventually die of cardiac
disease.
The combined risk of stroke, myocardial infarction, or

vascular death is about 9% per year.

About 2040% of people who have had a TIA or

ischaemic stroke have asymptomatic coronary heart disease.

A study of 2447 people enrolled in the Dutch TIA trial (with a

mean of 65 years of age) found that over a mean of 10 years [van

Wijk et al, 2005]:
o

Approximately 60% had died.

Almost 54% had experienced at least one new vascular

event.

After the first 3 months, the risk of a further vascular

event declined over the next 3 years, but then increased over
the following years. The authors noted that this could be due to
poor compliance with drugs and less care being taken over
lifestyle issues, as well as increasing age.

After a stroke: risks of death and dependency

After a stroke, what is the prognosis for survival and
functional status?
Immediateprognosis

Survival: the inpatient death rate for people admitted with a

stroke was found to be about 24% [National Audit Office, 2005].

Early recurrent stroke: the risk of stroke recurring within

30 days of an ischaemic stroke was found to depend on the cause

of the stroke:
About 20% for stroke caused by large-vessel cervical or

intracranial atherosclerosis with stenosis.

o

About 5% for cardioembolic stroke.

About 1% for lacunar stroke (caused by blockage of a

small non-branching end artery deep in the brain).
About 3% for stroke of uncertain cause [Petty et al,

2000].
Functional status: around half of stroke survivors were left

dependent on others for everyday activities [National Audit Office,

2005].
Longtermprognosis

Survival: a study in Perth, Australia, found that, having

survived 30 days after a stroke, the risk of dying in the next

10 years of:
o

Recurrent stroke was about 25%.

A cardiovascular event (excluding stroke) was about

33% [Hardie et al, 2003].
Impact of functional status on long-term survival:

The median survival time for people after an ischaemic

stroke 6 months previously was longer in those who were

independent in activities of daily living:

If independent, 9.7 years (95% CI 8.9 to 10.6).

If dependent, 6.0 years (95% CI 5.7 to 6.4) [Slot et

al, 2008].

Ongoing neurological deficit

How do I assess the cause of a sudden onset ongoing
neurological deficit?
Suspect stroke in anyone presenting with an acute onset,
ongoing focal neurological deficit that cannot be explained
byhypoglycaemia or other stroke mimics:
Especially if they fail the FAST (Face, Arm, Speech,

Time) test because of:

Facial weakness:

Ask the person to smile or show their teeth.

The FAST test is failed if there is new facial

asymmetry such as the mouth or eye droops.
Arm weakness:

Raise the person's arms to 90 if they are sitting

or 45 if they are lying. Ask the person to maintain the
position when you let go.

The FAST test is failed if, when you let go, one arm
falls or drifts down.
Speech problems:

Involve the person in conversation and determine

whether the speech is slurred or the person has difficulty
finding the name for commonplace objects (for example,
cup, table, chair, keys, pen). If they have difficulty seeing,
place the objects in their hands. If they have a companion,
check whether this is a new problem.

The FAST test is failed if there is a new

unexplained speech problem.
Also suspect stroke in people who have an otherwise

unexplained sudden onset of an ongoing neurological

deficit such as a:
o

Visual field defect.

Disorder of balance.

Coordination disorder.

Unilateral weakness confined to the leg.

Disorder of perception.

Scenario: Suspected acute stroke

Scenario: Suspected acute stroke due to ongoing
neurological deficit
Agefrom16yearsonwards

Pre-admission management
How should I manage someone presenting with an acute
stroke?
For people diagnosed with suspected stroke:
Arrange emergency admission within one hour to a

specialist stroke unit:

o

Greater urgency may be necessary if their clinical

condition is poor (for example, depressed level of
consciousness, progressing symptoms, severe headache).

If the diagnosis is made by a telephone consultation tell

them to dial 999 for an ambulance.

A small number of people with a severe comorbidity

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.
For people with symptoms starting within the last six

hours:
o

Ensure that ambulance control understands the urgency

of the situation and that the person needs to be taken
immediately to the nearest hospital with facilities for stroke
thrombolysis.

Ensure that the hospital is warned to expect the person.

Do not start antiplatelet treatment until haemorrhagic

stroke has been ruled out by a brain scan.

Scenario: Suspected transient

ischaemic attack
Scenario: Suspected transient ischaemic attack presenting after neurological symptoms have resolved
Age from 16 years onwards

Assessing risk of stroke after TIA

How do I assess the risk of stroke following a suspected
transient ischaemic attack?
Determine the stroke risk following a transient

ischaemic attack (TIA) by assessing:

o

The person's blood pressure.

For atrial fibrillation. If in doubt arrange an ECG. For

further information on assessing for atrial fibrillation see the

topic on Atrial fibrillation.
For diabetes. If the person is not known to be a

diabetic, test for diabetes especially if they are symptomatic.

For further information on assessing for diabetes see the topic
on Diabetes - type 2
For symptoms of a previous TIA within the last 7

days.
The ABCD2 score:

A age: 60 years of age or more, 1 point.

B blood pressure at presentation: 140/90 mm

Hg 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; 1059 minutes, 1 point.

D presence of diabetes: 1 point.

People are at high risk of an early stroke if they have any

of the following:
o

An ABCD2 score of 4 or more.

Atrial fibrillation.

More than one TIA in one week.

A TIA while on an anticoagulant.

People are at low risk of an early stroke if they:

Have an ABCD2 score of 3 or less.

Present more than a week after their last symptoms

have resolved.

Managing high risk of stroke after TIA

How should I manage someone at high risk of stroke
following a transient ischaemic attack?
For people at high risk of a stroke following a transient
ischaemic attack (TIA):
Refer for specialist assessment within 24 hours of the

onset of symptoms.

Give a statin such as simvastatin 40 mg.

Give an antiplatelet drug unless they are taking an

anticoagulant drug, when they should be admitted immediately
without giving treatment.
If they are not taking an anticoagulant or an

antiplatelet drug, immediately give either clopidogrel

300 mg (off-label use) or aspirin 300mg.

Do not delay treatment in people with

uncontrolled blood pressure.

Consider prescribing a proton pump inhibitor if the

person is at high risk of gastrointestinal adverse effects.

For further information on antiplatelet therapy

(including managing adverse effects), see the CKS topic
onAntiplatelet treatment.
If they are taking low-dose aspirin regularly,

continue the current dose of aspirin until reviewed by a

specialist.

If non-compliance is suspected, give either

clopidogrel 300 mg or aspirin 300 mg.

Advise them not to drive until they have been seen by a

specialist (when definitive guidance will be given).

Managing low risk of stroke after TIA

How should I manage someone at low risk of a stroke
following a transient ischaemic attack?
For people at low risk of a stroke following a transient
ischaemic attack:
Refer for specialist assessment as soon as possible,

but definitely within one week of onset of symptoms.

Give a statin such as simvastatin 40 mg daily.

Give an antiplatelet drug.

If they are not taking an antiplatelet drug,

immediately give either clopidogrel (off-label use) or

aspirin (each as a 300 mg loading dose and 75 mg daily
thereafter until they have been had been reviewed by a
specialist).

Do not delay initiating aspirin treatment in people

with uncontrolled blood pressure.

Consider prescribing a proton pump inhibitor if the

person is at high risk of adverse gastrointestinal effects or
experiences aspirin-induced dyspepsia.

For further information on antiplatelet therapy

(including managing adverse effects), see the CKS topic
onAntiplatelet treatment.
If they are taking low-dose aspirin regularly,

continue the current dose of aspirin until reviewed by a

specialist.

If non-compliance is suspected, give either

clopidogrel or aspirin (each as a 300 mg loading dose and 75

mg daily thereafter until they have been had been reviewed

by a specialist).
Consider assessing and managing cardiovascular

disease risk factors while awaiting specialist review. For further

information see the CKS topic on CVD risk assessment and
management.
Advise them not to drive until they have been seen by a

specialist (when definitive guidance will be given).

Scenario: Confirmed stroke - long-term

care and support
Agefrom16yearsonwards

Follow up
When and how should I follow up someone who has had a
stroke?
Followingastroke:

Where there are no problems requiring more frequent

assessments, schedule primary care follow up within 6 weeks of

discharge, again within 6 months of discharge, and then annually
to:
o

Assess the need for further specialist review, advice,

information, support, and rehabilitation see Referral
guidance.

Assess social care needs.

Assess health care needs .

Check and optimize lifestyle measures for secondary

prevention of cardiovascular disease.

Check and optimize drug treatments for secondary

prevention of cardiovascular disease.

Provide advice about driving after a stroke if appropriate.

Provide advice about returning to work after a stroke if

appropriate.

Annually check and the record blood pressure and lipid profile.

Arrange annual pre-winter influenza immunizations.

Assessing health care needs

How should I assess the health care needs of a person who
has had a stroke?
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.
Depression, anxiety, emotionalism, disturbed social

interaction 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.

o

Visual impairments and hemianopia .

Bladder and bowel problems urinary incontinence,

faecal incontinence, constipation.
Swallowing problems, oral health, malnutrition,

dehydration oral health, malnutrition, dehydration, artificial

feeding, and the ability to take medication.
o

Sexual dysfunction .

Difficulties with activities of daily living personal,

social, and vocational:
There is a separate section on Driving after a

stroke.
Many of the problems require referral to a specialist service.

Specialist services and the problems that they can manage are
summarized in the section Referral guidance.
Neurological problems
Balance impairment:

Balance training and walking aids should be considered

for people with balance impairment.

Many people have impaired balance after a stroke. This

is due to a combination of:

Reduced limb and trunk motor control.

Altered sensation on one side.

Altered representation in the brain of the body and

posture, often associated with left visual and spatial neglect.

Falls and injury prevention:

Falls and injury prevention, and assessment of bone

health, should be part of every stroke rehabilitation plan.

Training on how to get up after a fall should be provided

for the person and their carers.

For more information, see the CKS topic on Falls - risk

assessment.
Reduced movement, weakness, clumsiness (motor

control impairment):
People with impaired motor control should be referred to

a physiotherapist with experience in neurodisability.

Weakness on one side (hemiparesis) is probably the

single most disabling factor after a stroke.

Impaired tone spasticity and spasms:

Anyone with motor weakness after a stroke should be

assessed for spasticity.

There is considerable debate on the definition,

physiology, and importance of spasticity.

For 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 difficulty for the carer.
Spasticity can be treated by:

Exercise and stretching refer to a

physiotherapist.

Intramuscular botulinum toxin (for focal spasticity

affecting one or two joints) refer to specialist stroke
service.

Antispastic drugs (for generalized spasticity). First

try baclofen, gabapentin, or tizanidine.

If adequate control cannot be achieved with one of

these drugs, refer to a specialist with expertise in managing
spasticity who can consider trying combinations of these
drugs or other treatments.
Splinting of the arm and hand should not be used

routinely after stroke.

Impaired sensation:

People with marked sensory loss but good motor

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

avoid accidental injury.
Touch, position sense, pain and other sensations may be

impaired after a stroke. Its severity is probably associated with

the extent of motor loss.
Pain
Neuropathic pain:

Five percent to 20% of people experience neuropathic

pain after a stroke.

It can occur together with spasticity or sensory loss. It is

(in principle) separate from musculoskeletal pain.

Everyone who has had a stroke should be asked whether

they are experiencing pain as a result of the stroke.

Neuropathic pain can be treated with one or more of:

An antidepressant such as amitriptyline.

An anticonvulsant such as carbamazepine,

gabapentin.

For more information on drug treatments for

neuropathic pain, see the CKS topic on Neuropathic pain - drug
treatment.

People with pain that is poorly controlled within a few

weeks should be referred to a specialist in pain management.
Shoulder pain and subluxation:

People with arm weakness after a stroke should be

asked about shoulder pain from time to time.

People with shoulder pain and their carers should have

advice on position and handling the weak arm overhead arm
slings and shoulder supports should not be used.

Offer simple analgesics (for example, paracetamol, a

nonsteroidal anti-inflammatory drug [NSAID] with a proton
pump inhibitor [PPI] for gastroprotection) to people with
shoulder pain intra-articular corticosteroids should not be
used.

Consider referring people with 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:

After a stroke, immobility and abnormal posture can

cause pain, especially in people who have osteoarthritis or
inflammatory arthritis.

Everybody with significant motor loss after a stroke

should be asked about musculoskeletal pain.

People with musculoskeletal pain should be assessed to

determine whether the pain can be reduced by improvements
in handling techniques, posture or movement.

Offer simple analgesics to be taken regularly:

Paracetamol, up to 1 g four times daily.

An NSAID together with a PPI for

gastroprotection. The recommendation to routinely use a PPI
is in line with NICE guidelines.
Codeine or similar morphine derivative.

Depression, anxiety, emotionalism, disturbed social

interaction
Mood disturbance is common after a stroke and presents as

depression, anxiety, or both.

The severity of mood disturbance is associated with the

severity of cognitive impairments, motor impairments, and

limitation of activity.
Mood disturbances can exacerbate other impairments and

limit the recovery of function.

Depression:

Depression is common but often remits as function is

recovered.

Everyone who has had a stroke should be screened for

depression from time to time.

People with depression should be screened for anxiety

and emotionalism.

People with depression sufficient to cause distress or

impede rehabilitation and not responding to primary care
management should be assessed by an expert (for example, a
clinical psychologist, appropriately trained stroke physician,
psychiatrist).

Contributory factors (for example, pain, social isolation)

should be addressed.

People with minor depression should be:

Monitored for progression.

Involved in increased social interaction, increased

exercise, goal setting, and other psychosocial interventions.
People with more severe or persistent depression should

be offered one or more of:

Antidepressant drug treatment, to be monitored,

and continued for at least 6 months if a benefit is achieved.

Psychological therapy.

For more information, see the CKS topic on Depression.

Anxiety:

Anxiety after stroke is often focused on fear of falling

and fear of recurrence.

Everyone should be screened for anxiety after a stroke.

Anyone with anxiety sufficient to impede recovery or to

cause distress should be assessed and considered for
psychological treatment.
Emotionalism:

People who cry (or, less commonly, laugh) in an overly

emotional way or after what appears to be minimal provoking
stimuli are said to have emotionalism or emotional lability.

People with troublesome emotionalism may be offered

antidepressant drug treatment.

Refer people with troublesome emotionalism not

responding to primary care management to a specialist.

Social interaction interpersonal relationships:

Stroke infrequently causes disinhibited or aggressive

behaviour.
People whose style of social interaction after a stroke

causes distress to others should be assessed by a clinical

psychologist, and other specialists (for example, psychiatrist or
speech and language therapist) if necessary.
Management may include:

Information and advice for the person, their

family, and others in contact socially or professionally.

Treatment of causal or aggravating factors (for

example, an antidepressant or an antipsychotic).

Cognitive impairments
General:

Almost all people with cerebrovascular disease have

some degree of cognitive loss.

Everyone who has had a stroke or transient ischaemic

attack (TIA) should be considered to have at least some

cognitive losses initially, and should be screened to identify the
range of cognitive impairments (e.g. with the Mini-Mental State
Examination or short Orientation-Memory-Concentration Test):

The Mini-Mental State Examination tests

orientation, registration, attention, calculation, recall, and
language.

The short Orientation-Memory-Concentration Test

discriminates among mild, moderate, and severe cognitive
deficits.

People who have had a stroke should be assessed

before returning to cognitively demanding activities (e.g.
driving, some work activities).

People with cognitive impairment should be formally

assessed by a specialist.
The approach to management should include:

Identification 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 organizers, and audio alarms).
Attention and concentration:

Disturbed alertness is common after stroke, especially in

the initial period of recovery, and with right cerebral
hemisphere strokes, when it can be asymmetrical with the left
side more severely affected.
Memory:

Almost all people who have had a stroke experience

memory difficulties. About 20% of people who survive for
6 months after a stroke have dementia.
Disturbances of spatial awareness neglect:

Disturbances of spatial awareness are more common in

people with right cerebral hemisphere brain damage and
hemianopia. The person acts as if they have reduced
awareness of some part of their environment, usually the left
side.
Disturbance of perception visual agnosia:

After a stroke, some people have a specific difficulty in

recognizing objects (agnosia). Agnosia is usually visual.

Behaviours due to visual agnosia can be mistakenly

attributed to impaired memory, language, or deliberate

pretence.
Apraxia loss of the conceptual ability to organize

activities to achieve a goal:

People with motor apraxia have difficulty in carrying out

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

and muscle strength.
Apraxia is usually associated with damage to the left

cerebral hemisphere.
Any person found to have apraxia should:

Have their profile of impaired and preserved

action abilities determined using a standardised approach
(for example, Test of Upper Limb Apraxia (TULIA))

Have the impairment and the impact on function

explained to them, their family, and their treating team

Be given therapies and/or taught compensatory

strategies specific to the deficits.
Disturbances of executive functioning:

'Executive functioning' refers to the ability to plan and

execute a series of tasks and to the ability to foresee the
consequences of actions.

The dysexecutive syndrome encompasses several

impairments including difficulties with planning, organizing,
initiating, and monitoring behaviour and adapting it as
circumstances change.

Any person who appears to have adequate skills to

perform complex activities but who fails to organize the tasks
needed should be formally assessed.

Speech and communication difficulties

Peoplewithspeechdifficultiesshouldbereferredtoaspeechandlanguagetherapistforassessment
andtreatment:

Aphasia impairment of language:

Aphasia (also known as dysphasia) is a specific

impairment of language function; the ability to form and
understand words, whether orally or in writing.

Aphasia is associated with damage to the dominant

cerebral hemisphere (usually the left). Subtle difficulties with
communication can occur with damage to the non-dominant
cerebral hemisphere.
Dysarthria:

Dysarthria occurs when control over the muscles

responsible for speech is impaired. Speech is slurred.
Dysarthria is often associated with swallowing difficulties
(dysphagia).
Apraxia of speech:

A small proportion of people with stroke have specific

impairment of the ability to plan and execute the multiple
skilled motor tasks required for successful talking; this is
apraxia of speech. It is usually associated with damage to the
left cerebral hemisphere.

Visual 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 (difficulty in
recognizing objects), and visuospatial neglect.

Loss of part of a visual field (hemianopia) is also common.

Age-related visual problems may also be present and include

cataract, glaucoma, macular degeneration, and uncorrected

refractive errors.
Everyone who has had a stroke should have their visual acuity

assessed (while wearing their glasses) check whether they can

read the print in a newspaper and whether they can clearly see
distant objects.
People with a visual field defect should be:

Informed about the consequences for driving see the

section on Driving after a stroke.

Taught compensatory techniques if the defect causes

practical problems this may require referral.
Treatment with prisms should only be considered if the person

is aware that prisms might not have any benefit for them and if
the treatment is provided and evaluated by an expert.
Bladder and bowel problems
Bowel and bladder impairment:

Disturbance of control of excretion is common in the

acute phase of a stroke and remains a problem for a significant
minority of people.
Incontinence:

Incontinence is demeaning for the person, is a major

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

People with 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.

For problems that need specialist treatment and support

in the community, consider referral to a continence adviser.

Constipation:

People with troublesome constipation should:

Have a review of their drugs to minimize use of

constipating drugs.
Be given advice on diet, fluids, and physical

activity.

Be offered oral laxatives.

Be offered rectal laxatives only if severe problems

remain.
For more information, see the CKS topic on Constipation.

Swallowing problems, oral health, malnutrition, dehydration

Swallowing problems and oral health:

Difficulty in swallowing (dysphagia) is common in people

who have had a stroke.

Dysphagia can lead to:

Food, fluid, or saliva entering the lungs and

causing aspiration pneumonia.

Reduced intake of food and drink, causing

malnutrition or dehydration.

Embarrassment when eating in social settings.

Everybody who has had a stroke should have their

ability to swallow assessed as soon as possible by a person

with appropriate training.

People with difficulty in swallowing should be assessed

by a speech and language therapist, or other appropriately

trained professional. Management often requires a
multidisciplinary team.
All people who are not swallowing should have oral and

dental hygiene maintained (by the person or their carers)

through regular (for example, 4-hourly) removal of secretions
and brushing of teeth or dentures.
People who have been assessed for swallowing

problems may need to be reassessed.

Nutritional problems:

Malnutrition, poor nutrition, and dehydration are

common in people who have had a stroke:

To identify adults who are malnourished, at risk of

malnutrition (undernutrition), or obese, the Malnutrition
Universal Screening Tool (MUST) is recommended.

MUST also includes management guidelines which

can be used to develop a care plan, and is available online
atwww.bapen.org.uk.

The management of people being artificially fed

should be checked.

Once nutritional status has been checked,

consider supplementation with vitamin D3 and calcium if
there is a risk of deficiency (particularly if the person is
house bound or are living in a care home).

For problems that need specialist assessment,

treatment, and support in the community, consider referral to a
dietitian or a speech and language therapist.

Sexual dysfunction
In people who have had a stroke, sexual dysfunction is

common for many reasons, including altered sensation, limited

mobility, effects of drugs, and changes in mood.
People who have had a stroke should be asked, at an

appropriate moment, whether they have any concerns about their

sexual functioning.
People who request help should be:

Reassured that sexual activity is not contraindicated

after a stroke and is extremely unlikely to precipitate a further

event.
o

Assessed for treatable causes.

Assessed for the use of a phosphodiesterase type 5

inhibitor, such as sildenafil (although these drugs should not be
prescribed for 3 months after a stroke and until blood pressure
is controlled).

Advised about ways to overcome practical problems.

Referred to a person with expertise in managing sexual

dysfunction if problems persist despite primary care
management.
For more information, see the CKS topic on Erectile

dysfunction.
Difficulties with activities of daily living
Difficulties with activities of daily living should be assessed in

terms of:
o

Difficulties with personal activities of daily living,

including dressing, washing, feeding, and personal hygiene.

Difficulties with extended activities of daily living,

including domestic and community social activities.

Difficulties with vocational activities of daily living,

including productive work and leisure activities.

People who have had a stroke should be formally assessed (by

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

activities of daily living.
People who have limitations on any aspect of the activities of

daily living should be referred to an occupational therapist with

experience in neurological disabilities.
Management may include:

Information and advice on coping with the disabilities.

Aids, equipment, and home or work adaptations to

achieve safe activities (and the training needed to use the aids,
equipment, and adaptations).
There is a separate section on Driving after a stroke.

Lifestyle advice for secondary prevention

What lifestyle advice should be offered following a stroke to
reduce cardiovascular disease risk?
Advise lifestyle measures that may reduce the risk of stroke

and other cardiovascular disease events, including:

o

Stopping smoking.

Adopting a cardioprotective diet, including reducing salt

intake.

Regular exercise.

Prudent use of alcohol men should drink no more than

three units per day, and women no more than two units per
day, with at least 2 alcohol-free days per week.

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 !!Link!! in the CKS topic on CVD

risk assessment and management.

Drug treatments for secondary prevention

What drug treatment should be offered following a stroke to
reduce cardiovascular disease risk?
Cardiovasculardiseaseriskwillnormallybeassessed,andtreatmentinitiatedinsecondarycare.
Followingdischargeforastroke:

Ensure optimal management of:

Atrial fibrillation if present. For detailed management

advice see the CKS topic on Atrial fibrillation.

Diabetes if present. For detailed management advice

see the CKS topic on Diabetes - type 2.

Hypertension if present. Treatment should be started

prior to discharge from hospital or 2 weeks after the stroke

(which ever is the soonest), unless a hypertensive emergency
requires urgent reduction in blood pressure.

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 130
150 mmHg) may be appropriate.

For detailed management advice see the CKS

topic on Hypertension - not diabetic.

Ensure an antiplatelet drug has been offered unless the

person has an indication for an anticoagulant for example

because they are in atrial fibrillation or they have had a cerebral

venous thrombosis.
Aspirin 300 mg daily for 2 weeks is given

immediately after an ischaemic stroke is confirmed by

brain imaging.
Clopidogrel 75 mg daily is then given long-term if

it can be tolerated and is not contraindicated.

Consider 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.

For further information on who is at high risk of

gastrointestinal bleeding and prescribing issues on
antiplatelet therapy (including managing gastrointestinal
issues), see the CKS topic on Antiplatelet treatment.

If clopidogrel is contraindicated or not tolerated, give a

combination of modified-release dipyridamole (200 mg twice
daily) and low dose aspirin.

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.
Ensure a statin has been offered. This is normally started

48 hours after an acute stroke.

o

Seek specialist advice before initiating a statin in people

with a history of haemorrhagic stroke, particularly those with
inadequately controlled hypertension.

Recheck the cholesterol one to three months after

starting treatment and increase treatment if the cholesterol is

more than 4 mmol/L or low-density lipoprotein (LDL) cholesterol

is more than 2 mmol/L.
For further information see the CKS topic on Lipid

modification - CVD prevention.

Managingatrialfibrillationanddiabetesafterastroke

Atrial fibrillation

The recommendation to manage atrial fibrillation is

based on pragmatic CKS advice. Stroke and thromboembolism
are the main complications of atrial fibrillation (AF) [National
Collaborating Centre for Chronic Conditions, 2006]. People with
AF have a five-fold greater risk of stroke and thromboembolism
than people without AF [NICE, 2006].
Diabetes

The recommendation to manage diabetes is based on

pragmatic CKS advice. Diabetes is second only to smoking as
the major aetiological factor in atherosclerotic vascular disease
[BMA, 2004]. The risk of stroke is up to three times greater in
people with diabetes than those without diabetes [WeMeReC,
2005].

Treatinghypertensionafterastroke

Reducing blood pressure

There is evidence from randomized controlled trials that

reducing blood pressure after a stroke or a TIA prevents further
cardiovascular events. For a detailed discussion see
the evidence section in the CKS topic Hypertension - not
diabetic.
When to start antihypertensive treatment:

NICE found no evidence to suggest that manipulating

blood pressure in acute stroke (within the first 72 hours) using
beta-blockers or calcium-channel antagonists, compared with

control or placebo, had any beneficial effect on mortality,

dependency, or stroke recurrence. Because there are also
concerns about possible adverse effects with early reduction in
blood pressure, NICE recommends starting antihypertensive
treatment in people with acute stroke only if there is a
hypertensive emergency.
The recommendation to wait about 2 weeks before

starting treatment with an antihypertensive for people who

have had an acute stroke is based on expert opinion from a
review article [Sudlow, 2008]. After an acute stroke blood
pressure tends to fall spontaneously. It is thought that waiting
until blood pressure has stabilised to start an antihypertensive
lowers the risk of reducing cerebral perfusion [Sudlow, 2008].
Blood pressure targets:

The recommended blood pressure targets are those

recommended by guidelines published by NICE and the RCP

ICSWP [NICE, 2011; Intercollegiate Stroke Working Party, 2012].

NICE recommends a target blood pressure of

140/90 mmHg or less for people with existing cardiovascular
disease or target organ damage. This is consistent with the
National Stroke Strategy, which recommends a systolic blood
pressure less than 140 mmHg for prevention [DH, 2007].

For secondary prevention of stroke, the RCP ICSWP

guideline recommends a blood pressure target of
130/80 mmHg based on expert opinion from the Joint British
Hypertension Society [BHS, 2004; Intercollegiate Stroke
Working Party, 2012 ]. This blood pressure target is also
advocated by the Joint British Societies guideline [British
Cardiac Society et al, 2005].

A higher target blood pressure (for example,

systolic blood pressure of 150 mmHg) for people with
bilateral severe carotid artery stenosis is recommended by
the RCP ICSWP guidelines [Intercollegiate Stroke Working
Party, 2012]. No evidence suggests that people with severe

stenosis should have a systolic blood pressure more than

150 mmHg.
Antiplatelettreatmentafterastroke

Long-term antiplatelet therapy is

recommended because evidence from a large meta-analysis

indicates that prolonged antiplatelet therapy reduces the risk of
all-cause mortality, vascular mortality, and non-fatal vascular
events (stroke and myocardial infarction) in people with a history
of stroke or transient ischaemic attack [Antithrombotic Trialists'
Collaboration, 2002].
For a detailed discussion of the evidence supporting these

recommendations, including the choice of antiplatelet treatment,

see the CKS topic on Antiplatelet treatment.
Statintreatmentimmediatelyafteranacutestroke

Evidence reviewed by the NICE Guideline Development Group

found that statin withdrawal is associated with worse clinical

outcomes after ischaemic stroke than when premorbid statin
treatment is continued. They found no evidence regarding the
safety and efficacy of initiating lipid-lowering statin therapy for
people with an acute stroke. The consensus of the NICE Guideline
Development Group was [National Collaborating Centre for
Chronic Conditions, 2008]:
o

There is no evidence for initiating statins in acute stroke,

but there is evidence to support continuing statin treatment in
those who were taking statins before the stroke.

It would be safe to start statins after 48 hours. There is

benefit from initiation of statins after the acute phase of stroke
in vascular risk reduction.

Longtermstatintreatmentafterastroke

Evidence reviewed by the RCP ICSWP found that lipid-lowering

therapy with statins was beneficial for people with cardiovascular

disease and specifically cerebrovascular disease [Heart Protection

Study Collaborative Group, 2002;Amarenco et al, 2006].
In the Heart Protection Study (HPS), taking simvastatin

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

events) resulted in a relative risk reduction of 17% in vascular
deaths, 27% in major coronary events and 25% in stroke.
In a second study, atorvastatin 80 mg daily (given to

people with a history of TIA or stroke in the preceding 6

months) resulted in a relative risk reduction of 15% in stroke
and 35% in major coronary events [Amarenco et al, 2006].
Prescribing statins for people who have had a

haemorrhagic stroke:
The RCP ICSWP recommended that statins should be

prescribed with caution, if at all, in people who have had a

haemorrhagic stroke, particularly if they have inadequately
controlled hypertension [Intercollegiate Stroke Working Party,
2012]:

The manufacturer of atorvastatin warns that, for

people with prior haemorrhagic stroke or lacunar infarct, the
balance of risks and benefits of atorvastatin 80 mg is
uncertain and the potential risk of haemorrhagic stroke
should be considered carefully before initiating treatment
[Pfizer Ltd, 2007; ABPI Medicines Compendium, 2014].

One meta-analysis found the evidence for statins

causing haemorrhagic stroke to be uncertain [Law and
Rudnicka, 2006]. Cohort studies showed an association while
randomized trials were uninformative because the confidence
intervals on the summary estimate were too wide. However,
the authors concluded that the possible risk is greatly
outweighed by the protective effect against thromboembolic
stroke and coronary artery disease.

One study found that the risk of haemorrhagic stroke

was increased in people who were taking atorvastatin: hazard

ratio 1.68, 95% CI 1.09 to 2.59; p = 0.02 [Goldstein et al,

2008].
CKS therefore recommends seeking specialist advice

before prescribing a statin for people who have had a

haemorrhagic stroke, particularly if they have uncontrolled high
blood pressure.

Driving after a stroke

What should I advise about driving after a stroke?
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:
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 II 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:

o

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.
For all people (group I or II licence) who wish to resume

driving after recovering from a stroke:

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 hemispatial 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.

Returning to work after a stroke

What advice should I give about returning to work after a
stroke?
For people that have had a stroke advise that:

Stroke affects everyone in a different way and it is

difficult to tell immediately after a stroke who will be able to

return to work or how quickly this may happen.
If the person wishes to return to work (paid or unpaid)

options include:

Discussing a return to work with their GP or a

member of the stroke care team who can advise on whether
the person is fit to go back to work. The person should be
assessed for cognitive functioning, ability to communicate,
and any other practical issues involved in returning to work.

Discussing their work requirements and options

with their employer. For example, if they want to work parttime, full time, or if there is another post available within the
organisation that may be more appropriate.

Talking to an employment adviser at a

local Jobcentre Plus (www.gov.uk) who will be able to give
advice on disability, retraining and transferable skills.

Referral guidance
To which specialists should I refer people who have specific
problems following a stroke?
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

clinical commissioning groups.
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.

Assess the risk of pressure sores and prevent their

development.

A community matron may be the appropriate referral

for people with high-intensity needs. They can coordinate
inputs from all other agencies.

A community pharmacist can identify the support

needed to enable the person to manage their own medication
safely.

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.

An occupational therapist can assess, advise, and

provide aids, equipment, or adaptations for people who have
problems with everyday activities at home or work.

An orthoptist can give advice about the management

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

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 social worker can help to ensure that rehabilitation

plans are meeting the needs of the person, and support the
person and their family through financial, relationship or
housing problems.
A speech and language therapist can assess and

treat people with:

Communication and language difficulties.

Swallowing problems or requiring artificial feeding.

Scenario: Confirmed TIA - long-term

care and support
Scenario: Confirmed transient ischaemic attack - longterm care and support
Age from 16 years onwards

Follow up after TIA

When and how should I follow up someone with a confirmed
diagnosis of transient ischaemic attack?
Followingatransientischaemicattack(TIA):

Follow up within 1 month of the event (in primary or

secondary care) and then annually in primary care to:

o

Check and optimize lifestyle measures for secondary

prevention of cardiovascular disease.

Check and optimize drug treatments for secondary

prevention of cardiovascular disease.

Provide advice about driving after a TIA if appropriate.

Annually check and record blood pressure and lipid profile.

Arrange annual pre-winter influenza immunizations.

Annualbloodpressureandlipidprofile

The recommendations on the frequency of recording blood

pressure and lipid profiles are in line with recommendations in

national guidelines and reflect the Quality and Outcomes
Framework of the General Medical Services contract
[Intercollegiate Stroke Working Party, 2012; BMA and NHS
Employers, 2013a].
Annualprewinterinfluenzaimmunization

The recommendation that people who have had a stroke or

transient ischaemic attack be offered annual immunization

against influenza is in line with guidelines published by Public
Health England [DH, 2013] and the Quality and Outcomes
Framework of the General Medical Services contract [BMA and
NHS Employers, 2012].
Thebasisforotherrecommendations

These can be found within the sections that have been linked

to.

Lifestyle advice for secondary prevention

What lifestyle advice should I give someone following a
transient ischaemic attack to reduce cardiovascular disease
risk?
Advise lifestyle measures that reduce the risk of stroke and

other cardiovascular disease events, including:

o

Stopping smoking.

Adopting a cardioprotective diet, including reducing salt

intake.

Regular exercise.

Prudent use of alcohol men should drink no more than

three units per day, and women no more than two units per
day, with at least 2 alcohol-free days per week.

Achieving and maintaining a satisfactory body weight.

For more information, see the !!Link!! in the CKS topic on CVD

risk assessment and management.

The RCP ISWP found little evidence on lifestyle measures to

prevent the recurrence of a stroke or a transient ischemic attack

(TIA). The RCP ISWP base their recommendations on lifestyle
measures on evidence for the primary prevention on vascular
events.
Recommendations for limiting alcohol consumption are in line

with advice on sensible drinking from the Department of Health.

The recommendation to advise all people to have at least two
alcohol-free days is based on alcohol guidelines from the House of
Commons Science and Technology Committee [House of
Commons, 2011].

Drug treatments for secondary prevention

What drug treatments should be offered a person following
a transient ischaemic attack to reduce cardiovascular
disease risk?
Cardiovasculardiseaseriskwillnormallybeassessed,andtreatmentinitiatedinsecondarycare.
Followingdischargeforatransientischaemicattack(TIA):

Ensure optimal management of:

Atrial fibrillation if present. For detailed management

advice see the CKS topic on Atrial fibrillation.

Diabetes if present. For detailed management advice

see the CKS topic on Diabetes - type 2.

Hypertension if present. Treatment should be initiated

immediately after the diagnosis of TIA has been confirmed by a
specialist.

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 130
150 mmHg) may be appropriate.
For detailed management advice see the CKS

topic on Hypertension - not diabetic.

Ensure an antiplatelet drug has been offered long-term

unless they have an indication for an anticoagulant for example

because they are in atrial fibrillation or they have had a cerebral
venous thrombosis.
Clopidogrel (75 mg daily) is the preferred long-term

antiplatelet.

Consider 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.

For further information who is at high risk of

gastrointestinal bleeding and prescribing issues on
antiplatelet therapy (including managing gastrointestinal
issues), see the CKS topic on Antiplatelet treatment.

If clopidogrel is contraindicated or not tolerated, give a

combination of modified-release dipyridamole (200 mg twice
daily) and low dose aspirin.

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.

Ensure a statin has been offered as soon as possible after

a TIA.
Recheck the cholesterol one to three months after

starting treatment and increase treatment if the cholesterol is

more than 4 mmol/L or low-density lipoprotein (LDL) cholesterol
is more than 2 mmol/L.
For further information see the CKS topic on Lipid

modification - CVD prevention.

ManagingatrialfibrillationanddiabetesafteraTIA

Atrial fibrillation

The recommendation to manage atrial fibrillation is

based on pragmatic CKS advice. Stroke and thromboembolism
are the main complications of atrial fibrillation (AF) [National
Collaborating Centre for Chronic Conditions, 2006]. People with
AF have a five-fold greater risk of stroke and thromboembolism
than people without AF [NICE, 2006].
Diabetes

The recommendation to manage diabetes is based on

pragmatic CKS advice. Diabetes is second only to smoking as
the major aetiological factor in atherosclerotic vascular disease
[BMA, 2004]. The risk of stroke is up to three times greater in
people with diabetes than those without diabetes [WeMeReC,
2005].

TreatinghypertensionafteraTIA

Reducing blood pressure

There is evidence from randomized controlled trials that

reducing blood pressure after a stroke or a TIA prevents further
cardiovascular events. For a detailed discussion see
the evidence section in the CKS topic Hypertension - not
diabetic.

When to start antihypertensive treatment

The recommendation to start antihypertensives

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

issued by NICE [National Collaborating Centre for Chronic
Conditions, 2008] and the RCP ICSWP [Intercollegiate Stroke
Working Party, 2012]. A delay in starting antihypertensives is
recommended for people who have had a stroke because there
are concerns about possible adverse effects with early
reduction in blood pressure. However this is not the case in TIA
and it is reasonable to start antihypertensives promptly for
these people [Sudlow, 2008].
Blood pressure targets:

The recommended blood pressure targets are those

recommended by guidelines published by NICE and the RCP

ICSWP [NICE, 2011; Intercollegiate Stroke Working Party, 2012].

NICE recommends a target blood pressure of

140/90 mmHg or less for people with existing cardiovascular
disease or target organ damage. This is consistent with the
National Stroke Strategy, which recommends a systolic blood
pressure less than 140 mmHg for prevention [DH, 2007].

For secondary prevention of stroke, the RCP ICSWP

guideline recommends a blood pressure target of
130/80 mmHg based on expert opinion from the Joint British
Hypertension Society [BHS, 2004; Intercollegiate Stroke
Working Party, 2012 ]. This blood pressure target is also
advocated by the Joint British Societies guideline [British
Cardiac Society et al, 2005].

A higher target blood pressure (for example,

systolic blood pressure of 150 mmHg) for people with
bilateral severe carotid artery stenosis is recommended by
the RCP ICSWP guidelines [Intercollegiate Stroke Working
Party, 2012]. No evidence suggests that people with severe
stenosis should have a systolic blood pressure more than
150 mmHg.

AntiplatelettreatmentafteraTIA

Long-term antiplatelet therapy is

recommended because evidence from a large meta-analysis

indicates that prolonged antiplatelet therapy reduces the risk of
all-cause mortality, vascular mortality, and non-fatal vascular
events (stroke and myocardial infarction) in people with a history
of stroke or transient ischaemic attack [Antithrombotic Trialists'
Collaboration, 2002].
For a detailed discussion of the evidence supporting these

recommendations, including the choice of antiplatelet treatment,

see the CKS topic on Antiplatelet treatment.
LongtermstatintreatmentafteraTIA

Evidence reviewed by the RCP ICSWP [Intercollegiate Stroke

Working Party, 2012] found that lipid-lowering therapy with

statins was beneficial for people with cardiovascular disease and
specifically cerebrovascular disease [Heart Protection Study
Collaborative Group, 2002; Amarenco et al, 2006].
o

In the Heart Protection Study (HPS), taking simvastatin

40 mg daily (given to people at high risk of cardiovascular
events) resulted in a relative risk reduction of 17% in vascular
deaths, 27% in major coronary events and 25% in stroke [Heart
Protection Study Collaborative Group, 2002].

In a second study atorvastatin 80 mg daily (given to

people with a history of TIA or stroke in the preceding 6
months) resulted in a relative risk reduction of 15% in stroke
and 35% in major coronary events with treatment [Amarenco
et al, 2006].The recommendation to start treatment with a
statin after a TIA is based on guidelines issued by NICE and the
RCP ICSWP [NICE, 2011; Intercollegiate Stroke Working Party,
2012], and is extrapolated from recommendations made for
stroke.

Driving after a TIA

What should I advise about driving after transient ischaemic
attack?
AlwaysconsultthelatestDriverandVehicleLicensingAgency(DVLA)regulationstoensure
thatyouradviceisaccurateanduptodateseethe'AtaGlance'bookletavailableon
theDVLAwebsite.

For people with a group II licence for large goods

vehicles or passenger carrying vehicles who have had a

transient ischaemic attack (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 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 II 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 TIA:

o

They must not drive for at least 4 weeks.

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.

They should inform their car insurance company before

resuming driving, as failure to do so could result in the
insurance being void.