NORTH STAFFORDSHIRE
STROKE UNIT MANUAL
Editor C. Roffe
This is a working document aiming to provide guidance on the management of stroke patients on the stroke unit. It
should be available for use for all professionals working with stroke patients within the stroke service. It is as yet
incomplete, and any the stroke team would be grateful for comments on completed sections and contributions for
sections not completed yet.
Completed sections are indicated by the initials of the author and the date of completion in the index. Underlined words
in the index are hyperlinks. Clicking on these words will take you to the section. The appended documents are not
accessible outside my office since they link to files on my computer. If you need copies of these documents please
email christine.roffe@northstaffs.nhs.uk.
A paper copy of this document should be available for ward use and the document should also be saved to the
desktop on the ward and in your office and replaced by the new version when an update is mailed.
The guideline is general, and individual patients may require deviations from the
recommended treatment.
Index
General points
Philosophy of care
The stroke service
Admission procedures
Triage for Admission to the ASU
The hot transfer protocol
Transfer criteria for the RSU
Acute stroke management
Diagnosis of stroke CR May 05
Causes of stroke CR May 05
Stroke classification and prognosis CR May 05
Why is acute stroke management important? CR May 05
needs review
Care pathway for acute stroke management
Thrombolysis
CR 30 05 2010
EarlyMobilisation and stimulation E Hall June 2005
72 hour monitoring and intervention protocol 06 07 2011
Airway management
RW 2002
Hypoxia
CR 15 05 2010
Pyrexia
JC/CR 2003
Early Blood Pressure Management
JC/CR 2003 revised 15 05 2010
Hypotension
JC CR 2003
Hypertension within the first week JC CR 2003
Medical management of severe hypertension
CR 2002 needs review
Hyperglycaemia
CR 15 05 2010
Neurological deterioration
Crescendo TIAS
CR 15 05 2010
Intracerebral haemorrhage
needs to be fully delveloped
Correction of abnormal INR
CR 30 06 2010
Assessment of swallowing
RW 02, needs review
Thrombosis prophylaxis
CR 20 04 2010
Assessments
Medical treatments
The first day meeting
Ward routines and ward rounds on the ASU
Communication and
information
The relatives' clinic
Carers Group meetings
Complications
Cerebral Oedema
Confusion and agitation
Haemorrhagic conversion of a cerebral infarct
DVT and PE
CR 20 04 2010
Depression
CR 1.12.04
Incontinence
Urinary Retention
CR 17.17.10
Shoulder Pain
CR 29.11.04
Reducing Stroke Risk
Rehabilitation
Work and Leisure
Post Stroke Seizures
Spasticity
A. Ward, 30.12.04
Drooling
A. Ward ?
Smoking
Hypertension (long term management)
Hyperlipidaemia
CR
29.11.04
Alcohol
Diabetes
Atrial fibrillation
R. Campbell Sept 08
Anticoagulation with warfarin
CR 22.06.2010
Other sources of emboli
Avoidance of HRT
Polycthaemia
Carotid endartrectomy
Diet
Exercise
PFO, ASD
CR May 2010
Hemiparesis/ hemiplegia
Perceptual difficulties after stroke E.Hall 6.6.05
Aphasia
Hemiparesis/ hemiplegia
Resuming hobbies and interests E Hall June 05
Driving E Hall June 05
Travel E. Hall June 05
Common problems
Discharge
Discharge planning
The collaborative care discharge documentation
The stroke checklist
Discharge letter
Out-patient review
One month follow-up call
Liaison with the Stroke Association
The stroke clinic
CR 1.5.2010
Audit
Education and Training
Research
Sources of information
Appendix
Stroke care pathway day 1
Stroke care pathway day 2 and 3
ASU Acute Stroke Monitoring Actions Chart
Scandinavian Stroke Scale
NIHSS Scale
CR 15 05 2010
Rankin Scale
Barthel Scale
MMSE
Hospital Anxiety and Depression Scale (HAD) proforma link
Whamm falls risk tool
Waterlow Scale
Nutrition assessment
Care plan for starting enteral feeding
Swallowing assessment
Collaborative Care Discharge Documentation
Discharge letter template
CR 30.04.2010
Stroke Clinic 6 week follow-up proforma
CR 1.5.1010
Stroke Clinic 6 week patient questionnaire
CR 1.5.1010
Stroke 6 month follow-proforma
CR 1.5.2010
Stroke 6 month follow-up questionnaire
CR 1.5.2010
Stroke clinic 3-month follow-up proforma (not in use 2010) CR 2.12.04
Three months follow-up Questionnaire (not in use 2010) CR 2.12.04
Annual Warfarin Review Form
CR 7.10.2008
Ward Team Philosophy of the Acute Stroke Unit
The multi-professional team of the Acute Stroke Unit is committed to providing the best treatment, care and
emotional support to patients and their relatives during the acute stage of their stroke. Our aim is to promote
independence, health and well-being.
Patients will be treated, monitored and cared for by skilled and knowledgeable staff with a strong interest in
stroke. All members of the multi-professional team will work closely together to provide up-to-date, evidence
based care in a welcoming, caring, safe and progressive environment.
The team will work together with patients, their relatives and carers to achieve the best outcome for each
individual. Patients and their families will be encouraged to take an active part in developing their
independence as soon as possible after a stroke.
The team will strive to ensure that patients are kept fully informed about their condition, treatments,
investigations and progress, and will be happy to respond to any queries and concerns. Wherever possible
and acceptable to the patient, we will endeavour to involve relatives and carers in this process.
The treatment and care provided on the Acute Stroke Unit will prepare patients for their return home or to
further rehabilitation, wherever possible. In spite of all efforts, some patients may not recover from their
stroke. The team is committed to provide support and comfort to these patients and their families.
Criteria for transfer to specialist stroke rehabilitation I
The ideal setting
These would be the criteria for transfer if the number of stroke rehabilitation beds was not limited. These
criteria can be used for determining bed numbers, but will not be usable clinically until the number of
rehabilitation beds has increased to 30-40.
Who should be transferred for specialist stroke rehabilitation?
All stroke patients who :
Are medically stable
Are not moribund
Are foreseen to need more than 10 days of continued rehabilitation once stable
When should stroke patients be transferred to specialist stroke rehabilitation?
As soon as thy are medically stable after the stroke. This would usually be within 3-10 days of admission.
Which patients should be transferred to rehabilitation and care settings other than the specialist stroke
rehabilitation ward?
The stroke rehabilitation ward should combine input from stroke specialists and specialists in general
rehabilitation allowing seamless care for older and younger stroke victims.
Patients who are moribund should be cared for in appropriate palliative care settings.
Patients who have cerebrovascular disease or a CT diagnosis of stroke but no significant stroke-related
disability which requires specialist stroke rehabilitation (new hemiparesis, dysphasia, ataxia) should be
referred to general rehabilitation beds.
Criteria for transfer to specialist stroke rehabilitation I
How to prioritise given limited stroke beds
While there is good evidence that all but moribund stroke patients and those who are sufficiently recovered to
be discharged home with appropriate support benefit from specialist rehabilitation, limited capacity of the unit
necessitates selective transfer of those most likely to benefit.
Criteria for patient selection are not absolute, and may vary depending on bed availability. However, the
principles of prioritisation will apply.
The main criteria for acceptance on the stroke rehabilitation unit are that:
1. The patient has a realistic chance of getting back home.
2. The patient requires specialist help to get back home.
In exceptional circumstances stroke patients who have no realistic chance to get back home may be
transferred to the stroke ward if their stroke-related care and rehabilitation needs are so severe and complex
that they can only managed by a specialist team.
Detailed criteria for screening are given on the next page.
SCREENING CRITERIA FOR ADMISSION TO THE STROKE REHABILITATION UNIT
Absolute criteria (must be fulfilled in patients considered for transfer)



New stroke with definite new clinical symptoms
No terminal illness
Medically stable
Other criteria A
 Patient was living at home before the stroke
 The patient is likely to benefit from rehabilitation
 The patient is able to co-operate with rehabilitation
 The patient has had a positive change in abilities since stroke onset
Other criteria B
 The patient has not progressed, cannot co-operate with rehabilitation and has no potential to benefit from
rehabilitation but




The patient wants to go back home
The carer wants the patient to go back home
The carer is aware that there will be no improvement in the patient's abilities at the time of discharge and
still keen and willing to take the patient home
The carer is physically and mentally able to take the patient home given appropriate training and support
If the patient fulfils the absolute criteria and A or B he/she should be listed for the specialist stroke
ward.
If the patient fulfils the above criteria, but has the potential to go back to work, or has specific needs for
reintegration, which would best be met by a service targeted at younger patients. Such patients will be
referred to Haywood hospital for rehabilitation.
If the patients fulfils the absolute criteria, but not A or B then he/she will be considered for generalist
rehabilitation. The patient will be put on the general waiting list for Bucknall Hospital by a member of
the stroke team or ASU staff, if appropriate (Please also refer to next page and to the Admission policy for
Bucknall Hospital).
PROTOCOL FOR TRANSFER TO GENERAL REHABILITATION BEDS AT BUCKNALL
HOSPITAL
The patient is unlikely to go back home but will have better quality of life if specific stroke-related disabilities
such as poor sitting balance, dysphagia or incontinence are addressed.



The patient has spent less than 6 weeks in hospital
The patient spent more than 6 weeks in hospital but has been medically unstable most of the time and will
improve with some time for recuperation
The patient is unlikely to go back home bit will have better quality of life if specific stroke related
disabilities such as poor sitting balance, dysphagia or incontinence are addressed.
Or
The patient has no stroke-specific rehabilitation needs and will get better in any rehabilitation environment).
All patients transferred to generalist rehabilitation will have the following documented in the notes:
1.
2.
3.
4.
Reason for transfer
Goals to achieve
Time frame in which the goals are expected to be achieved:
Specific instructions for the management of stroke related problems (if considered necessary):
Note: An Admission Policy for Bucknall Hospital is currently being developed. The above guidance may
change with time depending on the Bucknall admission criteria.
CRITERIA FOR REFERRAL OF PATIENTS TO THE HAYWOOD REHABILITAION UNIT

Criteria as for the specialist stroke ward, in addition

The patients should have the expectation to return to working life or homemaking.

Have specific needs for reintegration that could best be met by a service targeted at younger patients.
Triage of patients presenting with possible stroke
Definite Stroke
=> Fast track to ASU. Ring 07623 675 973 for bed availability. Must fit the below specifications
 New hemiparesis
with weakness affecting at least 2 out of 3 body parts on one side of the body (e.g face, arm, leg)
 With sudden onset
First noted on waking or patient must be able to tell the day and time of onset
In a patient who was previously well, mobile and has not had a head injury to cause the symptoms.
Refer to neurosurgeons if cause of symptoms is trauma, and to neurology if Subarachnoid haemorrhage or unusual non
atherothrombotic cause of stroke suspected.
May be a stroke
=> Doctor to review and make a diagnosis of stroke/ non-stroke/ unclear. Refer only to ASU if diagnosis of stroke confirmed by a
doctor.

Sudden unsteadiness with slurred voice or double vision

New sudden onset weakness of one side of the body involving only arm, or face, or leg

Sudden onset of jumbled speech (not confusion)
In a patient who was previously well, mobile and has not had a head injury to cause the symptoms.
Possible stroke, but other causes more likely
=> Look for other causes and admit to an acute medical or geriatric ward

Coma

Increase in weakness or speech problem in a patient with remaining neurological deficit from a prior stroke.
Stroke unlikely
=> Look for other causes, admit to a geriatric ward

Patient /carer unable to tell when the symptoms started

'Off legs'

Confusion
WHO Definition of stroke
A clinical diagnosis of stroke made when the patient suffers a sudden onset of



focal neurological deficit
which persists for more than 24 h
and is not caused by obvious other pathology (such as a blow to the head).
A focal neurological deficit is one which can be located to one specific area of the brain. For practical
purposes, typical focal signs to look out for when trying to diagnose a stroke are 1. hemiparesis or
hemisensory loss 2. aphasia (problems with production or understanding of speech) 3. hemianopia (inability
to see one half of the visual field) or blindness in one eye.
The sudden onset is important to distinguish the stroke from other neurological problems such as brain
tumors.
The duration of symptoms is important to distinguish a stroke (which persists for more than 24 h) from a TIA
which lasts for a shorter time.
Patients who present only with non-specific symptoms such as confusion, frequent falls, dizziness or
blackouts are unlikely to have a stroke as their main problem.
Patients who are unconscious on arrival may have had a very severe stroke, but other options such as a
seizure, alcohol excess, an overdose, a subarachnoid haemorrhage or a diabetic coma are more likely and need
to be excluded.
What is the cause of the stroke?
and why is it important to know the cause?
Most strokes (80%) are caused by cerebral infarcts, 15% are caused by intra-cerebral haemorrhage, 5% by other
underlying pathologies.
Infarcts and haemorrhages are difficult to distinguish clinically. A definite diagnosis can only be made by CT
head scan.
In most patients knowing the results of the san will not significantly alter management in the first few days.
However, some patients need more urgent investigation on the day of admission.
Look out for:

A history of head injury suggests a possible subdural or epidural bleed. These patients must be scanned
immediately and may need neurosurgical referral.

More gradual onset of symptoms, prominent pyrexia, headaches and confusion may point towards the
possibility of encephalitis or meningitis. If untreated, such patients will rapidly deteriorate. Patients
where encephalitis is suspected clinically need an urgent CT head scan and a lumbar puncture. The
prognosis worsens the more treatment is delayed.

A history of neck injury or whiplash may indicate carotid artery dissection. These patients need urgent
investigation (doppler, angiography).

A subarachnoid haemorrhage is associated with sudden onset extremely severe headaches, photophobia
and neck stiffness. Treatment with nimodipine will improve outcome.

The distinction between an intracerebral haemorrhage and an infarct is difficult on clinical grounds
alone. Severe headaches, vomiting, a history of alcohol abuse and treatment with warfarin may point to a
diagnosis of a bleed. Anticoagulated patients must be scanned on admission. In patients with intracerebral
haemorrhage anticoagulation must immediately be reversed by FFP infusion or vitamin K to prevent
deterioration. Reversal of anticoagulation may result in rapid clinical improvement.

A history of personality change and gradual onset of symptoms, especially if there are also headaches,
suggests a possibility of a brain tumour.
The OCSP classification of strokes into TACS, PACS, LACS, and POCSi
What does it all mean?
There are two main types of stroke. First, the anterior circulation type stroke, caused by ischaemia in the
carotid artery territory, and, second, the posterior circulation type stroke caused by infarction in the posterior
circulation (i.e. vertebral and basilar arteries). The most common of these is the anterior type stroke.
Total anterior circulation syndrome: TACS



hemiparesis (or hemisensory loss) and
hemianopia and
aphasia or heminattention
Poor prognosis. 30% of patients die within a month. After a year 60% will be dead and only 4% will become
independent again.
The partial anterior circulation syndrome: PACS

two out of the three symptoms above
Low mortality, 50% will become independent again. these patients may benefit from carotid endarterectomy
soon after the stroke.
Lacunar symdrome: LACS

hemiparesis without other associated symptoms
Low mortality. 50% will become independent again.
Posterior circulation syndrome: POCS
Multiple symptoms, often including:


hemianopia, squints, double vision
vertigo impaired balance and co-ordination
Why is acute stroke management important?
There is now overwhelming evidence that specialist stroke care improves outcome after acute stroke. Early specialist
care
 prevents stroke extension
 facilitates recovery
 prevents complications
The ischaemic penumbra is an area of damaged but potentially viable brain cells which surrounds the core area of the
cerebral infarct. These may either die or recover within the first 1-3 days after stroke onset. The role of acute stroke
care is to provide the patient with the best chance to maintain these cells in the ischaemic penumbra alive.
Important aspects of acute stroke care
 Early mobilisation (within the first 24 hours) has been shown to be one of the most important predictors of
good outcome after the stroke. Mobilisation includes bed exercises and positioning, sitting up , and in less
affected patients, getting out of bed as soon as possible.

Hydration: Most patients will come to the ward 12 or more hours after the stroke, and will not have had a during
since the event. Even patients without dysphagia are likely to be a bit dehydrated on arrival. Infusion of normal
saline should be started immediately, unless the patient can drink normally, or there is a specific contraindication
(severe heart or renal failure).

Blood pressure: sudden falls of blood pressure soon after the stroke may cause stroke extension. The target blood
pressure within the first few days after the stroke is higher than normal at 160-180/90-100. When the blood
pressure below this antihypertensive medications should be stopped and hydration reviewed. . The most common
causes of hypotension and labile blood pressure after the stroke are dehydration and infections. Both must be treated
promptly.

Hypertension is common after stroke. Unless the blood pressure is very high, that is greater than 220/115 and
there are signs of hypertensive encephalopathy, which can be detected by looking at the fundi, treatment with the
first few days of stroke is not recommended. Simple measures to allay fears and alleviate pain and discomfort often
lead to an improvement in blood pressure. In most cases the blood pressure falls spontaneously. If it remains
greater than 160/90 for more than two weeks treatment should be started.

Hyperglycaemia may increase infarct size. An insulin infusion should be considered if the blood glucose is above
11.

Hyperthermia may worsen outcome after stroke. Fevers and even subfebrile temperatures should be investigated
and treated.

Hypoxia. Patients with acute stroke have many reasons to become hypoxic. Keep the oxygen saturation above 90%
and look for a cause of deterioration if the saturation falls by 3% or more, even if still within the normal range.
Check positioning and airway in all patients with hypoxia. The most common causes for hypoxia are secretions in
the upper airways, aspiration, andr chest infections.
Care Pathway for Acute Stroke Management
This pathway will help to guide acute stroke treatment and rehabilitation and will be used for all patients
admitted with a working diagnosis of acute stroke.
Thrombolysis
Most strokes are caused by clots in the circulation of the brain. These clots can be dissolved by clot busting
treatment (thrombolysis), but only if the treatment is given within 4.5 hours of symptom onset. This treatment
may reduce death and disability buy up to 20 % but also carries a 10% risk of serious adverse events (severe,
mostly fatal brain haemorrhage or haemorrhage elsewhere in the body). It can only be given by stroke and
thrombolysis trained staffs in a specialist centre and after a CT head scan has been performed. Our hospital
has been recognised as a specialist centre, and we can there fore provide this treatment.
Potential patients for thrombolysis would be :




Clinical signs of acute stroke
Onset of stroke known and less than 4 hours ago
The patient was previously fit and well
The patient is not taking warfarin or INR <1.5.
Please call the thrombolysis phone 07709 638216 or bleep pager 101 (8-8 weekdays) immediately for
any potential thrombolysis candidate.
All patients given thrombolysis need to be seen by a physician with a special interest in stroke, have an
immediate CT head scan and an assessment of their neurological deficit using the NIHSS score at baseline, 2
hrs, 24 hr and at one week. They need to be admitted to the Acute Stroke Unit or the Neurology ward after
thrombolysis and their care and observations on the ward should be guided by the Thrombolysis Nursing Care
Plan.
Please click here for a link to
The Thrombolysis Assessment and treatment form http://www.stroke-instoke.info/acutestrokefiles/thrombolysispathway.doc
The Thrombolysis Nursing Care plan http://www.stroke-instoke.info/acutestrokefiles/thrombolysisnursepathway.doc
The SITS data entry site
http://www.acutestroke.org/index.php?module=ContentExpress&func=display&ceid=50&bid=20&btitle=SIT
S%20Register&meid=4
Please follow the following links for
The SITS-MOST register http://www.acutestroke.org/index.php
The IST-3 trial http://www.dcn.ed.ac.uk/ist3/
The NIHSS assessment training site http://asa.trainingcampus.net/uas/modules/trees/index.aspx
Early Mobilisation and Stimulation
Early mobilisation and stimulation is considered to be an important and integral feature of successful stroke
units (Indredavik et al, 1999).
It will depend upon the patient and the severity of their stroke as to what early mobilisation and stimulation
entails, however for most patients it should commence within the day of admission to the stroke unit (SIGN
Guidelines, 2002), ideally within less than 3 hours admission to the ward.
It is extremely important that patients are mobilised to their optimum position as soon as possible. For the
more severe stroke this may require using the profiling beds to support the patient in a more upright position,
for other patients it will be sitting out of bed. Those patients admitted with only a mild or rapidly resolving
event may be able to stand /walk independently shortly after admission.
Early mobilisation of patients reduces the risk of complications following stroke (SIGN, 2002; RCP, 2004)
including DVT, PE and respiratory problems. Appropriate positioning of the patient is widely advocated as a
strategy to discourage the development of abnormal tone and activity, contractures, pain and skin breakdown
(RCP, 2004). It is important to remember that the way in which a patient is positioned from the onset of
stroke will have an effect on their outcome – this has the potential to be a positive or negative affect.
Early mobilisation and stimulation of patients will also have an important psychological effect (Indredavik et
al, 1999). It will allow the patients to interact within their environment and to commence participation in
functional activities, albeit for some patients in a limited way.
For the principles of early mobilisation and stimulation to be adopted and be successful, it requires the ward
team to work together. Early mobilisation and stimulation is not the domain if the therapy staff, but requires
involvement of all ward staff to ensure success and maximise patient benefit.
Remember that for each day after admission the patient is not mobilised his/her chances of getting home
reduce by 20% (personal communication Indredavik 2004).
The 72 hour monitoring and intervention protocol
Stroke is a medical emergency. With active management in the initial hours after the stroke onset ischaemic
brain may be saved from infarction. Blood glucose, arterial oxygen concentration, hydration and temperature
should be maintained within normal limits. Hypotension or sudden drops in blood pressure reduced cerebral
perfusion and should be avoided. Infection should be managed actively, unless the patient is receiving
palliative care. Blood pressure, heart rate, glucose, temperature, neurological status (abbreviated Scnadinavian
Stroke Scale) and oxygen saturation should be assessed 6-hourly, any deviation from the normal range
defined should be treated immediately (see ASU Acute Monitoring and Interventions Chart).ii
Acute Stroke Unit
72 hour Acute Stroke Monitoring Actions Chart
The optimal BP is 160-180/90-100
early after the stroke.
BP<140/100
 Stop/reduce antihypertensives
 Ensure adequate hydration (saline)
BP<120/80
 As above
 Medical review
 Elevate end of bed
 Exclude/treat septicaemia
Glucose>11 mmol/l
This is only a quick guide.

Please refer to the full guidance for
detail.





BP>200/120
 Put patient at ease
 Check for pain or discomfort (
headaches, retention, impaction,
odd posture in bed) and treat, if
present
 Measure BP on both arms
 Medical review
 Make sure that patients who were
on regular antihypertensive drugs
have received their treatment, if nil
by mouth give via NGT or
prescribe parenteral alternative
 Check BP 2- hourly, or hourly if
>220/130
Drug treatment should be considered if:
 BP> 185/110 in thrombolysed
patients
 BP persistently >180/105 and the
patient has an acute intracerebral
haemorrhage or >230/120 and
hypertensive encephalopathy, or
aortic dissection, or hypertensive
heart failure, or AMI, or unstable
angina
 BP >220/120, and does not settle
with rest and relief of discomfort
within 1 h
 Discuss with stroke consultant. Spr,
staff grade before initiating
treatment, treatment may be
required.
 Use GTN infusion (50 mg/ in 50 ml
via syringe pump). Start at a rate of
0.3 ml/hr. Titrate upwards in
increments of 0.3 ml/hr until BP
falls by 10 mm Hg. Decrease dose
if drop in BP>20 mmHg. Escalate
dose faster (0.3 ml/h) if BP
increases while on GTN.
If correct and persistent after 1 hour
start sliding scale insulin (1 unit/mL in
0.9% saline) at a rate of 3 units/hour.
Monitor BM 2-hourly
Aim to keep BM between 6 and 11
Increase by 1 unit/h after 2 h if
glucose still>11 and not falling
significantly from initial value and
recheck after 2h
If glucose falls below 6 mmol/L
reduce rate to 1 unit/h give glucose
5%, and recheck after 1 h
If glucose <3 mmol/L hold insulin,
call doctor, and consider glucose 20%
infusion
Please note that this is a general
guideline, and that individual patients
may require different treatment.
Version 5 (06.07.2011)
T>37.5 OC




See Medical Guidelines ‘hyperglycaemia
in the ill patient’ for flow charts and
detail


3-hourly assessments for first 12 h and
then 6 hrly
1. Neurological observations (SSS)
2. GCS (if drowsy or unconscious)
6- hourly assessment of
1. Blood Pressure
2. Heart rate
3. Temperature
4. Respiration
5. Oxygen saturation
Daily assessment of
1. Blood glucose
Increase frequency of assessment if any of
the above are abnormal

Oxygen saturation <95% or
Oxygen saturation falls >3%




Neurological deterioration
 Check airway
 Elevate head of bed
 Check BP, HR, T, oxygen, and BM,
correct all abnormalities.
 Check FBC, U&E, INR.
 Inform doctor.
 Doctor to do NIHSS, check above and
exclude reversible causes:
 Pneumonia
 Septicaemia
 PE
 CCF
 Sedative drugs

If NIHSS >4 points worse consider
urgent CT
Paracetamol 1g QDS
Cooling strategies (reduce bedding,
fan etc)
Ask Doctor to see
Look for cause of pyrexia and treat
appropriately
Check FBC, MSU, blood culture,
CRP, examine chest, venflon site
If urinary catheter in place remove
unless required for retention or
fluid balance
Ask doctor to review if pyrexia not
settled within 24 hrs.


Check mouth and airway
Oropharungeal and nasopharyngeal
suction if ‘rattly’ or upper airway
secretions
Check position (sit out if possible)
or elevate head of bed
Position drowsy patients in the left
or right lateral position to allow
drainage of secretions
Exclude aspiration
Chest physiotherapy
If no response to above
 Medical review
 Exclude/treat pneumonia, PE,CCF,
bronchospasm or Cheyne-Stokes
respiration.
 Give oxygen 2l/min if saturation
persistently <95%, recheck after 30
min.
 ABG if no response or if history of
chronic severe chest problems
Airway Management
Intermittent airway obstruction is a common complication in patients with stroke with a reduced level of
consciousness, but may also occur in alert individuals, ad may lead to hypoxia. This in turn can lead to
reduced cerebral perfusion and hypercapnia, increasing intra-cranial pressure (ICP) and acidosis which are
harmful to damaged brain tissue.
Patients whose airways are compromised should be nursed in a position which maintains airway patency and
prevents retraction of the tongue and obstruction with the soft palate. Positioning that facilitates ventilation of
the lungs should also be considered. A Guedel airway may be required.



The patient should be lying on the side with the torso and pelvis tilted 30-45 degrees and supported by
a pillow along the patients back.
The patient’s head should be in a neutral position looking to the same side, supported with 1-2 pillows.
The upper–most limbs will need to be supported on pillows to facilitate lung expansion and prevent
abnormal postural tone.
Aspiration is very common after stroke, even in alert patients, and is silent in many cases. Suspect silent
aspiration in any patient who sounds rattly, drools saliva, and has retained food or secretions in the oral
cavity. A drop in saturation of more than 2% is a sensitive marker of aspiration and should prompt review of
swallowing, positioning and mouthcare. Aspiration also happens in patients who are nil by mouth. It may be
reduced or prevented by positioning the patient in a more upright position.
Monitoring of respiration and oxygen saturation
In patients with impaired airway oxygen saturation needs to be monitored regularly. The patient’s lung
movement should be observed for asymmetry of expansion. Rate, rhythm and depth of respirations should be
observed and recorded. An increase in respiratory rate may be a sign of pneumonia, heart failure, pulmonary
embolus or worsening stroke. Slow and irregular respirations may be early signs of raised intra-cranial
pressure. Cheyne–Stokes respirations may occur with hypoxia, heart failure or supra-tentorial damage. All
changes require medical review.
Hypoxia
Where oxygen saturation below 95%, the patient’s postion , airway and oral cavity need to be reviewed, and
cleared. This may improve results without any further treatment. If the oxygen saturation is below 90% and
there is no response to the above oxygen supplementation (24%) should be considered (see management of
hypoxia). Patients with known severe chronic chest conditions will require medical review prior to
administration with oxygen. Oxygen must always be humidified.
Administration of suction
Patients with audible pharyngeal secretions will require regular pharyngeal suction. Those with lower
respiratory secretions will require Chest Physiotherapy. Oxygen saturation should be checked before and after
suctioning, and high percentage oxygen administered for a few minutes before and after (unless contraindicated). Nasogastric feeding should be discontinued during the suction. Before resuming feeding after
suction correct position of the nasogastric tube must be confirmed by the usual method.
Oral Care
Patients who are Nil by Mouth due to reduced conscious level or dysphagia will require frequent and
thorough oral care to reduce the risk of aspiration pneumonia. Oral hygiene may need to be given in
conjunction with pharyngeal suction if there is a risk of aspiration (see Oral Care Guidelines). In some
patients more limited oral suction may be appropriate, but as with deeper suction.
Hypoxia
Hypoxia within the first few days of the stroke may worsen cerebral ischaemia and lead to extension of the
stroke. It may be present on admission, or develop at any time later on. Patients with reduced consciousness,
airway obstruction, dysphasia or preexisting cardiovascular problems are at particular risk.
Definition
Mild hypoxia is defined as an oxygen saturation below 95%. An oxygen saturation below 90% represents
severe hypoxia and requites urgent action.
Assessmment
Cyanosis is a late and unreliable sign of severe hypoxia. Oxygen saturation should be assessed by pulse
oximetry.
Measure oxygen saturation
 On admission
 6- hourly for 72 hours after the stroke
 More frequently if the patient is unwell or hypoxic
 daily thereafter
Oxygen saturation <95% or Oxygen saturation falls >3%
 Check mouth and airway
 Oropharyngeal and nasopharyngeal suction to remove secretions
 Check position (sit up if possible) or elevate head of bed
 Recovery position in drowsy or unconscious patients
 Exclude aspiration
 Chest physiotherapy
If



no response to above
Medical review
if saturation <95% give oxygen 2l/min and inform doctor, recheck after 30 min.
In patients with known severe and disabling chest problems the doctor must see the patient before
commencement of oxygen. Blood gases may be required before and after starting O2.
 CXR, EXG and arterial blood gases may be required
 Exclude/treat pneumonia, PE,CCF, bronchospasm or Cheyne-Stokes respiration.
 Very restless patients may not be able to tolerate oxygen. Consult with the doctor.
Ongoing monitoring
 While on O2, monitor 6 hourly or more frequently, as condition requires
 If SPO2 < 93% or SPO2 deteriorates in spite of above call doctor again and increase MEWS observations
to hourly
 In severely hypoxic patients higher oxygen concentrations and repeat ABG may be required.
 If stable, review oxygen treatment every 24 hours.
These guidelines are intended for use with most patients. In cases where the patients needs require variation to the
guidelines, these will be discussed with medical staff and the management plan clearly documented.
Pyrexia
Fever increases metabolic rate and oxygen consumption and may exacerbate tissue hypoxia and acidosis in
the ischaemic brain. Patients with acute stroke who have an elevated body temperature during the first day
after a stroke have a poorer outcome than those with a normal body temperature. There is not yet enough
evidence to definitely say whether treatment of an elevated body temperature improves stroke outcome in
humans, but until such evidence is available aggressive prevention and treatment of pyrexia is recommended.
Definition
Fever (pyrexia) is defined as a temperature above 37.5oC.
Assessment
 on admission
 6 hourly up to 72 hours
 then daily to end of second week
 review need for continued monitoring at end of second week.
AN ELECTRONIC TYMPANIC THERMOMETER SHOULD BE USED TO TAKE ALL
TEMPERATURES
Management
 Paracetamol 1g po/pr is given to all acute stroke patients on admission and after 6 hours to prevent
pyrexia
 If temperature is >37.5oC inform the doctor
 The doctor will look for a source of infection and arrange for treatment where appropriate.
 Paracetamol may be prescribed for 48 hours if no source of infection is found or in addition to antibiotics.
 Other methods of cooling (fans, tepid sponging) may be required.
 If the temperature does not return to within normal limits within 24 hours review management with doctor.If temperature is
38.0 at any time inform the doctor immediately.
These guidelines are intended for use with most patients. In cases where the patients needs require
variation to the guidelines, these will be discussed with medical staff and the management plan clearly
documented.
Early Blood Pressure Management
Variations in blood pressure after the stroke can affect cerebral blood flow and lead to worsening of the
stroke. Because the autoregulation of cerebral blood flow is impaired early after the stroke, even small falls in
blood pressure can be detrimental. While there is no definite evidence from clinical trials to support this the
current consensus opinion is that within the first 72 hours of stroke the optimal blood pressure is higher than
the 140/85 threshold used for secondary prevention. In many patients blood pressure rises in the acute phase
of stroke, but settles without treatment within a few days. For patients with persistent hppertension See
management of chronic hypertension for patients if the blood pressure remains >140/85 after the first 1-2
weeks post stroke.
The optimal BP is 160-180/90-100 early after the stroke.
Assessment
Measure blood pressure
 on admission
 6 hourly up to 72 hours
 then daily to end of second week
 review need for continued monitoring at end of second week
Hypotension (Too Low Blood Pressure)
Low blood pressure within the first two weeks after acute stroke may worsen outcome. In patients who have
long-standing hypertension (as suggested by themedical history or antihypertensive treatment) even normal
blood pressures such as 120/80mmHg may be too low, since their brains are used to higher day to day
pressures.
Symptoms
Patietns may not complain of any symptoms. Suspect low blood pressure or postural hypotension (blood
pressure falling when the patients stands up) if the patient is reluctant to stand, complains of dizziness, or does
not concentrate when standing.
Assessment
In any patient with dizziness or suspicion of intermittent hypotension lying and standingblood pressure
readings should be taken.
BP<160/100
 Stop/reduce antihypertensives
 Ensure adequate hydration (saline)
BP<120/80
 As above
 Medical review
 Elevate end of bed
 Exclude/treat septicaemia
In hypotensive patients the doctor will discontinue medications which lower the blood pressure and assess the
patient for causes of hypotension such as myocardial infarction, septicaemia, gastrointestinal bleeds, heart
failure or pulmonary embolism. An ECG, blood tests and a rectal examination may be required. An
intravenous infusion may be set up.
These guidelines are intended for use with most patients. In cases where the patients needs require
variation to the guidelines, these will be discussed with medical staff and the management plan clearly
documented.
Hypertension within the first week
In patients with acute stroke a rapid drug induced fall in blood pressure is more dangerous than high blood
pressure itself. Falls in blood pressure may induce a further stroke or worsen the current one. However:
some patients are very stressed by the admission and their blood pressure rises because of this. When the
patient settles the blood pressure falls. Such a natural fall in blood pressure does not worsen the stroke. Once
the patient isneurologically stable after the first 72 hours to 2 weeks antihypertensive therapy should be
started to achieve a blood pressure of 140/85 or below in non diabetics and 130/80 or blow in diabetics (see
Monitoring
 Blood pressure >200/100 inform doctor if does not settle with rest.
 Measurement >210/110 inform doctor, observe 2 hourly until blood pressure falls. Call doctor again if
blood pressure increases.
BP>200/120
 Put patient at ease
 Check for pain or discomfort ( headaches, retention, impaction, odd posture in bed) and treat, if present
 Measure BP on both arms
 Medical review
 Make sure that patients who were on regular antihypertensive drugs have received their treatment, if nil by
mouth give via NGT or prescribe parenteral alternative
 Check BP 2- hourly, or hourly if >220/130
Drug treatment should be considered if:
 BP> 185/110 in thrombolysed patients
 BP persistently >180/105** and the patient has an acute intracerebral haemorrhage or hypertensive
encephalopathy, or aortic dissection, or hypertensive heart failure, or AMI, or unstable angina)
 BP >240/130, and does not settle with rest and relief of discomfort within 1 h*
 Discuss with stroke consultant. Spr, staff grade before initiating treatment, treatment may be required.
 Use GTN infusion (50 mg/ in 50 ml via syringe pump). Start at a rate of 0.3 ml/hr. Titrate upwards in
increments of 0.3 ml/hr until BP falls by 10 mm Hg. Decrease dose if drop in BP>20 mmHg. Escalate
dose faster (0.3 ml/h) if BP increases while on GTN.
 Other treatment options are:
 Captopril 6.25 mg o/ngt/iv or
 labetalol 5 mg iv
 Do not lower BP by more than 20 mmHg.
*RCP guidelines 2008 do not recommend treatment of any level of BP unless ICH or complications of hypertension are present.
**EUSI 2011
These guidelines are intended for use with most patients. In cases where the patients needs require variation to the
guidelines, these will be discussed with medical staff and the management plan clearly documented.
Medical Management of Acute Post Stroke Hypertensioniii
Many patients with stroke have elevated blood pressure. Cerebral blood flow autoregulation may be defective
in the area of the infarction, and passively dependent on the mean arterial pressure. Drops in blood pressure
must be avoided, if an adequate cerebral perfusion pressure is to be maintained.
Target BP for patients with prior known hypertension:
Target BP for patients without a history of hypertension:
180/100-105
160-180/90-100
Management of moderate hypertension [BP > 200/110mmHg]
Check whether the patient is in pain or discomfort (retention? Impaction? Headaches? Odd posture? Etc) and
treat appropriately.
Check whether the patient was on drugs affecting the blood pressure before, whether they are written up, and
whether they have been given (watch out for patients nil by mouth). Reinstate regular antihypertensive
treatment (oral or via nasogastric tube, Avoid sublingual nifedipine).
Keep patient in a calm atmosphere, and continue to observe BP.
Management of severe hypertension [>=240/130 mm Hg]
General instructions
Don’t panic. Inform SpR and consultant.
Do basic measures, as above, confirm high readings.
Measure in both arms and monitor on the arm with the higher pressure.
Treat immediately if
 Signs of hypertensive encephalopathy (seizures, seizures, reduced conscious level [out of proportion to the
severity of the stroke), papiloedema or retinal haemorrhages)
 Hypertensive heart failure
 Marked renal failure with microscopic haematuria and proteinuria
 Aortic dissection
Otherwise review after 1 hour and see whether it has fallen, if not start treatment.
Try oral /nasogastric treatment first, if possible.
If intravenous treatment is necessary stay with the patient on initiation of treatment
Measure Blood pressure every 5 minutes while giving the drugs, the every 15 mites, every 30 minutes once
the fall has stabilised.
Stop injection or infusion if BP falls by 10 mm Hg. If fall maintained repeat same treatment after one hour.
If the BP comes up again, restart infusion, repeat injection with same dose.
If blood pressure rises, continue until a response achieved. It may be necessary to try a number of different
antihypertensives, as outlined below.
Do not lower the BP by more than 20 mm Hg in the first 2 hours.
Do not lower BP by more than a further 20 mm Hg in the next 12 hours.
Once BP <= 140/130 keep at same level for 24 hours and then gradually reduce further.
Aim to get to 160/90 in 7-10 days (e.g. not too fast).
Remember half-life of treatment and prescribe maintenance or review at the appropriate time points.
Monitor
 Neuro obs hourly
 BP half hourly
 Urine output hourly
 U&Es daily
Treatment options
Systolic BP>=240 and/or diastolic BP >=130 mm Hg
Orally
Captopril 6.25-12.5 mg
Atenolol 25-50 mg1
Parenterally
Labetalol 5-20 mg iv
Dihydralazine 5 mg iv plus metoprolol 5-10 mg iv
Clonidine 0.15-0.3 mg iv or s.c.
Diastolic BP > 140
GTN infusion
Sodium Nitroprusside
Specific Therapies
Labetalol
Cave: in patients with asthma or heart failure, or with bradycardia.
Monitor heart rate (manually or by monitor). Keep atropine ready for bradycardia.
Labetalol 2 mg iv over 5 minutes.
Repeat after 5 minutes, if no response.
1
Clinical guidelines 2002, accelerated hypertension
Give further 10mg boluses every 10 minutes up to a total of 50 mg, if no response.
Start infusion of 2mg/min, stop when BP starts to fall, max dose of 200 mg achieved or patient develops
bradycardia.
Titrate maintenance dose according to response (not more than 200 mg/24 hours).
GTN infusion [see clinical guidelines]
GTN 50 mg (10 ml) diluted to 50 ml with saline or glucose.
Start with 0.3 ml/min
Increase by 0.3 ml/min every 15 min until BP falls
Maximum dose 12 ml/hr.
Nitroglycerin 5 mg iv followed by 1-4 mg/h/iv
Metoprolol
Metoprolol 5 mg over 5 minutes IV
May be repeated after 5 minutes if no response
Side effects:
As with other beta blockers, watch especially for bradycardia, excessive BP fall and dyspnoea.
Hydralazine (give this with metoprolol 5-10 mg to avoid tachycardia)
Hydralazine 5 mg iv (in 10 ml Sodium Cl)
[as a slow bouls, or , better, infused over 25 minutes (which equals a recommended infusion rate of 200 mcg/min)]
Once the blood pressure starts falling it is reasonable to stop and wait, only continue if the fall has been less
than 20 mm Hg.
Repeat after 20-30 min if no response.
Maintenance 50-150 mcg/min
Contraindications:
Tachycardia, High output heart failure, SLE
Side effects:
Fall in BP may be too rapid
Tachycardia, flushing, fluid retention,
SLE-like syndrome (with long-term therapy), rarely rashes, fever and others.
Clonidine
See BNF
Management of Diabetes and Hyperglycaemia
High blood glucose values within the first 48 hours may worsen outcome after stroke.
Measure BLOOD GLUCOSE:
 On admission
 If normal - monitor once daily up to 72 hours.
 If > 8  confirm by BM or venous blood glucose  urine ketones check fasting venous blood
glucose/HbA1c within 24 hours
 If > 11 or ketones positive call doctor
 Monitor BMs 2 hourly for in patients on insulin pump.
 Review frequency for further monitoring at 72 hours.
The doctor is likely to manage the patient as follows:
The doctor will prescribe an insulin infusion infusion in all known diabetics and in all patients not known to
be diabetic prior to the stroke who are nil by mouth and have a BM>11. In patients able to take
oral/nasogastric food and mediations continue usual treatment and monitor Blood Glucose pre meal and 10pm
after discontinuation of infusion, check fasting glucose and HbAlc.
Insulin infusion regime (50 units ACTRAPID insulin in 50 ml N/Saline)
 If correct and persistent after 1 hour start sliding scale insulin (1 unit/mL in 0.9% saline) at a rate of 3





units/hour.
Monitor BM 2-hourly
Aim to keep BM between 6 and 11
Increase by 1 unit/h after 2 h if glucose still>11 and not falling significantly from initial value and recheck
after 2h
If glucose falls below 6 mmol/L reduce rate to 1 unit/h give glucose 5%, and recheck after 1 h
If glucose <3 mmol/L hold insulin, call doctor, and consider glucose 20% infusion
Insulin infusion will be continued for 72 hours or until stable. After this revert back to pre-stroke regime if
patient stable and able to eat.
See Medical Guidelines ‘hyperglycaemia in the ill patient’ for flow charts and detail
These guidelines are intended for use with most patients. In cases where the patients needs require variation to the guidelines, these
will be discussed with medical staff and the management plan clearly documented.
Management of crescendo TIAs
Crescendo TIAs are transient ischaemic attacks of increasing frequency and duration
(several episodes occurring within a few days). They may lead up to a full blown stroke.
The doctor is likely to manage the patient as follows:
(Crescendo TIAs are to be treated as an emergency.)
 Ask doctor to see patient urgently.
 Inform Dr Roffe/Dr Natarajan/Dr Arora or SpR deputy of the patient.
 A CT head scan should be performed within hours of admission (the admitting doctor has to speak
personally to the CT radiographer (daytime) or radiologist on call (night) to arrange this.
 Aspirin 300mg stat should be given immediately unless contraindicated.
 Thorough medical examination (to exclude AF, recent MI, other cardiac arrhythmias,
severe
hypotension or hypertension, endocarditis, polycthaemia, hyperviscosity syndrome, vasculitic
processes, sources of emboli, other intracerebral problems mimicking TIAs, spinal problems)
 Arrange urgent carotid doppler. If indicated after results received Doctor may contact vascular
surgeons (after discussions with consultant or deputy). Ring extension 2176/2935 during the day or
bleep general surgeon on call during the night.
 If the patient has TIAs in spite of being on aspirin and the CT head does not show a haemorrhage start
heparin bolus and infusion. Check KPTT 6 hours after the start of the infusion. Keep at 2.5 x the
normal value (see medical guidelines for detail).
Management of intracerebral haemorrhage
This section needs to be completed meantime:
See correction of abnormal INR in patients with ICH
See AHA guidelines 2007 for management of ICH
Guidelines for the Management of Spontaneous Intracerebral Hemorrhage in Adults. 2007 Update. A
Guideline From the American Heart Association, American Stroke Association Stroke Council, High Blood
Pressure Research Council, and the Quality of Care and Outcomes in Research Interdisciplinary Working
Group. Stroke 2007;38:1655-711.
These guidelines are intended for use with most patients. In cases where the patients needs require variation to the
guidelines, these will be discussed with medical staff and the management plan clearly documented.
INR correction in patients with intracerebral haemorrhage
Intracranial hemorrhage is not a one off event. Extension in the first 3 hrs is common. The danger for rebleed
continues for at least 48 hours. Therefore immediate correction of INR is essential. Intracranial haemorrhage
in patients on warfarin has a mortality of 60%.
The target INR should be 1.
Do INR immediately (use point of care device in A&E )
If no point of care device available urgent transport of sample to lab and phone call to haematologist to ensure
attention to sample as it arrives.
If INR >1.2
 reverse with prothrombin complex concentrate immediately (within 30 min). Consult with consultant
haematologist about dose.
 vit.K 5 mg iv to prevent (works within 5-6 h) or 10 mg (if INR >2 and no need to reanticoagulate).
 Stop warfarin in all patients with intracranial haemorrhage (even in patients with mechanical valves). In
patients with mechanical valves and other absolute indications for warfarin do not restart until
haemorrhage stabilized. If no absolute indication for warfarin stop warfarin for good2.
Also:
 Control blood pressure. If >200/1102 start GTN infusion (see control of blood pressure for regime).
Prothrombin complex concentrate contains high levels of vitamin K–dependent factors (II, VII, and X), and
factor IX complex concentrate contains factors II, VII, IX, and X. It requires smaller volumes of infusion than
FFP and corrects the coagulopathy faster. Their disadvantage is the risk of inducing thromboembolic
complications, ranging from superficial thrombophlebitis, deep vein thrombosis and pulmonary embolism,
and arterial thrombosis to disseminated intravascular coagulation. Concerns about viral transmission have
been minimized by the current rigorous screening of blood products.
Guidelines for the Management of Spontaneous Intracerebral Hemorrhage in Adults. 2007 Update. A
Guideline From the American Heart Association, American Stroke Association Stroke Council, High Blood
Pressure Research Council, and the Quality of Care and Outcomes in Research Interdisciplinary Working
Group. Stroke 2007;38:1655-711.
2
RCP Guidelines 2008
Assessment and management of swallowing problems (dysphagia)iv
Dysphagia affects around 47% -67% of stroke patients in the acute phase (Smithard et. al 1997; Hinds
&Wiles 1998). A patient with dysphagia is twice as likely to develop pneumonia (Smithard 1996; Barer
1987), and mortality is higher than amongst patients without dysphagia (Schmidt et. al 1991).
Approximately a half of patients with dysphagia are likely to see their symptoms resolve within the first few
days (Martino et.al), and as long as appropriately managed, their outcome is likely to be good. At the other
end of the scale are the patients whose symptoms are long – term (Kidd et.al 1995) and are likely to need
enteral feeding indefinitely. In between are a range of patients who have varying degrees of severity and need
intervention for a varying length of time (Martino et.al.2000; Perry & Love 2001).
The risk of malnutrition amongst stroke patients is high (Smithard 1996). There is a strong association
between nutrition and outcomes for stroke patients, in terms of mortality and morbidity (Davalos et.a;.1996;
Smithard et.al.1996; Barer 1987). National guidelines RCP 2000) advocate nutritional assessment within 48
hours of stroke onset, and consideration of alternative feeding for patients unable to take adequate oral diet.
The purpose of these guidelines is to ensure all acute stroke admissions are screened and low -risk patients
assessed by the nursing team. This will enable patients without symptoms or with non-complex/transient
symptoms to be fed as soon as possible, and patients with complex/persistent dysphagia to receive early
referral to Speech and Language therapy and dietetics and consideration for early alternative nutrition.
Guidelines
1. Screen for eligibility for assessment
1.1 All patients admitted to the acute stroke unit should be screened within 24 hours of stroke onset, and 12
hours of admission, to determine whether a nurse dysphagia assessment is appropriate. The screen will
include a judgement about the patient’s level of alertness, ability to sit upright and respiratory symptoms.
1.2 Patients with progressive neurological disorders, tracheostomy, or history of surgery or radiotherapy to
head/neck, are not appropriate for nurse assessment. These should be referred to Speech and Language
therapy.
1.3 If the patient fails the screen, it should be repeated daily, or sooner if indicated by the patients condition,
until the patient is able to undertake the assessment. The reason for the patient failing the screen must be
recorded in the Collaborative Care Documentation. The patient will remain Nil by Mouth, until a
successful assessment is achieved.
1.4 Patients unable to take normal diet and fluids should be given parenteral fluids within 12 hours of stroke
onset unless blood pressure is low (see 72 hour monitoring guidelines), in which case they may be needed
earlier.
1.5 The patients that fail the screens should receive nutritional assessment and be considered for alternative
feeding (Naso-Gastric), within 48 hours of admission, following consultation with medical and
paramedical staff, the patient where possible, and family. A dietician referral should be made.
1.5 Those patients’ who fail the screen on the 7th day of admission, should be considered for a referral to the
Nutrition Team, for assessment for a PEG. Discussion should take place within the MD Team and the
patient, where possible and family. A referral should be made to Speech and Language Therapy at this
point.
NB: in some circumstances, following discussion between the consultant, MD Team, patient / relatives, a
decision to with-hold/ withdraw artificial hydration feeding may be made. In these circumstances there is no
need to repeat screening, and the actions should be documented in the CCP.
2. Nurse Dysphagia Assessment; water test
2.1 Patients that pass the initial screen (alert and able to sit upright; no new respiratory symptoms) should
receive a nurse dysphagia assessment.
2.2 The assessment must be undertaken by appropriately trained nurses (see protocol for criteria/policy for
Scope of Professional practice), with at least 6 months experience in the specialist area.
2.3 Patients who fail the assessment should be managed according to guidelines 1.2-1.4., and be re-assessed
daily, (or more often if the patient’s condition indicates)until day 4, when a Speech and Language referral
will be made. Patients who fail toward the end of an assessment should be referred at the earliest
opportunity, so that oral trials may be commenced.
3. Assessment with diet
3.0 Patients’ who pass both stages of the water test without thickener, should be assessed with appropriate
diet. Where normal diet/fluids are prescribed, record fluid balance and nutritional assessment for 3 days
then review.
3.1 Patients who pass the assessment with thickened fluids should then be assessed with the appropriate
modified diet. Refer to dietician, and maintain food and fluid charts until patient has managed a normal
diet for 3 days.
3.2 All patients requiring a modified diet, should be re-assessed within 48 hour periods, to allow for progress
to a more normal diet. Patients still requiring a modified diet at 10 days will be referred to S&LT.
3.3 Patients exhibiting problems at any level, should be re-assessed, following a medical review, and referred
to S&LT/ dietetics.
4. Documentation
4.1 The outcome (including symptoms of dysphagia noted) of each screen / assessment must be documented
in the progress section of the CCP and an appropriate Core care plan amended to reflect individual
circumstances. The Assessment document must be filed within the Speech and Language section of the
CCP, along with the dysphagia pathway, where appropriate.
5. Other considerations
5.1 Patients with reduced consciousness, or otherwise unable to cope with oral/ respiratory secretions will
require regular airway management, including suction, oral hygiene and chest physiotherapy.
5.2 Please refer to Oral Care Guidelines for management of oral hygiene.
5.3 It is the nursing staffs responsibility to thicken fluids, where this is indicated.
Prevention of Deep Vein Thrombosis and Pulmonary Embolism
Venous thromboembolism often occurs within the first week of a stroke, and most often in immobile patients
with paralysis of the leg. Studies using radiolabeled fibrinogen suggest that deep vein thrombosis (DVT)
occurs in 50% of patients with hemiplegia, but clinically apparent DVT occurs in only 5%. Although autopsy
series have identified pulmonary embolism (PE) in a large proportion of stroke patients who die, clinically
evident PE occurs in only 1-2% of patients. v
Measures for DVT and PE prevention
1. Patients should be mobilized form the day of admission.
2.
Adequate hydration
3.
Aspirin 300 mg/day should be given to all infarcts (ideally on the day of admission) as long as CT has
excluded a haemorrhage or there are other contraindications) for the first 2 weeks, then reduce to 75 mg
per day.
4.
Patients at high risk of DVT (e.g. immovility&obesity, coexistent cancer, previous history of
thromboembolism) may require prophylactic heparin.
5.
Patients with intracerebral haemorrhage are at particular risk of DVT and PE since they do not receive
aspirin and cannot be treated with heparin once a thrombosis has occurred. Therefore prophylaxis is
essential. Additional leg mobilization should be performed to prevent stasis.
6.
Do not use prophylactic antiembolic stockings (Clots study 2009).
Monitoring
Legs should be inspected for signs of DVT ion a daily basis until mobile. Any complaint of breathlessness
should be reported to the ward doctor. Consider Doppler after 1 week in immobile patients who are not
anticoagulated.
Signs of DVT and PE
Deep vein thrombosis should be suspected in any patient with leg swelling, pyrexia or any pain in the leg,
foot or groin. Symptoms of a pulmonary embolism are breathlessness, chest pain, tachycardia and a fall in
oxygen saturation. Urgent Doppler at the first sign of possible DVT.
DVT/ PE prevention
Mobilize from the day of admission
Teach patient/Family leg exercises
Prevent dehydration
Start aspirin (unless contraindicated) as soon as possible after admission
Do Doppler after 1 week in patients at high risk of DVT
Do not use prophylactic heparin routinely, consider in patients at high risk of DVT (weigh up against risk of
haemorrhage).
COLLABORATIVE CARE
Patients Name
………………………………….
Persons responsible:
Unit No
………………………………….
Doctor
□
Nurse
Physio
□
OT
SLT
□
SW
Dietitian
□
Other
Problem No: Nutrition, Gastrostomy or Nasogastric Tube
GOAL : For Standardised Enteral Feeding Regimen to be established for newly inserted
NG/PEG tubes to be used until the patient is assessed by the dietitian.
Signature ………………………….. Date …………………………….
INTERVENTIONS:
1
Refer to the dietitian.
2
Flush tube with at least 50mls water using a 50ml syringe.
(i)
(ii)
3
Before and after feeding.
Before and after giving medication.
For newly inserted PEGs do not feed for the first 4 hours post PEG insertion.
Day 1
Water flush 100mls.
Nutrison standard 50mls/hr for 6 hours.
Water flush 100 mls.
Nutrison standard 75mls/hr for 6 hours.
Water flush 100mls.
Rest 6 hours.
Total fluid = 1050mls. I.V or S.C. fluids will be required.
Day 2
Water flush 200mls.
Nutrison standard 100mls/hr for 15 hours.
Water flush 200mls.
Rest 9 hours.
Total fluid = 1900mls.
This will provide 1500kcals, 60g protein.
Continue on this regimen until reviewed by the dietitian.
Remember to change the giving set every 24 hours. Always give feed at room temperature.
Raise the head at least 30 degrees to reduce the risk of aspiration.
Review date ………………………….
Review date …………………………
Goal achieved Yes  No 
If no, reason for non-achievement
Goal achieved Yes  No 
If no, reason for non-achievement
………………………………………
……………………………………….
JL/AJM/CHC/Collaborative Care 6 November 2001
Hypertension (long term management)
[include text on long term management of hypertension here. This document should be a reference text for
nurses, medical and other staff. Please include references where necessary as endnotes. Please see suggested
format below]
Prevalence of hypertension of in stroke patients , risk associated with hpoertension
Definition of hypertension
Treatment
Monitoring
Special considerations
Hyperlipidaemia (last edit 29.11.04 /CR)
Definition
Total cholesterol > 5 mmol /l
LDL cholesterol> 3.5 mmol/l
Or triglycerides > 2.2 mmol/l
Risks
While there is no independent evidence that hyperlipidaemia by itself increases stroke risk, several studies
have shown that treatment of hyperlipidaemia with statins reduces the risk of future ischaemic strokes by a
third, especially in patients with coexistent ischaemic heart disease or diabetes. vi vii
Treatment
The mainstay of treatment of hyperlipidaemia is diet, exercise and statins (see tables : treatment of
hyperlipidaemia, low cholesterol diet, healthy diet).
Cautions and exceptions
While diet is a crucial element in the treatment of younger patients with hyperlipidaemia, there is no evidence
of benefit in older patients. Unless the cholesterol is very high older patients should therefore be advised to
eat a healthy balance diet high in fruit and vegetables rather than asked to adhere to a strict low cholesterol
diet. Patients who have problems maintaining their weight after the stroke because of poor appetite,
dysphagia or other problems should be reassured that they need not worry about cholesterol and fats and
should eat what they like and are able to manage. Diet and statins should also be avoided in patients who have
a very limited prognosis (<2 years) due to a disabling stroke or to other life limiting co morbidities (e.g.
cancer), since they may suffer all the side effects but are unlikely to live long enough to benefit.
Information material
Leaflet for healthy diet (include details)
Stroke Association Cholesterol leaflet (include details)
Low cholesterol diet (include details)
Management of hyperlipidaemia
TREATMENT
TARGET
TARGET POPULATION
Grey highlighted text applies to stroke patients only. Last edit 29.11.04 see endnotes for references viii
Patients who fall into one of the following groups.
1.Established CHD, Ischaemic stroke, TIA or PVD.
2.Patients with a  30% of CHD over 10 y.
3.Diabetic patients with > 15% risk over 10 y.
4.Patients with familial dyslipidaemias.
And who have

A total chol > 5.0mmol/l or

A total chol >3.5 mmol/l and stroke or TIA

LDL-chol > 3.0mmol/l or

Triglycerides > 2.3mmol/l
• Total chol < 5.0mmol/l or reduced by 20 – 25%
(whichever lower).
• LDL-chol < 3.0mmol/l or reduced by 30% (whichever
lower).
• Triglyceride below 2.3 mmol/l.
Estimate CHD event risk using the Joint British
Societies Coronary Risk Predication Charts (see
BNF for patients aged <76 y).
Patients over the age of 80 and those with very
limited expected lifespan may not benefit from
satin therapy. Balance expected benefits with
potential risks and side effects.
See below for patients appropriate for
referral to Specialist.
Secondary causes of dyslipidaemia should be
excluded.
-effects
Prescribe
simvastatin 20mg at night or
atorvastatin 10mg each day or
Pravastatin 20 mg nocte (in pts. on warfarin)
providing the pt has no contraindications to statin therapy
and patient’s triglycerides < 10mmol/l.
Refer to individual drug SPCs for
contraindications and interactions. Examples of
common interactions are: warfarin, amiodarone,
clarithromycins, eruthromycin,
rifampicin.verapamil, diltiazem, cimetidine,
Counsel patient on diet and lifestyle.
Advise patient to report unexplained muscle
pain, tenderness or weakness.
TREATMENT NAD MONITORING
Repeat lipid profile every 4 – 6 weeks. Double the statin
dose until target achieved, maximum dose reached or
dose increase not tolerated.
Targets not achieved
Switch to more potent statin: rosuvastatin 10mg /d.
Repeat lipid profile every 4 – 6 weeks.
Double the dose of rosuvastatin until target achieved,
maximum dose reached, or dose increase not tolerated.
Targets not achieved
Prescribe
max. tol. dose of statin
+
ezetimibe 10mg OD.
Targets not achieved
Prescribe
max. tol. dose of statin
+
bezafibrate 400mg SR OD
or bezafibrate 200mg TDS.
The following pts are appropriate for specialist referral:
• Suspected familial hypercholesterolaemia.
• Suspected familial hyperlipidaemia.
• Failure of therapy.
• Severe hypercholesterolaemia (TC > 10mmol/l).
• Very severe hypertriglyceridaemia (TG > 10mmol/l).
Monitor LFTs after each dose increase.
Max. licensed dose of simvastatin is 80mg at
night and of atorvastatin is 80mg each day.
Note that other prescribed drugs may limit the
dose of statin that can be used. Refer to
individual SPCs.
▼Black triangle drug report all adverse
reactions.
Max recommended dose of rosuvstatin is 40 mg
OD.
This dose should only be used und specialist
supervision.
Take benzafibrate after food.
Benzafibrate can be used as monotherapy in
patients unable to tolerate a statin.
The combination of statin + fibrate increases
risk of myopathy.
.
Patients with triglycerides > 10mmol/l should
be prescribed benzafibrate 400mg SR daily
whilst awaiting Specialist review.
Patients who achieve target levels should remain on lipid lowering treatment indefinitely.
Lipid levels and LFTs should be checked annually.
Low cholesterol diet
[Include diet sheet here]
Atrial Fibrillation (last edit Sept 08)
Patients in AF have a recurrence rate 12% per year which is reduced by treatment with warfarin to 5% per
year.
Patients in AF with an infarct should be considered for anticoagulation with warfarin, (they are obviously in
the high risk group. Warfarin treatment is not started until 2 weeks after stroke. Until then aspirin 300 mg/d
should be given.
o High risk (annual risk of CVA 8-12%)



All patients with previous CVA or TIA.
All patients aged 75 and over with diabetes and/or hypertension.
All patients with valve disease, heart failure, thyroid disease and/or impaired LV function.
o Moderate risk (annual risk of CVA 4%)


All patients under 65 with clinical risk factors:
 diabetes, hypertension, peripheral arterial disease, ischaemic heart disease.
All patients over 65 not in high risk group.
o Low risk (annual risk of CVA 1%)

All patients under 65 with no history of embolism, diabetes, hypertension or other clinical risk
factors.
Treatment
o High risk:

Warfarin (target INR 2.0 - 3.0) if no contraindications.
o Moderate risk:

Warfarin or Aspirin (75-150 mg daily). Treatment must be decided in individual cases.
o Low risk:

Aspirin 75-150 mg daily.
Possible contraindications to Warfarin
o The following list shows the contraindications to Warfarin which are adapted from the exclusion criteria
used in the SPAF (Stroke Prevention in Atrial Fibrillation) trial.







Gastro-intestinal or urinary bleeding in previous 6 months.
History of 3 or more falls in the previous year (obtained at interview).
Record of recurrent or injurious falls in preceding year.
Inability to comply with treatment.
Alcohol >28 units per week for men or >21 units for women.
Uncontrolled hypertension.
Daily use of NSAIDs.
Anticoagulation for Arial Fibrillation after Stroke (last update 22.06.2010)
Use slow anticoagulation (OATES regime) (1) for older patients, frail patients, multiple comorbidities, or
multiple drugs. Younger fit stable patients can be started on the TAIT regime. Avoid rapid anticoagulation
after stroke (risk of bleed and transient hypercoagulabillity). Use a nomogram to guide dosing (2). See NPSA
(3) for further guidance.
The referral should be faxed to the Anticoagulant Management service. The fax should be followed up with a
telephone call to ext 4630 to check that firstly the referral has arrived and secondly to get an appointment for
the patient.
Specify on the referral how anticoagulation should be initiated
1. Slow anticoagulation TAIT regime
2. Slow Anticoagulation OATES regime with first INR after 7 (not 14) days, days but do not alter dose until
day 14 unless INR at day 7 is above 3.0.
1. Oates et al, Br J Pharmacol 1998. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1873664/pdf/bcp0046-0157.pdf
2. NPSA 2007/18 http://www.nrls.npsa.nhs.uk/EasySiteWeb/getresource.axd?
3. NPSA guidance on safe anticoagulation http://www.nrls.npsa.nhs.uk/resources/?entryid45=59814
Depression (last edit 1.12.04)
Depression is a common complication of stroke, and can occur at any time, e.g. in the first few weeks, or
years later. Diagnosis is often difficult, especially in dysphasic patients.
Suspect depression when the patient appears to have low mood, refuses to participate in social and
rehabilitation activities, avoids eye contact, is restless, anxious, or aggressive, complains of aches and pains,
has poor sleep and no appetite.
Screening
All patients should be screened for depression within one month of the stroke. Use the Hospital Anxiety and
depression Scale (HAD scale) for screening depression in patients who are able to complete the questionnaire
themselves.ix Use the Stroke Aphasic Depression Questionnaire (SADQ) for patients who are aphasic and
cannot respond themselves to the questions.x
Diagnosis
The diagnosis should be made by clinical assessment taking the results of the screening questionnaires into
account.
Treatment options
Discuss anxieties and worries with the patient in an informal and private setting, and attempt to resolve
reversible precipitants of low mood before drug treatment.
Consider referral to the clinical psychologist if the patient is able to talk and may benefit from counselling.
Fluoxetine 20 mg mane (especially in patients where tiredness is a prominent feature, but cave gastrointestinal
and other, often unspecific, side effects)
Paroxetine 20 mg mane (may be slightly better tolerated, but more likely to cause tiredness).
Dothiepin 75 mg at 8 pm (has more anticholinergic side effects, and is more sedating but is very useful in
patients where the main feature of depression is insomnia).
Citalopram 20 mg OD is the only SSRI tested and found effective in clinical trials in stroke patients, but is not
on the hospital formulary. It should be considered in patients who cannot tolerate other SSRIs .
If none of the above is effective, referral to a psychiatrist or psychogeriatricina should be considered.
Interpretation of the HAD scale xi xii
Score Depression (black bar on the left) and Anxiety (black bar on the right) responses separately. Score
responses from 0,1,2,3 with 0 being normal/happy and 3 being anxious/depressed. The authors of the HAD
scale usually recommend two cutoff points, 8/9 for a high sensitivity and 10/11 for high specificity, for both
their anxiety and depression subscales, allowing the practitioner to choose whether to include borderline
cases. However, in stroke patients the cut off points given below have been shown to be more sensitive and
specific.
1. Depression
A cutoff point of 8/9 produced a sensitivity of 0.45 and a specificity of 0.85.
A cutoff point of 10/11 produced a sensitivity of 0.35 and a specificity of 0.93.
Improved sensitivity and specificity were achieved in this sample using a cutoff point of 6/7 (sensitivity, 0.8;
specificity, 0.79).
2. Anxiety
A cutoff point of 8/9 produced a sensitivity of 0.5 and specificity of 0.87.
A cutoff of 10/11 produced a sensitivity of 0.42 and specificity of 0.92.
A better balance between sensitivity and specificity was achieved using a cutoff point of 6/7 (sensitivity, 0.83;
specificity, 0.68).
Interpretation of the Stroke Aphasic Depression Questionnaire (SADQ)
This score is well coreelatte with the HAD and the longer (21-item) SADQ. It has only been tested in 20
patietns. The median Score was 13 with an interquartile range of 9-17. No cut off for depression was defined.
Suspect depression if a patients scores 15 or more.
Urinary Retention
Retention is common after stroke, and almost invariably reversible if the patient was able to pass urine
normally before the stroke. It is caused by over stretching of the bladder in a patient who is bedbound and
cannot get to the toilet when he wants to, stress, impaction, and central mechanisms. Men with pre-existing
prostate problems are particularly likely to develop retention, but women are also affected.
General management
 Confirm retention by bladder scan.
 If confirmed, insert intermittent catheter to relieve retention
 Document the volume of urine draining straight after catheterisation.
 Exclude/treat faecal impaction
 If patient arrives on the ward with indwelling catheter remove immediately (unless the catheter is longterm. e.g. was present before admission).
 If unsuccessful, repeat after 24 h.
 If unsuccessful again, ask for medical review.
 DRE to assess prostate size / VE to check for pessaries etc.
Males and females without a history of previous bladder and prostate problems
 Intermittent catheterisation 3-4x/day
 If a bladder scan is available check bladder volume and catheterise if >500.
 If the patient is able to pass some urine reduce frequency of catheterisation as tolerated aiming for bladder
volumes < 500 ml.
Males with a history of prostate problems
 Tamsolusin 400 mcg/day, TWOC after 48 h, if unsuccessful
 Repeat TWOC after 1 week, if unsuccessful
 Increase tamsolusin to 800 mcg/day, repeat TWOC after 1 week, if unsuccessful
 Repeat TWOC after 2 weeks, if unsuccessful
 Consider adding doxazosin (if BP not too low) and TWOC after 1/52, If unsuccessful
 Consider intermittent self catheterisation (as above), if unsuccessful
 Start finasteride 5mg/d and repeat TWOC at monthly intervals
 Refer to urologist, consider prostatic stent
Females with a history of voiding problems
 Refer to urologist
Females with no previous voiding problems
 Improve voiding by applying suprapubic pressure (Crede manoeuvre) during the void
 Intermittent self catheterisation
 Betanechol*10-25 mg TDS 30 min before meals, TWOC after 48 h
Or distigmine bromide* 5mg od (slower onset of action)
Or carbachol* 2 mg TDS 30 min before meals (may have more side effects)
*avoid in patients with DU, asthma, hypotension, Parkinson's, epilepsy, urethral or bowel obstruction)
 TWOC after 48 hrs, if unsuccessful repeat after 1 week, if unsuccessful again, urology referral.
Shoulder pain
The most common cause of post stroke shoulder pain is stress on the joint due to the hemiparetic arm
dangling down unsupported and injury caused by carers pulling on the arm when sitting the patient up or
during transfers. It can be avoided by positioning the hemiparetic arm on a pillow and by appropriate transfer
techniques.
Approach to the patient with shoulder pain
 Make sure the arm is always well supported.
 Teach the patient not to allow the arm to hang unsupported.
 Check that all carers are using appropriate transfers.
 Discuss therapeutic options and with the physiotherapist.
 Simple analgesics
 consider NSAIDs, TENS, heat treatment.
This will relieve the discomfort in most cases. If not consider other or multiple causes:
Cause
Subluxation
Flaccid low tone arm
Palpable gap
Spasticity
High tone
Tense pectoralis major tendon
Wrist movem. precipit. should. pain
Osteoarthritis
H/O arthritis, neck and shoulder
pains
Palpable crepitus
Frozen shoulder
Can't elevate > 90
Rotat. more restr. than other movem.
Rotator Cuff Syndrome
H/O trauma, fall, painful arc syndr.
Pain located to mid humerus
Thalamic pain (rare)
Anaesthesia, Paraesthesiae
Shooting pains precipit. by light
touch or gentle stroking of hairs all
over the hemi side
Sympathetic dystrophy/ shoulder
arm syndome (v. rare)
Skin of the hand and lower arm
discoloured, warm and extremely
tender to minimal touch
Treatment options



























Postioning
Physiotherapy
Analgesics
Strapping
Suprascapular nerve block
Electrical stimulation
Physiotherapy
Muscle relaxants
Botulinum toxin injection
Physiotherapy
Heat treatments
Ultrasound
Glenohumeral joint injection
NSAIDs
Physiotherapy
Glenohumeral joint injection
Suprascapular nerve block
Rotator cuff exercises
Subacromial steroid injection
Amitryptiline
Carbamazepine
Gabapentin
Amitryptiline and Gabapentin
(Gentle) Physiotherapy
Avoid extreme heat/cold
Consult pain specialist ASAP
Sympathetic nerve block
Effect of tx
Satin induced myopathy (rare)
 Stop the statin
On a statin, muscle tendern., high CK
Consider fracture, dislocation, gout, bicipital tendinitis, brach. plexus injury and others….
Spasticity
Spasticity following stroke is characterised by increased tone and stiffness in the affected side and by spasms
and abnormal movements. It is but one feature of the upper motor neuron syndrome. It does not always need
treating, as it is sometimes helpful in assisting a patient to stand on a stiff limb, when the underlying weakness
would not otherwise allow it. It requires treating in about 16% of patients after stroke, when it is harmful and
troublesome. Spasticity may not present as a major problem during patients’ inpatient stay, but may present
aftewr the patient has returned home. The six month review is therefore a good time to assess its impact,
which can be as follows:
Impact of Spasticity on Health1
Unremitting pain from muscle spasms, limb deformity & pressure on pressure points
Treatment for pressure sores and other tissue viability problems
Contractures leading to abnormal body segment loading and sensory change
Limb deformity and altered body mechanics
Need for special wheelchairs and seating and pressure-relieving equipment
Progression to degenerative joint disease
Altered body image
Mood problems
Management
Successful spasticity management is a multidisciplinary activity and is based on physical management (good
nursing care, physiotherapy, occupational therapy). Positioning, exercise, stretching and strengthening of
limbs, splinting and pain relief are essential and all pharmacological interventions are adjunctive to a
programme of physical intervention. A treatment strategy is described below. The pharmacological options
depend on the pattern of the presenting problem. The figure shows the drugs of choice for the generalized
and focal problems of spasticity.
Management Strategy for Adults with Spasticity2, 3
Prevention of Provocative Factors
Team Decision Making
Physical
Treatment Options
Generalised Spasticity
Focal Spasticity
Oral Agents
Botulinum Toxin
Phenol Blockade
Medical
Orthopaedic Surgery
Characteristics of Anti-spastic Drugs4
Treatment
Value
Problems
Oral Agents
Baclofen & Dantrolene - cheap
Tizanidine – 7x cost
Gabapentin - expensive
40% of patients unable either to tolerate oral
agents because of side-effects or unable to
produce an adequate anti-spastic effect before
side-effects occur
Botulinum Toxin
Effective for focal spasticity
Simple to prescribe
Simple intramuscular injection
Need trained clinician to treat
Seen as expensive, but good value over the
four-month effect of the drug. Budgetary
limits. Reversible effects. Considerable
benefit to management
Cheap drug
Time consuming to give
Expensive to give in clinical time. Painful to
give. Potential for severe complications
Intrathecal Baclofen
Expensive hardware
Eight year life
Need for prolonged inpatient assessment
required. Requires patient compliance and
education. Need proper contract to deal with
pump renewals
Neurosurgery &
Orthopaedic Surgery
Expensive, but valuable.
Limited indications and patients
Painful, irreversible, invasive
Variable results & effectiveness.
Phenol Nerve &
Motor Point Block
Treatment Plan1
Patient with Established Troublesome Spasticity
Manage Provocative Factors
(Bowel, Bladder, Pain, Tissue Viability, Posture, etc)
Focal spasticity
Generalised
spasticity
1 month trial
physical therapy
Trial of oral baclofen if spasms &
loss of range of movement
Review at 1 month
Spasticity controlled or improving?
No
No
Review by Spasticity Service
1.
2.
Yes
Yes
Refer to Spasticity Service for
BTX/Other Rx
Regular Review.
Refer back if further
problems
Physiotherapy is aimed at reducing the problems caused by the spasticity and at achieving a natural
balance between both the affected and unaffected sides5. Painful spasticity, e.g. as in hemiplegic
shoulder pain, should be controlled physically and with local and nerve blockade. See shoulder pain
section.
Occupational therapists are responsible for providing splints and casts to allow more prolonged
stretching of limbs6, 7.
3.
4.
5.
Start baclofen at 5mg tds for one week. If there are no side effects, raise dose to 10mg tds and by a
further 10mg daily at weekly intervals until the desired effect or side effects occur. Maximum dose is
80-90mg daily.
If spasticity not controlled, the patient should be referred to the Spasticity Service for consideration of
secondary measures. The addition of, or change to, dantrolene or tizanidine may be attempted, but
experience shows that they are unlikely to achieve the desired therapeutic result, if baclofen does not.
If the patient has cortical dysaesthesia or neurogenic pain, gabapentin should be given in typical
therapeutic doses. This should be given for a minimum of six weeks and the dose titrated against
effects and side effects. Dosing should start at 300mg daily along the following plan. Elderly patients
may not be able to tolerate this increase and weekly increments should be applied rather than every
three days. If side effects do occur, patients should be instructed to decrease to the dose below and
attempt to increase it again after a few days. (Each 300mg capsule is delineated by an X).
Initiation of Gabapentin 300mg capsules (=X)
Days
AM
1-3
X
4-6
X
7-9
XX
10-12
XX
13 onwards
XXX
6.
8.
X
X
XX
XX
The dose should then be adjusted upwards(or downwards) according to effect, but may be raised to a
maximum of 3600mg daily, if required.
Botulinum toxin and phenol injections are indicated for the treatment of focal problems, but require
specialised service to achieve optimal effects and value1. Botulinum toxin is given by intramuscular
injection to the spastic muscle causing harm. Its effect lasts for three to four months and it is
completely reversible. It provides a window of opportunity for physical treatment to take place. It can
be given as soon as spasticity causes harm and only about 5% stroke patients will ever require it. It
may only have to be given on one or two occasions, but there is a population of stroke patients, who
develop chronic spasticity, who will require them more regularly. Three monthly intervals should
elapse before the toxin is re-injected, in order to prevent secondary non-response from neutralising
antibodies. Their indications are as follows.
a.
b.
c.
d.
7.
PM
Functional improvement, e.g. of mobility, transfers, dexterity/reaching.
Symptom reduction, e.g. pain & spasm relief, allowing orthoses to be worn.
Aesthetic improvement, e.g. body image or fit of clothes
Decrease in the burden of care, e.g. allowing better patient positioning, care & hygiene and
reducing limb deformity to allow easier dressing.
e. Enhancing service responses, e.g. by facilitating physical therapies, reducing use of antispastic
medication, reducing unnecessary treatments for complications, preventing or delaying surgery.
Ensure that there is good communication between the stroke team and the spasticity service team on
the aims of treatment and on follow up arrangements
Follow up requires consideration of goal achievement and other outcome measures. Documentation is
available from the spasticity service.
Who Will Develop Spasticity?
Patients with bilateral weakness may develop problems, but the most likely patients are those with the
following sensory and cognitive problems.
Sensory Loss
Cognitive Loss
Proprioception**
Light Touch
Visual Impairment e.g. uncorrected hemianopia
Memory
Perception***
particularly those with visuo-spatial and
sensory neglect)
Outcomes
There are no satisfactory measures for spasticity and the current ‘standard’, the Ashworth Score, measures
limb stiffness and not spasticity8. This will change over the next year or two and the current recommended
outcome measures are:
The Goal Attainment Score, as measured by a percentage of goal desired. This must be agreed with the
treating team prior to treatment. Patient/Carer satisfaction can be measured using a 10cm Visual Analogue
Scale of a Likert Scale9, but all other measures should be based on the International Classification of
Functioning & Health (2001)10, examples of which are:
Domain
Item
Some Suggested Measures
Impairment
Pain
Stiffness
Joint RoM
Muscle Power
10cm Visual Analogue Scale/Likert Scale
Ashworth Score
(Flexion & Extension) Angles
Dynamometry/MRC scale
Functioning
Mobility
Dexterity
Mood
10 metre Walking Time/Stride length
Get Up & Go Test
9 Hole Peg Test
HADS
Quality of Life
Some goal achievement
EQ5D, SF36
Goal Attainment scores
Participation
References
1. Ward AB, et al. Primary care guidelines on spasticity. 2004; London. Connect Medical.
2. Turner Stokes L, Ward AB. The Use of Botulinum Toxin in the Management of Adults with Spasticity. Clinical
Medicine (JRCPL) 2002; 2 (2): 128-130.
3. Guidance for the use of botulinum toxin in the management of spasticity in adults. Royal College of Physicians of
London Clinical Effectiveness & Evaluation Unit. July 2002. Royal College of Physicians, London
4. Ward AB. Spasticity. Chapter in ‘The Clinical Applications of the Botulinum Toxins’. Eds. Barnes MP, Ward AB.
Cambridge. Cambridge University Press – in press.
5. Bower E, McLellan D L, Arney J, Campbell M J. A Randomised Controlled Trial of Different Intensities of
Physiotherapy and Different Goal Setting Procedures in 44 Children with Cerebral Palsy. Developmental Medicine
& Child Neurology 1996; 38: 226-237
6. Zachewski J E, Eberle E D, Jefferies M. Effect of tone inhibiting casts and orthosis on gait. A case report. Physical
Therapy 1982; 62: 453-455.
7. Moore T J, Barron J, Modlin P, Bean S. The use of tone reducing casts to prevent joint contractures following
severe closed head injury. Journal of Head Trauma Rehabilitation 1989; 4: 63-65.
8. Bohannon RW, Smith MB. Inter-rater reliability of a modified Ashworth Scale of muscle spasticity. Physical
Therapy 1987; 67: 206-207.
9. Wade DT.Outcome measurement and rehabilitation. Clinical Rehabilitation 199; 13: 93-95.
10. Wade DT. Measurement in Neurological Disability. 1992 Oxford. Oxford University Press.
11. World Health Organisation. International Classification of Functioning and Health. 2001. World Health
Organisation. Geneva.
Drooling
ASD and PFO
The Staffordshire and Shropshire Cardiac & Stroke Network Guidelines for the investigation
of right to left shunts, presumed paradoxical embolism and their closure in young strokes
Version 1.0 November 2008
Background: The vast majority of strokes are ischaemic strokes (IS) and are mediated by
either spontaneous rupture of atheromatous plaque in the carotid artery and consequent
thromboembolism or as a result of atrial fibrillation. They occur in patients with a number of
cardiovascular risk factors; increasing age, smoking diabetes, hypertension and
hyperlipidaemia. A smaller number are haemorrhagic.
There is a much smaller group of stroke patients who are < 55 years old, who suffer an IS in
whom there is an association with right to left shunts (RLS); patent foramen ovale (PFO),
atrial septal defects(ASD) and pulmonary arteriovenous malformations (pulm-AVM). This
group have been termed cryptogenic stroke, because the expected association between
cardiovascular risk factors and IS are absent. Current data from meta-analysis suggests that
only large shunts (>5-15 bubbles on bubble contrast echocardiography, within 3 cardiac
cycles for ASD/PFO) or PFOs that are greater than 4mm are likely to cause paradoxical
embolism.
Device closure in RLS and stroke: PFOs are present in 40% of patients with cryptogenic
stroke and may be associated with paradoxical emboli, stroke being a common result.
Therapeutic options include antiplatelet agents, anticoagulation, percutaneous and surgical
closure. Casaubon et al [1] recently assessed the risk of recurrent TIA or IS between patients
in four treatment groups; antiplatelet agents (34%), anticoagulation (17%), device (39%) and
surgical closure (11%). The initial cohort consisted of 121 patients and recurrent events
occurred in 16 patients (9 antiplatelet, 3 anticoagulation, 4 device closure); 7 were strokes, 9
were TIAs. Patent foramen ovale closure was associated with fewer recurrent events.
Schuchlenz et al [2] randomised 280 consecutive patients with PFO and cryptogenic stroke to
receive platelet inhibitors (n = 66) or anticoagulation (n = 47) or device closure (n = 167). 33
(12%) patients had a recurrent cerebrovascular event. The annual recurrence rates were 13%
in patients treated with platelet inhibitors, 5.6% in those on oral anticoagulation, and 0.6% in
those after device closure. Independent predictors of recurrent cerebrovascular events were a
PFO larger than 4 mm or previous strokes. Patients with a large patent foramen ovale i.e
>4mm and a cryptogenic stroke had a substantial risk of recurrence even with medical
treatment.
Prior studies suggest that PFO diameter >4 mm is associated with a high probability of IS
with quite a degree of concordance. However the PFO may appear small on TTE, but
potentially be much larger under extreme loading conditions (childbirth, stress, trauma and
operations). This is evident in the catheter laboratory where a small PFO is easily opened to
15+mm, although the shunt on contrast echocardiography has usually been large.
Percutaneous shunt closure: The Liverpool experience [3] of ~150 device closures showed
that the predominant indication for PFO closure was cerebrovascular accident (CVA) (42.2%,
n = 46)- and for ASD, dilated right ventricle (68.4%, n = 52). Of all procedures, 94.6% (n =
175) were first time and 5.4% (n = 10) were redo for residual shunt. The overall complication
rate was 5%, of which 1% was classed as serious. This is supported by many single centre
series showing the procedure to be safe. It is now subject to formal national audit as part of
the Central Cardiac Audit Database (CCAD), a partnership between the Department of Health
and British Cardiac Society.
Imaging: Bubble contrast echocardiography has been the cornerstone in diagnosis of RLS for
over four decades. Despite being a relatively invasive procedure, transoesophageal
echocardiography (TOE) is considered the gold standard for detection of RLS, however other
echocardiographic techniques such as transthoracic echocardiography (TTE) with second
harmonic imaging and transcranial Doppler ultrasonography (TCD) have shown increased
sensitivity and specificity compared to TEE for the detection of RLS. Moreover, improvement
of skills and techniques used for detection of these shunts has led to greater detection of small
and large sized RLS in the echocardiographic laboratory without resorting to TOE.
We currently recommend transthoracic echocardiography with both a Valsalva manoeuvre
and a large sniff, which create optimum loading conditions to demonstrate a RLS. This should
be undertaken in a centre experienced in undertaking and interpreting these images.
Other indications:
Sleep apnoea: This has a greater incidence if obesity and right to left shunting exists. Device
closure has a beneficial effect only in anecdotal case reports so far.
Migraine: Currently the association between R-L shunts and migraine is confirmed in a
number of observational studies, but as yet no significant treatment effect from device closure
has been proven.
Platypnea-orthodeoxia syndrome: Dyspnea and arterial desaturation on upright position in
elderly subjects is described as platypnea-orthodeoxia syndrome (POS) and in some patients it
is due to right-to-left shunt across the atrial septal defect (ASD)/patent foramen ovale (PFO).
This is a current indication for device closure of a RLS
Echocardiography
Transthoracic bubble study: This should be undertaken by an operator trained and experienced
in the acquisition and interpretation of standard transthoracic and bubble ecchocardiography.
Ideally images should be obtained in apical 4 chamber view to allow simultaneous imaging of
right and left sides of the heart.
A 21 gauge cannula should be used in the antecubetal fossa and an agitated mixture of 8.5ml
saline, 1ml blood and 0.5ml air mL injected. One resting injection should be made followed
by three injections with a forced valsalva and also with a large sniff.
Transoesophogeal echocardiogram: This should be undertake in patients who may require
device closure, or where other intracardiac sources of embolisation are being sought;
myxoma, left atrial appendage clot.
Investigations
 All patients with ischaemic stroke who are <55 years old should undergo transthoracic
echocardiography with bubble contrast
 All patients with dilated right hearts and suspicion of RLS on echo post stroke should
undergo bubble contrast echocardiography
 All shunts that are classed as large should be referred potential device closure (>5
bubbles in 3 cardiac cycles)
 Large shunts in < 3 beats may indicate intracardiac RLS
 Large shunts > 3 beats may indicate pulmonary venous arteriovenous malformations,
which should be assessed by CT angiography. Clinical sign of hereditary haemorrhagic
telangiectasia should be sought
 Consideration should be given to excluding paroxysmal AF as a cause of stroke.
Definite indications for device closure
 Young stroke with large RLS (>5 bubbles in three beats) shunt due to PFO or ASD
 ASD
 PFO > 4mm on balloon sizing
 Platypnea-orthodeoxia syndrome
 Significant ASD with dilated right heart on echocardiogram
 Will need cardiac catheterisation or cardiac magnetic resonance imaging first to
quantify shunt size
Management post device closure
 Aspirin lifelong with three months of clopidogrel initially. If patients are within the first
two years post stroke, and were on persantin prior to device closure, this should be
restarted after the clopidogrel finishes
 Repeat bubble study at six months. If a residual shunt is seen at six months then a
further repeat bubble study should be arranged for one year
Reference List
1 Casaubon L, McLaughlin P, Webb G, et al. Recurrent stroke/TIA in cryptogenic stroke patients with
patent foramen ovale. Canadian Journal of Neurological Sciences 2007 Feb;34(1):74-80.
2 Schuchlenz HW, Weihs W, Berghold A, et al. Secondary prevention after cryptogenic cerebrovascular
events in patients with patent foramen ovale. Int J Cardiol 2005 May 11;101(1):77-82.
3 Egred M, Andron M, Albouaini K, et al. Percutaneous closure of patent foramen ovale and atrial septal
defect: procedure outcome and medium-term follow-up. Journal of Interventional Cardiology 2007
Oct;20(5):395-401.
Perceptual Difficulties following Stroke
Perception is the word used to describe the brain's ability to interpret and understand information received by
the senses. This means that patients can see and feel things, but they won't recognize what they are.
Perceptual deficits can be divided into the following areas:




Body Image – lack of visual/mental image of one’s body.
Body Scheme – difficulty in perceiving the position of the body, and the relationship to other body parts.
Spatial Relationship Deficits – difficulty in processing the position of two or more objects in relation to
oneself or each other.
Agnosias – Lack of recognition of familiar objects.
If perceptual difficulties are suspected the patient would benefit from further assessment by the occupational
therapist.
Cognitive Deficits Following Stroke
Stroke can disrupt a wide range of cognitive difficulties, resulting in difficulties in carrying out activities.
Cognitive deficits may adversely affect a person’s ability to participate in therapy, performs activities of daily
living and live independently. This can be both confusing and distressing for both the patient and their
families.
Below are brief descriptions of the most common cognitive impairments.
Neglect
Stroke may affect a person’s awareness of the space around them and the space occupied by their body. This
may present in the neglect of their upper limb or a failure to respond to things positioned in the space on the
neglected side.
The left side is the most commonly neglected following stroke.
Patients should be encouraged to attend to the side in which they are neglecting, however, if it is severe
neglect it may be much more appropriate to encourage the patient around to midline.
Attention and Concentration
Problems sustaining attention/concentration are common following stroke, especially right hemisphere
strokes. Patients can experience difficulties in maintaining concentration, making it hard to carry out
activities. This can be worse if they are tired, not interested in the activity or if there are distractions.
Dyspraxia
This is a disorder of the skilled voluntary movement that is not due to a sensory or motor impairment. People
who present with dyspraxia may be unable to perform activity due to an impaired conceptual ability to
organize the actions required to complete the task. Dyspraxia is most common following left hemisphere
lesions.
It is important that when working with patients who have dyspraxia that all staff involved approach tasks in
the same way, if tasks are repeated they are more likely to become familiar.
Executive Function
Executive functioning impairments can occur following stroke, especially if there is frontal lobe involvement.
Executive functions have an organising role on the inhibition and initiation of behaviour, therefore
impairments in this area may affect a person’s ability to plan, problems solve and self monitor.
Patients should be screened for cognitive impairment following stroke. Locally this tends to be done by the
occupational therapist. Referrals are also made to the clinical psychologist for further assessment and
guidance with patients presenting with complex problems.
Resuming hobbies and interests
This is a very important area that should be addressed with the patient and carer (if this is appropriate). It is
acknowledged that many patients following stroke will lose previous roles, hobbies and interests, which may
contribute to feelings of low mood, distress and depression. This may not be apparent to the patient and their
family until the time following discharge from the acute, rehabilitation or community services.
RCP Guidelines, 2004, state that “long term rehabilitation needs to address issues around ‘participation’”
This may necessitate the withdrawal of the medical and traditional rehabilitation services such as day hospital
services, and the substitution of these with leisure and social activities to encourage independence and
reintegration.
To facilitate this, patients’ need to be given access to the statutory and voluntary agencies that can support or
advise them in resuming their hobbies and interests or attempting areas of new interest.
Useful Local Contact Numbers Include:
Stokes R Us
01538 751671
Stroke Association
01782 845828
Different Strokes
0845 130 7172
Driving Following Stroke
Following stroke the DVLA state that you should not drive for one month.
Following this you may resume driving if a doctor feels that your clinical recovery is satisfactory.
You must inform your insurance of your stroke or TIA before you get back to driving. This applies even if
you are fully "back to normal".
There is no need to notify the DVLA unless there is residual neurological deficit one month after the episode.
In particular these neurological deficits include visual field and cognitive deficits and impaired limb function.
The DVLA will require notification if you have not fully recovered after one month but want to resume
driving and if there is a restriction to certain types of vehicle where adapted controls are required.
A driver who experiences multiple TIAs over a short space of time may require three month period freedom
of further attacks before resuming driving and should notify the DVLA.
Even if the doctor, the DLVA and the insurance have passed you as fit for driving it is your individual
responsibility to ensure that you are fit to drive. If you feel tired, unwell, if your can't concentrate or get
confused, or if your eyesight is not adequate you should not drive. Sometimes your health and fitness can
change form day to day, and it is your responsibility to decide if you are fit to drive every time you get into
the car.
Contact Details:
Driver and Vehicle Licensing Agency
Drivers Medical Group
Swansea
SA99 1DL
0879 600 0301
http://www.dvla.gov.uk/ (DLVA main site)
http://www.dvla.gov.uk/at_a_glance/ch1_neurological.htm
(information about stroke and driving )
Derby Regional Mobility Centre
Kingsway Hospital, Kingsway, Derby DE22 3LZ
01332 371929
http://www.drmc.uk.com
Mid Staffordshire Driving Assessment Service
Cannock Chase Hospital, Brunswick Road, Cannock, Staffordshire WS11 2XY
Tel: 01543 576416
Fax: 01543 576401
Travel
There is no reason not to travel after the stroke. A holiday may help both the stroke patients and the carers
feel better. Here are some contact numbers to help with travel arrangements and mobility problems. There is
no need to consult your doctor beforehand if you feel well, but you may be more reassured and get some
valuable advice if you do so. Patients on warfarin may have to arrange for INR checks in their holiday resort.
Contact numbers for local rail services offering support for disabled passengers:
Central Trains 08457 056027
www.centraltrains.co.uk
Connex central 08706 030405
Midland Mainline 08457 125678
Virgin Trains 08457 443366
Contact numbers for coach travel:
National Express 08705 80 80 80
www.gobycoach.com
Air travel can be considered 3 months after the stroke. Before that time insurances do not usually cover and
airlines are unlikely to accept the passenger, even if all or most of the symptoms of the stroke have resolved.
After 3 months even stroke sufferers with persistent severe disabilities can fly as long as they can sit long
enough in a chair and have no severe heart or lung problems. Wheelchairs and assistance with transport for
disabled passengers are available at all airports, but will require prior booking.
Contact numbers for assistance at Airports:
East Midlands Airport 01332 852852/852885
London Gatwick Airport 01293 503124
London Heathrow Airport 0208 745 7495
Manchester Airport 0161 4893000
These contact numbers are not intended to be recommendations of services.
Appendices
T OC
Date
Time
Best level of
mobilisation
achieved
A
B
C
Blood Pressure
D
E
Heart rate
F
Respiratory Rate
250
240
230
220
210
200
190
180
170
160
150
140
130
120
110
100
90
80
70
60
50
40
35
30
25
15
10
Best level of mobilisation
BM Result
Oxygen saturation
Oxygen concentration (if given)
Conscious level
Fully alert
Drowsy, but can be awakened to full consc.
Reacts to commands, can't be fully awakened
Coma
Speech
No communication problems
Problems w. expression or w. understanding
More than yes/no, but not longer sentences
Only yes/no or less
Eye movement
Normal eye movements
Can look straight, but not to affected side
Eyes look away form the affected side
Arm motor power (on the affected side)
Raises arm with normal strength
Raises arm with reduced strength
Raises arm with flexion in elbow
Can move, but not against gravity
No movement
Leg motor power (on the affected side)
Raises leg with normal strength
Raises leg with reduced strength
Raises leg with flexion in knee
Can move, but not against gravity
No movement
Total (max 32)
6
4
2
0
10
6
3
0
4
2
0
6
5
4
2
0
6
5
4
2
0
40
39.5
39
38.5
38
37.5
37
36.5
36
35.5
35
H A D SCALE
Name:
Date:
Doctors are aware that emotions play an important part in most illnesses. If your doctor knows about these
feelings he will be able to help you more. This questionnaire is designed to help your doctor to know how you
feel. Read each item and place a firm tick in the box opposite the reply which comes closest to how you have
been feeling in the past week.
Don’t take too long over your replies: your immediate reaction to each item will probably be more accurate
than a long thought out response.
I feel tense or wound up:
Most of the time
A lot of the time
Time to time, occasionally
Not at all
A
3
2
1
0
I still enjoy the things I used to enjoy:
Definitely as much
Not quite so much
Only a little
Hardly at all
0
1
2
3
D
I feel as if I am slowed down:
Nearly all the time
Very often
Sometimes
Not at all
A
D
3
2
1
0
I get a sort of frightened feeling like butterflies in
the stomach:
Not at all
0
Occasionally
1
Quite often
2
Very often
3
I get a sort of frightened feeling as if something
awful is about to happen:
Definitely, quite badly
3
Yes, but not too badly
2
A little, but it doesn’t worry me
1
Not at all
0
I have lost interest in my appearance:
Definitely
3
I don’t take as much care as I should
I may not take quite as much care 1
I take as much care as ever
0
I can laugh and see the funny side of things:
As much as I always could
0
Not quite so much now
1
Definitely not so much now
2
Not at all
3
I feel restless as if I have to be on the move
Very much indeed
3
Quite a lot
2
Not very much
1
Not at all
0
Worrying thoughts go through my mind:
A great deal of the time
3
A lot of the time
2
From time to time, but not too often
1
Only occasionally
0
I look forward with enjoyment to things:
As much as I ever did
0
Rather less than I used to
1
Definitely less than used to
2
Hardly at all
3
I feel cheerful:
Not at all
Not often
Sometimes
Most of the time
3
2
1
0
I get sudden feelings of panic:
Very often indeed
Quite often
Not very often
Not at all
I can sit at ease and feel relaxed:
Definitely
Usually
Not often
Not at all
0
1
2
3
I can enjoy a good book/radio or TV programme
Often
0
Sometimes
1
Not often
2
Very seldom
3
A________
D__________
3
2
1
0
The Community Stroke Aphasic Depression Questionnaire
(SADQ 10 item )
Please indicate how often in the last week the patient has shown the following behaviours:
Often
3
1.
2.
3.
Does he/she have weeping spells?
Does he/she have disturbed nights?
Does he/she avoid eye contact
when you talk to him/her?
4. Does he/she burst into tears?
5. Does he/she complain of aches and
pains?
6. Does he/she get angry?
7. Does he/she refuse to participate in
social activities?
8. Does he/she get restless and
fidgety?
9. Does he/she sit without doing
anything?
10. Does he/she keep himself/herself
occupied during the day?
Total
Sometimes
2
Rarely
1
Never
0
Discharge Summary Template
Presenting Complaints:
Investigations:
right/ left hemiparesis/ other
CT brain confirms: Cerebral infarct/ haemorrhage/ non specific changes
(e.g. Small vessel disease old infarcts)/ normal/ other (e.g. brain tumour)
Diagnosis:
Carotid Dopplers: give result
1. Ischaemic Stroke (thrombolysed / not thrombolysed)
Normal/ mild/ moderate atheroma.
Critical stenosis or non critical stenosis
Total anterior Circulation Ischaemic Stroke (TACI)
Partial anterior circulation ischaemic Stroke (PACI)
Lacunar Ischaemic Stroke (LACI)
Posterior circulation ischaemic Stroke (POCI)
Small vessel disease of the brain
Vascular dementia secondary to small vessel disease of the brain
ECG: Sinus rhythm / Ischaemic changes/AF
CXR: Normal /Abnormal
Bloods: relevant abnormal findings. Plus fasting or random glucose and
cholesterol
2. Haemorrhagic Stroke
Non traumatic Intra-parenchymal haemorrhage
Traumatic Intra-parenchymal haemorrhage
Subarachnoid haemorrhage
Subdural Haematoma
Note: It is important to enter all the columns. If CXR and ECG are normal it
has to be entered as Normal chest x-ray and Sinus rhythm. Abnormal blood
results should be documented.
Carried out Procedures:
3. TIA (give ABCD2 Score)
4. Other diagnosis – for example, migraine, seizure, mets
Co morbidities:
Diabetes
Hypertension
Smoker
Alcohol excess
Atrial fibrillation
Increased BMI
Hypercholesterolemia
Old age – over 65
Living alone
Frailty
Dementia
COPD
Others...
Thrombolysis
Venous access
NG tube
PEG tube
Catheterisation
Physio/OT assessment
SALT assessment
Trial participation (name of trial)
Medications:
Aspirin
Dipyridamole
Simvastatin
Ramipril
Bendroflumethiazide
Metformin
Gliclazide
Additional Comments:
Follow up:
NIHSS on admission
6 weeks or No follow up.
Discharge Destination: Home, NH, RH, and transfer to other (specify ward)
If the Consultant mentions a different follow up date that has to be changed
accordingly
Level of mobility: Mobile / Immobile/ Hoisted
Continence:
Bowel: Continent / Incontinent
Bladder: Continent/Incontinent
Life style advice
Dietary advice
Target BP 140/ 85 or 130 /80 for Diabetic patients and CRF
Hb1Ac % 6 – 8
Cholesterol: TC less than 4 and LDL less than 2
Driving advice
Flying advice
Any other recommendations to GP like monitoring renal functions or any
changes to admission medications should be documented in this section
For All patients transferred to other wards hospital (rather than discharged
home):
Anticipated discharge destination:
Goals to achieve in the other ward before discharge.
Kindly always make sure that you enter your name and bleep number for
records. If not it will be difficult for us to find who did the discharge summary.
Joint discharge Plan (to be completed by OT):
All patients discharged form hospital should have a joint health and social
care discharge plan, unless they are fully independent, they refuse such a
plan, or a joint plan is inappropriate for other reasons.
This should be devised by the OT , discussed with social services, and the
patient/family and the content of the plan documented in the discharge
summary.
go back to index
74
Stroke follow-up 1 (6 week post discharge) Assessment form
Name
Weight
Blood pressure
Heart rate
ECG
Date
Diagnosis, comorbidities, and risk factors (consult and update stroke checklist)
Scores:
Rankin:
MMTS:
HAD A:
HAD D:
No of falls:
Current medication
Progress/ Problems since hospital discharge
Any problems coping? Yes/no
Carer stressed? Yes/no/na
Involvement of social or rehabilitation services
 ESD
 Stroke Association call/ visit
 Stroke Club / Young strokes/ Dysphasia support
 Psychological support
 Home help
 Other
go back to index
75
Life after stroke (yes/no/NA; check if any problems, and if help/ advice needed, document
needs)
 Driving
 Work/ Housework
 Hobbies/ Travel
 Family/friends
 Sex
 Other
Problems which may need addressing
 Incontinent?
 Cognitive problems?
 Depression/ Anxiety?
 Spasticity/ pain?
 Excessive tiredness?
 Anything else the patient would like help with?
Management Plan
 If thrombolysed, copy letter with Rankin score to C. Roffe for SITS register.
 If interested in becoming involved in research/ development/ peer support/ teaching copy
letter to PPI file with area of interest and contact no
 Referral for psychological assessment/ treatment
Yes / Not needed/ Not wanted
 Other referrals
 Risk factor management handed over to GP Yes / no / specify why not)
 6 month follow-up handed over to GP Yes / no / specify why not
 Investigations ordered (No / yes/ specify)
go back to index
76
Stroke Follow-up 1 Patient Questionnaire
Name: __________________________
Date____________
This questionnaire can be completed by the patient, a relative, friend or carer on the patient’s
behalf .
Where do you live now? Please tick the box which applies to you
 In my own home / In the home of a relative
 In a residential home / a nursing home
Have you been admitted to hospital again for any reason after you were discharged?
 Yes what was the reason?
 No
Are you left with any symptoms or problems after your stroke?
Please tick one box next to the statement which best describes your present state

0 I have no symptoms at all.

1 I have a few symptoms, but I am able to carry out all previous activities and duties.

2 I am unable to carry out all previous activities, but am able to look after my own affairs without
assistance.

3 I need some help with looking after my own affairs, but am able to walk without assistance.

4 I am unable to walk without assistance and unable to attend to my own bodily needs without
assistance, but I do not need constant care and attention.

5 I have major symptoms which severely handicap me. I am bedridden and incontinent and I need
constant attention day and night.
Are you interested to get involved in peer support, teaching, research, or service development?
Would you be interested in getting involved in a peer support group for stroke patients and carers? Yes/
no
Would you be interested in getting involved in developing stroke services? Yes/ no
Would you be interested in helping stroke researchers develop or conduct studies? Yes/ no
Would you be interested in helping with student/postgraduate teaching? Yes/ no
Is there anything you would like to discuss with the doctor when you see him/her?
go back to index
77
Stroke follow-up 2 assessment form (6 months post discharge)
Name
Weight
Blood pressure
Heart rate
ECG
Date
Scores:
Rankin:
MMTS:
Diagnosis, comorbidities, and risk factors (consult and update stroke checklist)
 Is GP checking BP/ cholesterol/ diabetes/ medications?
HAD A:
HAD D:
Current medication
No of falls:
Progress/ Problems since 6-week assessment
 Any problems coping?
 Carer stressed?
Involvement of social or rehabilitation services
 Still receiving rehabilitation?
 Has the patient had [psychological supprt?
 Stroke Club / Young strokes/ Dysphasia support
 Home help
 Other
go back to index
78
Life after stroke
(yes/no/NA; check if any problems, and if help/ advice needed, document needs)
 Driving
 Work/ Housework
 Hobbies/ Travel
 Family/friends
 Other
Problems which may need addressing
 Incontinent?
 Cognitive problems?
 Depression/ Anxiety?
 Spasticity/ pain?
 Excessive tiredness?
 Anything else the patient would like help with?
Management Plan
 Discharge from hospital follow-up yes/ no specify why not
 Hand over risk factor management and annual stroke checks to GP if not already in place
 Hand over 12 month review and subsequent annual reviews to GP/ Primary care if no
community long-term specialist stroke follow up service in place
 Referrals for problems requiring therapy/specialist input not needed/ needed (specify)
 Offer contact address/number of consultant secretary to patient in case problems occur in
future.
go back to index
79
go back to index
80
Follow-up 2 Patient Questionnaire
Name: __________________________
Date____________
This questionnaire can be completed by the a relative, friend or carer on your behalf.
Where do you live now? Please tick the box which applies to you
 In my own home / In the home of a relative
 In a residential home / a nursing home
Have you been admitted to hospital again for any reason after you were discharged?
 Yes what was the reason?
 No
Are you left with any symptoms or problems after your stroke?
Please tick one box next to the statement which best describes your present state

0 I have no symptoms at all.

1 I have a few symptoms, but I am able to carry out all previous activities and duties.

2 I am unable to carry out all previous activities, but am able to look after my own affairs without
assistance.

3 I need some help with looking after my own affairs, but am able to walk without assistance.

4 I am unable to walk without assistance and unable to attend to my own bodily needs without
assistance, but I do not need constant care and attention.

5 I have major symptoms which severely handicap me. I am bedridden and incontinent and I need
constant attention day and night.
Are you interested to get involved in peer support, teaching, research, or service development?
Would you be interested in getting involved in a peer support group for stroke patients and carers?
no
Yes/
Would you be interested in getting involved in developing stroke services? Yes/ no
Would you be interested in helping stroke researchers develop or conduct studies? Yes/ no
Would you be interested in helping with student/postgraduate teaching? Yes/ no
Is there anything you would like to discuss with the doctor when you see him/her?
go back to index
81
Stroke clinic 3 months follow-up
Name:
Date:
Date of stroke:
Circle true terms/statements
Use  to indicate no
Aetiology:
Infarct
Intracerebral Haemorrhage
Other
OCSP Classification
TAC
PAC
LAC
POC
TIA
Hemiparesis
left
right
nil
both
Other Diagnoses:
1.
4.
7.
2.
5.
8.
Current Treatment:
1.
4.
7.
2.
5.
8.
3.
6.
9.
Remediable Risk Factors:
Hypertension
Clinic BP:
Hypercholesterolaemia
Last Cholesterol:
Diabetes Mellitus
Obesity
Smoking
Excess alcohol
Atrial fibrillation
Significant carotid stenosis
Social and Rehab Services:
Scores:
Barthel on discharge:
Barthel now:
Rankin:
Euroquol:
Nottm Ext ADL:
HAD A:
HAD D:
Falls since discharge:
No
Yes
Number:
Problems since discharge:
Management/ Plans
Driving Advice
Risk factor booklet
Clinical Trials
Discharge from clinic
Risk factor management : GP
Referrals:
go back to index
Other
Investigations
Results to Clinic / GP:
 FBC
 U&E
 LFTs
 CK
 cholesterol
 Carotid Doppler



82
Stroke clinic follow-up Questionnaire
Name:
Date:
Date of stroke:
Where do you live now? Please tick the box which applies to you






Im my own home
In the home of a relative
In a residential home
In a nursing home
In a continuing care hospital
I have not yet left hospital after my stroke
Who do you live with ? Please tick the box which applies to you
 I live alone
 I live with a spouse/partner
 I live with family/friends
Have you been admitted to hospital again for any reason after you were discharged?
 Yes (once)
 Yes (more than once)
 No
Are you left with any symptoms or problems after your stroke?
Please tick the tick one box next to the statement which best describes your present state
 0 I have no symptoms at all.
 1 I have a few symptoms, but these do not interfere with my everyday life.
 2 I have symptoms which have caused some changes in my life, but I am still able to
look
after myself.
 3 I have symptoms which have significantly changed my life and I need some help in
looking after myself.
 4 I have quite severe symptoms which mean I need help from other people but I am not so
bad as to need attention day and night.
go back to index
83
 5 I have major symptoms which severely handicap me and I need constant attention day and
night.
Mod. Rankin total:________
go back to index
84
This page contains some more specific questions on how the stroke has affected your day to day life
and physical functioning
Barthel ADL
Please circle the number for the statement that best describes each
function
1.Bowels
0 Incontinent (or needs to be given an enema)
1 Occasional accident (once a week)
2 Continent
2. Bladder
0 Incontinent or catheterised and unable to manage alone
1 Occasional accident (max. once per 24h )
2 Continent (for more than seven days)
3. Grooming
0
1
4. Toilet use
0 Dependent
1 Needs some help but can do some things alone
2 Independent (on and off, wiping, dressing)
5. Feeding
0 Unable
1 Needs help in cutting, spreading butter etc.
2 Independent (food provided in reach)
6. Transfer
0
1
2
3
Unable – no sitting balance
Major help (physical, one or two people), can sit
Minor help (verbal or physical)
Independent (but may use any aid)
7. Mobility
0
1
2
3
Immobile
Wheelchair independent, including corners etc
Walks with help of 1 person (verbal or physical help)
Independent (but may use any aid)
8. Dressing
0 Dependent
1 Needs help but can do about half unaided
2 Independent (including buttons, laces, zips etc)
9. Stairs
0 Unable
1 Needs help (verbal, physical, carrying aid)
2 Independent, up and down
10. Bathing
0 Dependent
1 Independent (Bath: must get in & out unsupervised and wash self
or Shower: unsupervised/unaided
Needs help with personal care
Independent: face, hair, teeth, shaving (implements provided)
Total
go back to index
85
These questions will help us to find whether your wellbeing is affected by any of your medical
problems. Some questions may address similar topics than the previous pages, but this will help us
to get more specific information about how well you are
Euroquol
Mobility
Please tick the box which best describes your level of mobility
 0 I have no problems walking
 1 I have some problems walking
 2 I am confined to bed
Self care
Please tick the box which best describes your ability to care for yourself
 0 I have no problems with self care
 1 I have some problems washing and dressing
 2 I am unable to wash or dress myself
Usual activities
Please tick the tick one box next to the statement which best describes your ability to perform your usual
activities



0 I am able to perform usual activities
1 I have some problems performing unusual activities
2 I am unable to perform usual activities
Pain or discomfort
Please tick the box next to the statement which best describes your level of pain or discomfort
0 I have no pain or discomfort
1 I have moderate pain or discomfort
2 I have extreme pain or discomfort
Anxiety and depression
Please tick the box next to the statement which best your level of anxiety and depression
0 I am not anxious or depressed
1 I am moderately anxious or depressed
2 I am extremely anxious or depressed
Total____
go back to index
86
The EuroQuol Questionnaire
To help you to say how good (or bad) your health is we have
drawn a scale (rather like a thermometer) on which the best
health you can imagine is marked by 100 and the worst
health you can imagine is marked by 0.
We would like you to indicate on this scale how good or bad
your health is in your own opinion today.
Please do this by drawing a line from the box below to
whichever point on the scale indicates how good or bad your
current health is.
Best imaginable health state
100
Your own health today is:
0
Score: _____%
go back to index
Worst imaginable health state
87
89
This is a long list of questions designed to find out if and how your medical condition has affected
your ability to do day to day activities and to pursue work and leisure interests
Do you [please tick the option that describes best what you actually do]
Nottingham extended ADL
3
Alone
easily
2
Alone
with
difficulty
1
With
help
0
Not
at all
Mobility: Do you
Walk around outside?
Climb stairs?
Get in and out of the car?
Walk on uneven ground?
Cross roads?
Travel on public transport?
Eating and Drinking: Do you
Manage to feed yourself?
Manage to make a hot drink?
Take hot drinks from one room to another?
Do the washing up?
Make yourself a hot snack?
Domestic tasks: Do you
Manage your own money when out?
Do your own shopping?
Wash small items of clothing?
Do a full clothes wash?
Leisure and communication: Do you
Read newspapers and books?
Use the telephone?
Write letters?
Go out socially?
Manage your own garden?
Drive a car?
Total:
go back to index
89
H A D SCALE
90
Name:
Date:
Doctors are aware that emotions play an important part in most illnesses. If your doctor knows about these
feelings he will be able to help you more. This questionnaire is designed to help your doctor to know how you
feel. Read each item and place a firm tick in the box opposite the reply which comes closest to how you have
been feeling in the past week.
Don’t take too long over your replies: your immediate reaction to each item will probably be more accurate
than a long thought out response.
I feel tense or wound up:
Most of the time
A lot of the time
Time to time, occasionally
Not at all
3
2
1
0
A
I still enjoy the things I used to enjoy:
Definitely as much
Not quite so much
Only a little
Hardly at all
0
1
2
3
D
I feel as if I am slowed down:
Nearly all the time
Very often
Sometimes
Not at all
A
D
3
2
1
0
I get a sort of frightened feeling like butterflies in
the stomach:
Not at all
0
Occasionally
1
Quite often
2
Very often
3
I get a sort of frightened feeling as if something
awful is about to happen:
Definitely, quite badly
3
Yes, but not too badly
2
A little, but it doesn’t worry me
1
Not at all
0
I have lost interest in my appearance:
Definitely
3
I don’t take as much care as I should
I may not take quite as much care 1
I take as much care as ever
0
I can laugh and see the funny side of things:
As much as I always could
0
Not quite so much now
1
Definitely not so much now
2
Not at all
3
I feel restless as if I have to be on the move
Very much indeed
3
Quite a lot
2
Not very much
1
Not at all
0
Worrying thoughts go through my mind:
A great deal of the time
3
A lot of the time
2
From time to time, but not too often
1
Only occasionally
0
I look forward with enjoyment to things:
As much as I ever did
0
Rather less than I used to
1
Definitely less than used to
2
Hardly at all
3
I feel cheerful:
Not at all
Not often
Sometimes
Most of the time
3
2
1
0
I get sudden feelings of panic:
Very often indeed
Quite often
Not very often
Not at all
I can sit at ease and feel relaxed:
Definitely
Usually
Not often
Not at all
go back to index
0
1
2
3
I can enjoy a good book/radio or TV programme
Often
0
Sometimes
1
Not often
2
Very seldom
3
A________
D__________
3
2
1
0
90
91
This is the last page of the questionnaire
Memory
Please tick the box next to the statement which best describes your memory
My memory is as good as before the stroke
My memory has deteriorated since the stroke
Things I can't do now but would like to do again
Are you taking part in any research studies?
 YES
NO
Would you like to find out more about research?
 YES
NO
If there were a stroke service development group,
would you be interested in attending or helping?
 YES
NO
Would be interested in doing volunteer work with
stroke patients on the wards or in the community?
 YES
NO
I completed the form [tick what applies to you]
 On my own
 With some help from a relative, friend or carer
 A relative, friend or carer completed the form for me
The information on this questionnaire may be used for research and audit purposes after your name has
been removed. If you do not want your anonymised data to be used in research and audit please tick the
boxes below.
 I am happy for the data to be used for research and audit
 I do not want the this questionnaire be used for research
 I do not want this questionnaire be used for audit.
go back to index
91
92
Annual Warfarin Review
Name:
Date:
Indications for warfarin
Target INR:
Intended duration of treatment
Other diagnoses/ problems
Current medications
Knowledge of warfarin
Indications:
Y
Side effects:
Y
Target INR :
Y
Duration of treatment: Y
Drug interactions:
Y
Food interactions:
Y
Any potential contraindications for warfarin?
N
N
N
N
N
N
Bleeding
Unstable INRs
Unstable comorbidity
Falls
Other
Y
Y
Y
Y
N
N
N
N
If prescribed for AF/ paroxysmal AF is there still evidence of persistent AF?
(do annual ECG to confirm)
ECG
Y / no
Pulse
y / no
History y/ no
If not in AF now, when was the last documented episode? _________
Yellow warfarin booklet complete?
Can the patient be transferred to an outreach clinic?
Has the patient been offered the opportunity
to take part in research?
Y N
Y N
Y N
no studies
not appropriate
Comments. actions and next appointment:
go back to index
92
93
Stroke Checklist
Name____________________ Age_______
Date of stroke____________
Unit No________________
= yes o = no
CT head result
OCSP Stroke Classification
Stroke symptoms
 Non-specific changes
 Total ant. circulation syndrome
 R/L Hemiparesis

New
infarct
 Partial ant. circulation syndrome
 Hemianopia

Old
infarct(s)
 Lacunar syndrome
 Viaual/tactile inattention
 Hemorrhage
 Posterior circulation syndrome
 Dysphasia (language problem)
 Other
 Dysarthria (can' t produce sounds)
Scandinavian Stroke Scale Score
 Not done
 Cerebellar symptoms
[Range: Normal (58)- Most severe (0)]
 Brain stem symptoms
On admission
Final Diagnosis
 Hemisensory loss
On transfer

Cerebral
infarct
 Swallowing problems
On discharge
 Intracerebral haemorrhage
 Incontinence
 Other
HADS score
 Other

Date
Score A
D

Cognition (MMTS/AMTS)
Date
Score

Date
Score

Other diagnoses and relevant information
1 _____________________________ 4______________________________ 7 _______________________________
2 ______________________________
5 ______________________________
8 ______________________________
3_______________________________
6 ______________________________
9 ______________________________
NO
NO
NO
YES
Yes
Yes
Risk factors
Hypertension
Cholesterol
DM
Smoker
>28u alcohol/week
AF
Heart Murmur
Oestrogen Tx
Lack of exercise
Other risks (specify)
Target
Secondary prevention
BP on discharge
-
Echo :
Antithrombotics/anticoagulants
Aspirin/Dypyridamole/Clopidogrel
Warfarin
Indication:
Avoid antithrombotics and anticoagulants
Carotid surgery
Carotid doppler
Doppler result
Surgical referral
Target INR
Duration of treatment
Dates/details/action or reason why action inappropriate
Outstanding Results
Follow up
Comments (information to include in the discharge summary)
Admission tests (mark N for normal)
FBC
INR
U&E ______GLUCOSE _____LFTs
go back to index
ESR
ECG ____________ CXR __________
93
94
The stroke clinic
Clinic Environment
Display copies of stroke matters and stroke association info leaflets in the clinic area for patients to peruse
while they are waiting. Make sure the information cards with the www.stroke-in-stoke.info website
details are on display and the information leaflet folders are available and stocked.
New patients
All new patients should be seen or discussed with the consultant on the first or second visit.
Blood pressure should be measured while they are waiting.
6 week follow-up
Go through 6 week follow-up questionnaire and address points where the patient may need help. Review
stroke discharge check-list and chase missing results. Complete the Stroke clinic follow-up proforma.
Tidy up secondary prevention. Do not attempt to control blood pressure or lipids in the clinic but refer to
GP with precise instructions. Has the patient returned to their normal social activities (hobbies, driving,
sex). Do they need help, advice, encouragement?
Check whether warfarin booklet is filled in appropriately (esp Dx, duration of RX and target INR.
Check whether the patient is on antidepressants and give clear guidelines as to when they should be
reviewed or discontinued.
Check whether patient has cognitive or emotional issues and document outcome. All patients with
cognitive/ emotional problems must be referred for assessment and management to a psychologist (or
other experienced person), unless the patient declines. This must be documented (will be audited).
Hand over risk factor management, 6 month follow-up, and any investigations required to the GP.
6 month follow-up (by a community specialist stroke team if available, otherwise on clinic or in primary
care)
Go through follow-up form and questionnaire and address points where the patient may need help.
If followed in clinic check that GP is now managing secondary prevention and document this in the letter.
Check if psychological needs identified at 6 weeks have been addressed.
Check that the patients has been seen by appropriate specialist if referrals have been made at last visit.
Address life after stroke needs identified in questionnaire.
Document Rankin, HADS, Blood pressure, weight, ECG result, and MMTS.
This is the discharge visit. Make sure that secondary prevention has been taken over by GP, that all
problems identified have been addressed, and that the patient knows what to do if future problems arise.
Advise to contact GP or consultant/secretary if any problems in future.
Advise GP of discharge of patient and give him instructions for follow up e.g. regular, but at 6 mo, 12
mo and then annual reviews of Medication / Risk factor management /Mood /Stroke complications /Need
for specialist reassessment of rehabilitation/ treatment needs.
go back to index
94
95
Young Strokes
Patients who have had a stoke when younger then 45 should be followed in the young stroke clinic
(contact Dr Roffe’s secretary for dates). Information about Different Strokes and Strokes R Us should be
on display.
Repeat clinic attenders
Repeat attendances should be kept to an absolute minimum. The ward clerk should check whether the
patient needs x-rays, bloods or results prior to seeing the doctor. This should be specified in the last clinic
entry.
Blood tests, x-rays etc
Please list outstanding tests at the end of the letter. The secretary will include the results in the typed
letter and you can check them as you review the letter. If you dictate the letter when the results are
already available, include them in the letter, and just list the outstanding results that need to be chased in
the letter.
Tapes
Include a list containing the following with each tape and the notes
1. Clinic day and name of doctor
2. Number on tape
3. Patient name
4. Unit no
5. Bloods and tests requested
6. Referrals to
7. Follow-up yes/no when?
8. Copy all clinic letter to patients unless they indicate the do not wish a copy.
9. For nursing home patients also make a copy for the matron of the home and family
For patients followed within 1 month alert the secretary to type the letter as a priority.
go back to index
95
96
INR patients
INR patients (CROF3) will usually be seen in the waiting area. They only attend for warfarin prescription. If they have other
unrelated medical problems those should be referred to the GP or a formal clinic appointment should be made. This is to avoid
delaying the rest of the clinic patients. If you have ample time it will be at your discretion to treat other conditions.
If the patient is new to you always check booklet, and whether the patient knows basics of warfarin complications and
instructions before prescribing.
Check that booklet complete (page 1) at each visit.
Check that the patient has had no serious health problems or bleeding since the last visit. If INR stable prescribe next dose and
follow up. Use the INR follow-up stickers provided by Springfield Unit staff to document INR, follow-up and the new dose
recommended.
All INR patients should have annual follow up in the stroke Clinic to formally review indications and complications (use
annual warfarin review proforma to document the outcome). Check need for annual review at each visit. Patients referred to
the outreach clinic will need a letter to the GP to check who will do the annual follow up (ask Jean Leverett for a standard
letter proforma).
If INR unstable establish cause, if possible.
Any patient who has his/her own transport or can be taken to clinic should be discharged to the outreach clinics as soon as
stable. Patients who are immobile should be referred to the GP/District nurse. Patients who cannot be followed up by either
will continue follow –up in the Springfield unit.
go back to index
96
97
Examination tray for stroke clinic
1. Ophtalmoscope
2. Auriscope
3. Patella hammer (with plastic handle)
4. Two large test tubes (eg outer container for high risk specimens)
5. Cotton wool buds
6. Orange sticks
7. Spatulas
8. Torch
9. Tuning fork
10. Scent bottles
11. Red hat pin
12. Objects: key, pen, coin
go back to index
97
98
Stroke clinic preparation
1.
Send clinic questionnaire and blood test forms (FBC, U&E, LFTs and fasting glucose and cholesterol) with the
appointment letter.
2.
Print out special reports CVA1 and CVA2 as well as recent Doppler results
3.
Include pre clinic blood results with notes
Stroke clinic letters
Include all results available within 1 week in letters, make a note of results outstanding at the end of the letter.
Copy to patients when requested.
Copy letters to day hospital staff for patients attending the DH.
Stroke clinic questionnaires
Make sure each questionnaire is labeled with name, date and Unit No.
Copy the questionnaire. Keep one copy in the notes and file one in the office for audit purposes.
go back to index
98
99
i
Further Reading: Bamford J et al. Classification and natural history of clinically identifiable subtypes of cerebral infarction.
Lancet 1992; 337: 1522-1523.
ii
Refer to Inrevik 1999, RCPguideline 2004, EUSI 2004 and AHA stroke guidance 2004.
iii
Based on the EUSI recommendations for stroke (website Jan 2002 and Cerebrovasc Dis 2000;10;335;-351) unless stated
otherwise. The recommended treatment threshold in Europe is BP >220/140. I have used the more conservative limits of
>240/140, as used in some centres, especially in North America. The lower valuse is cited as 130 in some places and 140 in
others. Needs review with 2004 guidance and cross checking with 72 hour monitoring and Acute hypertension section.
iv
North Staffs Combined Healthcare NHS Trust Elderly Care Dysphagia Management Guideline: Acute Stroke Unit. R
Wells, Draft 3; Mar 2002. Needs to be revised and updated to refer to the care pathway.
v
The Intercollegiate Stroke Working Party. National ClinicalGuidelines for Stroke. Royal College of Physicians, London,
2004 p 49.
vi
Cholesterol and risk of stroke: There is no strong evidence of any independent association between serum cholesterol and
risk of stroke (Prospective Studies Collaboration. Cholesterol, diastolic blood pressure, and stroke: 13,000 strokes in 450,000
people in 45 prospective cohorts. Lancet 1995; 346: 1647-53). Despite this, an overview of cholesterol lowering with statin
drugs found that treatment with statins reduces risk of stroke (Hebert PR, Gaziano JM, Chan KS, Hennekens CH. Cholesterol
lowering with statin drugs, risk of stroke, and total mortality. JAMA 1997; 278: 313-21. There are possible explanations for
this apparent contradiction. Firstly, there is some evidence that low cholesterol is associated with increased risk of
haemorrhagic stroke ( Iso H, Jacobs DR Jr, Wentworth D et al for the MRFIT Research Group. Serum cholesterol levels and
six year mortality from stroke in 350,977 men screened for the Multiple Risk Factor Intervention Trial. N Engl J Med
1989;320: 904-10) , so it may be that this masks a positive association between serum cholesterol and risk of ischaemic stroke.
Secondly, it may be that statins lower stroke risk indirectly by lowering risk of myocardial infarction, which is an established
risk factor for stroke. Thirdly, it may be that statins do not reduce stroke risk by lowering cholesterol, but by some other
mechanism. The evidence for cholesterol lowering to prevent stroke is strongest for patients with existing coronary heart
disease, so in the context of the epidemiology of risk factors for stroke, serum cholesterol is of most relevance in this subgroup of patients. [ text form Mant, Wade and Winner. Health care assessment. http://hcna.radcliffe-oxford.com/strframe.htm]
vii
Collins R, Armitage J, Parish S, Sleight P, Peto R; Heart Protection Study Collaborative Group. Effects of cholesterollowering with simvastatin on stroke and other major vascular events in 20536 people with cerebrovascular disease or other
high-risk conditions. Lancet. 2004 Mar 6;363(9411):757-67. Simvastatin 40 mg/ d.. Also provides evidence of effectiveness in
patients with preexisting cerebrovasc disease (e.g non disabling stokes or TIAs), and with normal cholesterol. In patients with
preexising cerebrovasc dis it reduced cardiovascular events and revascularisatuions but not strokes. In patients with other
vascular evernts or diabetes as risk factor it reduced strokes by 1/3. The effect starts rapidly. Reduction of stroke not significant
during the first year, but was already significant in the second year. No increase in ICH in treated group. Reference also
contains metanalysis of previous trials of statins for stroke prevention.
viii
UHNS Hyperlipidaemia Guidelines 2004 Dr Neary and Angela Davis
Medicines Management Interface Pharmacist, UHNS 01782 552076, e-mail. Angela.Davis@uhns.nhs.uk
Grey shaded areas have been added by Dr C. Roffe
Notes for stroke patients:
The Intercollegiate Stroke Working Party. National ClinicalGuidelines for Stroke. Royal College of Physicians, London, 2004.
( suggests to treat all patients with a total Chol >3.5 mmol/l. references summarised in table 3.5.4.)
There is still little evidence for patients aged > 80.
There is no evidence for frail patients with disabling strokes (they have been excluded from all trials).
Statins prevent stroke risk by about 1/3 in patients with a history of IHD.
ix ix
O'Rourke S, MacHale S, Signorini D, Dennis M. Detecting psychiatric morbidity after stroke: comparison of the GHQ and
the HAD Scale. Stroke. 1998;29:980-5.
go back to index
99
100
x
Sutcliffe LM, Lincoln N. The assessment of depression in aphasic stroke patients: the development of the Stroke Aphasic
Depression Questionnaire. Clinical Rehabilitaiton 1998;12:506-513.
xi
Zigmond AS, Snaith RP. The hospital anxiety and depression scale. Acta Psychiatr Scand 1983;67:361–370.
xii
O'Rourke S, MacHale S, Signorini D, Dennis M. Detecting psychiatric morbidity after stroke: comparison of the GHQ and
the HAD Scale. Stroke. 1998;29:980-5.
go back to index
100