BASP’s vision is to provide leadership in: the improvement of clinical services; science and research; education and training relating to the health and wellbeing of our patients, their carers and the public.
Description of Speciality
Stroke is the most common cause of severe disability and the fourth most common cause of death in the UK. It costs the economy £9 billion a year (£4.38 billion in health and social care costs; over 5% of NHS resources). Twenty-five per cent of patients are under 65, and people from certain ethnic minorities are at a higher risk. (Source: State of the Nation: Stroke statistics).
Stroke medicine is a sub-specialty that attracts physicians from different specialty training pathways, most commonly geriatric medicine or neurology. Other potential parent specialties include rehabilitation medicine, cardiology, general internal medicine, and clinical pharmacology and therapeutics. Stroke physicians may care exclusively for stroke patients or may have clinical responsibilities within their parent specialty and/or general medicine. Stroke physicians are represented by the British Association of Stroke Physicians (BASP).
Rapid access transient ischaemic attack (neurovascular) clinics enable accurate diagnosis and aim to optimise secondary prevention. Stroke physicians contribute to neurovascular clinics, acute stroke care and rehabilitation services. All acute hospitals in the UK now either have a stroke unit on site or have rapid access to this service (usually by redirection of ambulances when patients are suspected of having had a stroke or urgent transfer) National Clinical Guideline for Stroke.
Hyperacute stroke units offer rapid specialist and multidisciplinary assessment of patients with suspected stroke. Up to 25% of patients have a stroke mimic condition. Hyperacute stroke units offer 24/7 thrombolysis for patients with acute ischaemic stroke. Recent advances in the evidence base in support of thrombectomy mean that services will need to develop further to ensure equitable access of eligible patients to such therapies.
Once stable, stroke patients are transferred to either an acute stroke unit or stroke rehabilitation unit where they receive specialist multidisciplinary care. Stroke patients need specialist rehabilitation either in hospital or at home, and to access further rehabilitation and support, often for many years.
Improvements in acute care remain unmatched by progress in delivering more effective post-hospital support, in particular comprehensive access to early supported discharge (ESD) services and specialised community stroke rehabilitation.
Direct from the community (Hyperacute & acute stroke)
As stroke is an acute medical emergency, most people with acute stroke access services directly from the community via a 999 call. Public awareness campaigns have served to heighten understanding that stroke is an emergency and that treatments are time-dependent. Paramedics are trained to administer standardised pre-hospital clinical assessments that increase the accuracy of detection of stroke.
Stroke is a medical emergency, in which rapid diagnosis and treatment are critical. The hyperacute phase of stroke generally refer to the first hours of assessment and treatment. All patients with stroke need to be treated on a stroke unit with appropriate expert multidisciplinary staff. Specific hyperacute treatments include thrombolysis and mechanical thrombectomy for ischaemic stroke, and critical care treatment and neurosurgery for intracerebral haemorrhage.
After the first day or so, once any emergency treatments are completed, patients with stroke are treated on an acute stroke unit. Here the focus is on establishing an accurate diagnosis, and providing the best quality supportive care from nursing, therapies and other teams including neuropsychology. The aim of acute stroke unit care is to recognize and treat complications quickly, and to maximize early functional recovery.
From primary care (TIA clinics)
For patients where the diagnosis of stroke is not immediately clear, or who present late, referral to stroke services from primary care for investigative and diagnostic purposes may occur, but the majority of people with suspected stroke are admitted directly as an emergency.
The majority of people with suspected transient ischaemic attack (TIA) are referred from primary care to TIA (neurovascular) clinics. This should be done as an emergency. Other sources of referral of people with suspected TIA include emergency departments, ophthalmology departments and paramedics.
From hospital-based settings
About 5% of stroke patients have an acute stroke while already in hospital, and they should be transferred to a stroke unit with the same urgency used for people with out of hospital stroke. Other stroke patients require repatriation from regional neuroscience centres, having undergone specialist interventions that include thrombectomy and hemicraniectomy.
Inpatient stroke care
Stroke patients should be cared for on a stroke unit throughout their inpatient stay. Stroke units have been shown to reduce death and disability due to stroke.
There are different models of stroke care:
i. a hyperacute stroke unit, which cares for inpatients up to 72 hours post stroke. Patients are then transferred to an acute stroke unit
ii. a stroke unit, which provides both hyperacute and acute stroke unit care
iii. a comprehensive stroke unit, which provides hyperacute, acute stroke care and rehabilitation
iv. a stroke rehabilitation unit.
All stroke units should be appropriately staffed to provide specialist multidisciplinary care.
Hyperacute stroke services provide immediate access to specialist medical and nursing staff, immediate access to brain imaging and thrombolysis for eligible patients. A consultant with expertise in stroke medicine is available 24/7 and there are at least daily consultant ward rounds 7 days per week. There should be a minimum of six thrombolysis trained physicians on an acute stroke rota. Telemedicine can be used for remote assessment but should include a high-quality video link and review of brain imaging. Staff should be trained in use of the technology and the quality of care and decision making should be regularly audited. It is important to ensure that arrangements are in place to ensure timely repatriation of patients from hyperacute stroke units to their local stroke unit. Thrombectomy (opens PDF, 348.66KB) has been shown to be an effective treatment for patients with large artery occlusion and regional services are being developed to provide this intervention.
A multidisciplinary team provides stroke care and rehabilitation on an acute stroke unit and a stroke rehabilitation unit. The multidisciplinary team consists of the following specialists:
- occupational therapist
- speech and language therapist
- clinical neuropsychologist/clinical psychologist
- social worker
An acute stroke unit should have a consultant-led ward round 5 days per week and a stroke rehabilitation unit should have consultant-led ward rounds one or two times a week. There should be a coordinated multidisciplinary team meeting at least once a week with regular board rounds between formal meetings (see also the National Clinical Guideline for Stroke).
As the risk of stroke is greatest in the first few days following a transient ischaemic attack (TIA), patients with suspected TIA should be assessed urgently within 24 hours of symptoms by a specialist physician in a TIA (neurovascular) clinic or on an acute stroke unit. Patients with suspected TIA who seek medical advice more than 1 week after the event occurred should be assessed by a specialist physician as soon as possible within the following 7 days. Local stroke services should have a rapid referral system in place to enable timely assessment, investigation and treatment 7 days per week.
Patients with TIA who are in sinus rhythm should receive clopidogrel (300mg loading dose and 75mg thereafter). TIA patients with atrial fibrillation require urgent brain imaging and should then be offered rapid onset anticoagulation: either a novel oral anticoagulant (NOAC) or warfarin with tinzaparin cover until the international normalised ratio (INR) is therapeutic. Other secondary prevention measures include lifestyle advice (on smoking, alcohol excess, exercise and diet), blood pressure lowering and statins. Patients with carotid circulation TIAs require an urgent carotid Doppler ultrasound and patients who are found to have a severe symptomatic carotid stenosis should be offered carotid endarterectomy. Carotid endarterectomy should be performed within 7 days of onset of symptoms. All patients should be advised about driving in accordance with DVLA regulations. Patients with TIA and their families should be given information about how to recognise the symptoms of a stroke and what action to take if they occur.
Early supported discharge
An early supported discharge service enables patients to be discharged earlier than usual to continue rehabilitation in their own home. An early supported discharge team includes the following specialists:
- occupational therapist
- speech and language therapist
- clinical neuropsychologist/clinical psychologist.
An early supported discharge team should provide rehabilitation and care at the same intensity as is available on a stroke unit. Early supported discharge reduces dependency and the need for institutional care for stroke patients with mild or moderate stroke (see Cochrane review of organised inpatient (stroke unit) care and the National Clinical Guideline for Stroke).
Stroke outpatient clinics
Stroke patients are usually reviewed 4–6 weeks post discharge in a stroke outpatient clinic. At the clinic the review includes: physical, psychological and emotional consequences of stroke; secondary prevention; and rehabilitation. It offers a further opportunity for the patient and their family to discuss what has happened, the prognosis and any ongoing issues and concerns. Stroke patients should be reviewed at 6 months and annually thereafter in primary care (see the National Clinical Guideline for Stroke).