Makindo Medical Notes

This chapter covers the acute presentation and treatment of people with stroke and TIA. The recommendations relate to the diagnosis and management of the underlying condition. Original here Stroke Guidelines 2023

3.1 Pre-hospital care

Most people with acute stroke (95%) have their first symptoms outside hospital. It is vital that members of the public and healthcare professionals (e.g. primary care team members...

A	Description	Year
A	People seen by ambulance clinicians outside hospital with sudden onset of focal neurological symptoms should be screened for hypoglycaemia with a capillary blood glucose, and for stroke or TIA using a validated tool. Those people with persisting neurological symptoms who screen positive using a validated tool should be transferred to a hyperacute stroke service as soon as possible.	2016
B	People who are negative when screened with a validated tool but in whom stroke is still suspected should be treated as if they have stroke until the diagnosis has been excluded by a specialist stroke clinician.	2016
C	The pre-hospital care of people with suspected stroke should minimise time from call to arrival at hospital and should include a hospital pre-alert to expedite specialist assessment and treatment.	2016
D	Patients with suspected stroke whose airway is considered at risk should be managed appropriately with suction, positioning and airway adjuncts.	2016
E	Patients with residual neurological symptoms or signs should remain nil by mouth until screened for dysphagia by a specifically trained healthcare professional.	2016
F	Patients with suspected TIA should be given 300 mg of aspirin immediately and assessed urgently within 24 hours by a specialist physician in a neurovascular clinic or an acute stroke unit.	2016
G	Patients with suspected stroke or TIA should be monitored for atrial fibrillation and other arrhythmias.	2016

3.2 Management of TIA and minor stroke – assessment and diagnosis

Any person with a fully resolved acute onset neurological syndrome that might be due to cerebrovascular disease needs urgent specialist assessment to establish the diagnosis and to...

A	Description	Year
A	Patients with acute focal neurological symptoms that resolve completely within 24 hours of onset (i.e. suspected TIA) should be given aspirin 300 mg immediately unless contraindicated and assessed urgently within 24 hours by a stroke specialist clinician in a neurovascular clinic or an acute stroke unit.	2023
B	Healthcare professionals should not use assessment tools such as the ABCD2 score to stratify risk of TIA, inform urgency of referral or subsequent treatment options.	2023
C	Patients with suspected TIA that occurred more than a week previously should be assessed by a stroke specialist clinician as soon as possible within 7 days.	2016
D	Patients with suspected TIA and their family/carers should receive information about the recognition of stroke symptoms and the action to be taken if they occur.	2016
E	Patients with suspected TIA should be assessed by a stroke specialist clinician before a decision on brain imaging is made, except when haemorrhage requires exclusion in patients taking an anticoagulant or with a bleeding disorder when unenhanced CT should be performed urgently.	2023
F	For patients with suspected TIA, MRI should be the principal brain imaging modality for detecting the presence and/or distribution of brain ischaemia.	2023
G	For patients with suspected TIA in whom brain imaging cannot be undertaken within 7 days of symptoms, MRI (using a blood-sensitive sequence, e.g. SWI or T2*-weighted imaging) should be the preferred means of excluding haemorrhage.	2023

3.3 Management of TIA and minor stroke – treatment and vascular prevention

Patients who have short-lived symptoms due to cerebrovascular disease remain at high risk of further vascular events, and this risk is highest in the first few days. Consequently, ...

A	Description	Year
A	Patients with minor ischaemic stroke or TIA should receive treatment for secondary prevention as soon as the diagnosis is confirmed, including: Support to modify lifestyle factors (smoking, alcohol consumption, diet, exercise); Antiplatelet or anticoagulant therapy; High intensity statin therapy; Blood pressure-lowering therapy with a thiazide-like diuretic, long-acting calcium channel blocker or angiotensin-converting enzyme inhibitor.	2023
B	Patients with TIA or minor ischaemic stroke should be given antiplatelet therapy provided there is neither a contraindication nor a high risk of bleeding. The following regimens should be considered as soon as possible: For patients within 24 hours of onset of TIA or minor ischaemic stroke and with a low risk of bleeding, the following dual antiplatelet therapy should be given: Clopidogrel (initial dose 300 mg followed by 75 mg per day) plus aspirin (initial dose 300 mg followed by 75 mg daily for 21 days) followed by monotherapy with clopidogrel 75 mg once daily OR Ticagrelor (initial dose 180 mg followed by 90 mg twice daily) plus aspirin (300 mg followed by 75 mg daily for 30 days) followed by antiplatelet monotherapy with ticagrelor 90 mg twice daily or clopidogrel 75 mg once daily at the discretion of the prescriber; For patients with TIA or minor ischaemic stroke who are not appropriate for dual antiplatelet therapy, clopidogrel 300 mg loading dose followed by 75 mg daily should be given; A proton pump inhibitor should be considered for concurrent use with dual antiplatelet therapy to reduce the risk of gastrointestinal haemorrhage; For patients with recurrent TIA or stroke whilst taking clopidogrel, consideration should be given to clopidogrel resistance.	2023
C	Patients with TIA or ischaemic stroke should receive high-intensity statin therapy (e.g. atorvastatin 20-80 mg daily) started immediately.	2023
D	Patients with non-disabling ischaemic stroke or TIA in atrial fibrillation should be anticoagulated, as soon as intracranial bleeding has been excluded, with an anticoagulant that has rapid onset, provided there are no other contraindications.	2016
E	Patients with ischaemic stroke or TIA who after specialist assessment are considered candidates for carotid intervention should have carotid imaging performed within 24 hours of assessment. This includes carotid duplex ultrasound or either CT angiography or MR angiography.	2023
F	The degree of carotid artery stenosis should be reported using the North American Symptomatic Carotid Endarterectomy Trial (NASCET) method.	2016
G	Patients with TIA or acute non-disabling ischaemic stroke with symptomatic severe carotid stenosis of 50–99% (NASCET method) should: Be assessed and referred for carotid endarterectomy to be performed as soon as possible within 7 days of the onset of symptoms in a vascular surgical centre routinely participating in national audit; Receive optimal medical treatment: control of blood pressure, antiplatelet treatment, cholesterol reduction through diet and medication, and lifestyle advice including smoking cessation.	2016
H	Patients with TIA or acute non-disabling ischaemic stroke who have mild or moderate carotid stenosis of less than 50% (NASCET method) should: Not undergo carotid intervention; Receive optimal medical treatment: control of blood pressure, antiplatelet treatment, cholesterol reduction through diet and medication, and lifestyle advice including smoking cessation.	2016
I	Patients with recurrent attacks of transient focal neurological symptoms despite optimal medical treatment, in whom an embolic source has been excluded, should be reassessed for an alternative neurological diagnosis.	2016
J	Patients who meet the criteria for carotid intervention but who are unsuitable for open surgery (e.g. inaccessible carotid bifurcation, re-stenosis following endarterectomy, radiotherapy-associated carotid stenosis) should be considered for carotid angioplasty and stenting.	2016
K	Patients who have undergone carotid revascularisation should be reviewed post-operatively by a stroke clinician to optimise medical aspects of vascular secondary prevention.	2016

3.4 Diagnosis and treatment of acute stroke – imaging

Stroke is a medical emergency and if outcomes are to be optimised there should be no time delays in diagnosis and treatment. Any person with the acute onset of a focal neurological...

A	Description	Year
A	Patients with suspected acute stroke should be admitted directly to a hyperacute stroke service and be assessed for emergency stroke treatments by a specialist clinician without delay.	2016
B	Patients with suspected acute stroke should receive brain imaging as soon as possible (at most within 1 hour of arrival at hospital).	2023
C	Interpretation of acute stroke imaging for decisions regarding reperfusion treatment should only be made by healthcare professionals who have received appropriate training.	2023
D	Patients with ischaemic stroke who are potentially eligible for mechanical thrombectomy should have a CT angiogram from aortic arch to skull vertex immediately. This should not delay the administration of intravenous thrombolysis.	2023
E	Patients with stroke with a delayed presentation for whom reperfusion is potentially indicated should have CT or MR perfusion as soon as possible (at most within 1 hour of arrival at hospital). An alternative for patients who wake up with stroke is MRI measuring DWI-FLAIR mismatch.	2023
F	MRI brain with stroke-specific sequences (DWI with SWI or T2*-weighted imaging) should be considered in patients with suspected acute stroke when there is diagnostic uncertainty.	2023

3.5 Management of ischaemic stroke

Thrombolysis with alteplase is now administered to between 10 and 11% of patients with acute stroke in the UK and Ireland (Scottish Stroke Care Audit, 2022; Sentinel Stroke National Audit Programme, 2023) ...

A	Description	Year
A	Patients with acute ischaemic stroke, regardless of age or stroke severity, in whom treatment can be started within 4.5 hours of known onset, should be considered for thrombolysis with alteplase or tenecteplase.	2023
B	Patients with acute ischaemic stroke, regardless of age or stroke severity, who were last known to be well more than 4.5 hours earlier, should be considered for thrombolysis with alteplase if: Treatment can be started between 4.5 and 9 hours of known onset, or within 9 hours of the midpoint of sleep when they have woken with symptoms They have evidence from CT/MR perfusion (core-perfusion mismatch) or MRI (DWI-FLAIR mismatch) of the potential to salvage brain tissue (see Table 3.5.1 below). This should be irrespective of whether they have a large artery occlusion and require mechanical thrombectomy.	2023
C	Patients with acute ischaemic stroke otherwise eligible for treatment with thrombolysis should have their blood pressure reduced to below 185/110 mmHg before treatment.	2016
D	Thrombolysis should only be administered within a well-organised stroke service with: Processes throughout the emergency pathway to minimise delays to treatment to ensure that thrombolysis is administered as soon as possible after stroke onset; Staff trained in the delivery of thrombolysis and monitoring for post-thrombolysis complications; Nurse staffing levels equivalent to those required in level 1 or level 2 nursing care with training in acute stroke and thrombolysis; Timely access to appropriate imaging and trained staff; Protocols in place for the management of post-thrombolysis complications.	2016
E	Emergency medical staff, if appropriately trained and supported, should only administer thrombolysis for the treatment of acute ischaemic stroke provided that patients can be subsequently managed within a hyperacute stroke service with appropriate neuroradiological and stroke specialist support.	2016
F	Patients with acute ischaemic stroke eligible for mechanical thrombectomy should receive prior intravenous thrombolysis (unless contraindicated) irrespective of whether they have presented to an acute stroke centre or a thrombectomy centre. Every effort should be made to minimise process times throughout the treatment pathway and thrombolysis should not delay urgent transfer to a thrombectomy centre.	2023
G	Patients with acute anterior circulation ischaemic stroke, who were previously independent (mRS 0-2), should be considered for combination intravenous thrombolysis and intra-arterial clot extraction (using a stent retriever and/or aspiration techniques) if they have a proximal intracranial large artery occlusion causing a disabling neurological deficit (NIHSS score of 6 or more) and the procedure can begin within 6 hours of known onset.	2023
H	Patients with acute anterior circulation ischaemic stroke and a contraindication to intravenous thrombolysis but not to thrombectomy, who were previously independent (mRS 0-2), should be considered for intra-arterial clot extraction (using a stent retriever and/or aspiration techniques) if they have a proximal intracranial large artery occlusion causing a disabling neurological deficit (NIHSS score of 6 or more) and the procedure can begin within 6 hours of known onset.	2023
I	Patients with acute anterior circulation ischaemic stroke and a proximal intracranial large artery occlusion (ICA and/or M1) causing a disabling neurological deficit (NIHSS score of 6 or more) of onset between 6 and 24 hours ago, including wake-up stroke, and with no previous disability (mRS 0 or 1) should be considered for intra-arterial clot extraction (using a stent retriever and/or aspiration techniques, combined with thrombolysis if eligible) providing the following imaging criteria are met: Between 6 and 12 hours: an ASPECTS score of 3 or more, irrespective of the core infarct size; Between 12 and 24 hours: an ASPECTS score of 3 or more and CT or MRI perfusion mismatch of greater than 15 mL, irrespective of the core infarct size.	2023
J	Clinicians interpreting brain imaging for eligibility for mechanical thrombectomy should have the appropriate knowledge and skills and should consider all the available information (e.g. plain and angiographic images, colour maps, AI-derived figures for core/penumbra and mismatch overlays).	2023
K	Patients with acute ischaemic stroke in the posterior circulation within 12 hours of onset should be considered for mechanical thrombectomy (combined with thrombolysis if eligible) if they have a confirmed intracranial vertebral or basilar artery occlusion and their NIHSS score is 10 or more, combined with a favourable PC-ASPECTS score and Pons-Midbrain Index. Caution should be exercised when considering mechanical thrombectomy for patients presenting between 12 and 24 hours of onset and/or over the age of 80 owing to the paucity of data in these groups.	2023
L	The selection of anaesthetic technique for thrombectomy should be guided by local protocols for general anaesthesia, local anaesthesia and conscious sedation which include choice of anaesthetic agents, timeliness of induction, blood pressure parameters and postoperative care. Selection of anaesthesia should be based on an individualised assessment of patient risk factors, technical requirements of the procedure and other clinical characteristics such as conscious level and degree of agitation. General anaesthesia should be considered in the following circumstances: Patients with agitation or a reduced level of consciousness, or those judged to be at high risk of requiring conversion to general anaesthesia; Patients with airway compromise or who are already intubated, or at risk of aspiration due to nausea or vomiting; Patients in whom, due to technical or anatomical factors, thrombectomy is anticipated to be more complicated.	2023
M	Hyperacute stroke services providing endovascular therapy should participate in national stroke audit to enable comparison of the clinical and organisational quality of their services with national data, and use the findings to plan and deliver service improvements.	2016
N	Patients with middle cerebral artery (MCA) infarction who meet the criteria below should be considered for decompressive hemicraniectomy. Patients should be referred to neurosurgery within 24 hours of stroke onset and treated within 48 hours of stroke onset: Pre-stroke mRS score of 0 or 1; Clinical deficits indicating infarction in the territory of the MCA; NIHSS score of more than 15; A decrease in the level of consciousness to a score of 1 or more on item 1a of the NIHSS; Signs on CT of an infarct of at least 50% of the MCA territory with or without additional infarction in the territory of the anterior or posterior cerebral artery on the same side, or infarct volume greater than 145 mL on MRI DWI.	2016
O	Patients with acute ischaemic stroke treated with thrombolysis should be started on an antiplatelet agent after 24 hours unless contraindicated, once significant haemorrhage has been excluded.	2016
P	Patients with disabling acute ischaemic stroke should be given aspirin 300 mg as soon as possible within 24 hours (unless contraindicated): Orally if they are not dysphagic; Rectally or by enteral tube if they are dysphagic. Thereafter aspirin 300 mg daily should be continued until 2 weeks after the onset of stroke at which time long-term antithrombotic treatment should be initiated. Patients being transferred to care at home before 2 weeks should be started on long-term treatment earlier.	2016
Q	Patients with acute ischaemic stroke reporting previous dyspepsia with an antiplatelet agent should be given a proton pump inhibitor in addition to aspirin.	2016
R	Patients with acute ischaemic stroke who are allergic to or intolerant of aspirin should be given an alternative antiplatelet agent (e.g. clopidogrel).	2016

3.6 Management of intracerebral haemorrhage

About 11% of all patients presenting to hospital in the UK and Ireland with acute stroke have intracerebral haemorrhage (ICH) as the cause (Kelly et al, 2012; Intercollegiate Stroke...

A	Description	Year
A	Patients with intracerebral haemorrhage in association with vitamin K antagonist treatment should have the anticoagulant urgently reversed with a combination of prothrombin complex concentrate and intravenous vitamin K.	2016
B	Patients with intracerebral haemorrhage in association with direct oral anticoagulant (DOAC) treatment should have the anticoagulant urgently reversed. For patients taking dabigatran, idarucizumab should be used. If idarucizumab is unavailable, 4-factor prothrombin complex concentrate may be considered. For those taking factor Xa inhibitors, 4-factor prothrombin complex concentrate should be considered and andexanet alfa may be considered in the context of a randomised controlled trial.	2023
C	Patients with acute spontaneous intracerebral haemorrhage with a systolic BP of 150-220 mmHg should be considered for urgent treatment within 6 hours of symptom onset using a locally agreed protocol for BP lowering, aiming to achieve a systolic BP between 130-139 mmHg within one hour and sustained for at least 7 days, unless: The Glasgow Coma Scale score is 5 or less; The haematoma is very large and death is expected; A macrovascular or structural cause for the haematoma is identified; Immediate surgery to evacuate the haematoma is planned, in which case BP should be managed according to a locally agreed protocol.	2023
D	Patients with intracerebral haemorrhage should be admitted directly to a hyperacute stroke unit for monitoring of conscious level and referred immediately for repeat brain imaging if deterioration occurs.	2023
E	Patients with intracranial haemorrhage who develop hydrocephalus should be considered for surgical intervention such as insertion of an external ventricular drain.	2016
F	Patients with intracerebral haemorrhage in whom the haemorrhage location or other imaging features suggest cerebral venous thrombosis should be investigated urgently with a CT or MR venogram.	2023
G	The DIAGRAM score (or its components: age; intracerebral haemorrhage location; CTA result where available; and the presence of white matter low attenuation [leukoaraiosis] on the admission non-contrast CT) should be considered to determine the likelihood of an underlying macrovascular cause and the potential benefit of intra-arterial cerebral angiography.	2023
H	Early non-invasive cerebral angiography (CTA/MRA within 48 hours of onset) should be considered for all patients with acute spontaneous intracerebral haemorrhage aged 18-70 years who were independent, without a history of cancer, and not taking an anticoagulant, except if they are aged more than 45 years with hypertension and the haemorrhage is in the basal ganglia, thalamus, or posterior fossa. If this early CTA/MRA is normal or inconclusive, MRI/MRA with susceptibility-weighted imaging (SWI) should be considered at 3 months. Early CTA/MRA and MRI/MRA at 3 months may also be considered in patients not meeting these criteria where the probability of a macrovascular cause is felt to justify further investigation.	2023

3.7 Management of subarachnoid haemorrhage

The incidence of subarachnoid haemorrhage (SAH) has been declining in the UK and Ireland (Kelly et al, 2012) and mortality has improved significantly in recent years with improvements...

A	Description	Year
A	Any person presenting with sudden severe headache and an altered neurological state should have the diagnosis of subarachnoid haemorrhage investigated by: Immediate CT brain scan (also including CT angiography if a protocol is agreed with the neurosciences centre); Lumbar puncture 12 hours after ictus (or within 14 days if presentation is delayed) if the CT brain scan is negative and does not show any contraindication; Spectrophotometry of the cerebrospinal fluid for xanthochromia.	2016
B	Patients with spontaneous subarachnoid haemorrhage should be referred immediately to a neurosciences centre and receive: Nimodipine 60 mg 4 hourly unless contraindicated; Frequent neurological observation for signs of deterioration.	2016
C	Following transfer to the neurosciences centre, patients with spontaneous subarachnoid haemorrhage should receive: CT or MR angiography (if this has not already been done by agreed protocol in the referring hospital) with or without intra-arterial angiography to identify the site of bleeding; Specific treatment of any aneurysm related to the haemorrhage by endovascular embolisation or surgical clipping if appropriate. Treatment to secure the aneurysm should be undertaken within 48 hours of ictus for patients of appropriate status (Hunt and Hess or World Federation of Neurological Sciences grades 1-3), or within a maximum of 48 hours of diagnosis if presentation was delayed.	2016
D	After any immediate treatment, patients with subarachnoid haemorrhage should be monitored for the development of treatable complications, such as hydrocephalus and cerebral ischaemia.	2016
E	After any immediate treatment, patients with subarachnoid haemorrhage should be assessed for hypertension treatment and smoking cessation.	2016
F	Patients with residual symptoms or disability after definitive treatment of subarachnoid haemorrhage should receive specialist neurological rehabilitation including appropriate clinical/neuropsychological support.	2016
G	People with two or more first-degree relatives affected by aneurysmal subarachnoid haemorrhage and/or polycystic kidney disease should be referred to a neurovascular and/or neurogenetics specialist for information and advice regarding the risks and benefits of screening for cerebral aneurysms.	2016

3.8 Cervical artery dissection

A small proportion of patients with acute ischaemic stroke will have a dissection of a carotid or vertebral artery as the underlying cause of their stroke. As non-invasive carotid...

A	Description	Year
A	Any patient suspected of cervical artery dissection should be investigated with CT or MR including angiography.	2016
B	Patients with acute ischaemic stroke suspected to be due to cervical arterial dissection should receive thrombolysis if they are otherwise eligible.	2016
C	Patients with acute ischaemic stroke suspected to be due to cervical arterial dissection should be treated with either an anticoagulant or an antiplatelet agent for at least 3 months.	2016
D	For patients with cervical arterial dissection treated with an anticoagulant, either a DOAC or a Vitamin K antagonist may be used for three months.	2023
E	For patients with acute ischaemic stroke or TIA secondary to cervical artery dissection, dual antiplatelet therapy with aspirin and clopidogrel may be considered for the first 21 days, to be followed by antiplatelet monotherapy until at least three months after onset.	2023

3.9 Cerebral venous thrombosis

Cerebral venous thrombosis (CVT) is a rare cause of an acute stroke syndrome. Headache, seizures and focal (sometimes bilateral) neurological deficits are typical presenting featur...

A	Description	Year
A	Any patient suspected of cerebral venous thrombosis should be investigated with CT or MRI including venography.	2016
B	Patients with cerebral venous thrombosis (including those with secondary cerebral haemorrhage) should receive full-dose anticoagulation (initially full-dose heparin and then warfarin with a target INR of 2–3) for at least three months unless there are comorbidities that preclude their use.	2016
C	Patients with ischaemic stroke and symptomatic deep vein thrombosis or pulmonary embolism should receive anticoagulant treatment provided there are no contraindications.	2016
D	Patients with intracerebral haemorrhage and symptomatic deep vein thrombosis or pulmonary embolism should receive treatment with a vena caval filter.	2016

3.10 Acute stroke care

Many patients presenting with acute neurological deficits secondary to vascular disease will have other problems requiring attention during and after their initial diagnosis (Secti...

A	Description	Year
A	Patients with acute stroke should be admitted directly to a hyperacute stroke unit with protocols to maintain normal physiological status and staff trained in their use.	2016
B	Patients with acute stroke should have their clinical status monitored closely, including: Level of consciousness; Blood glucose; Blood pressure; Oxygen saturation; Hydration and nutrition; Temperature; Cardiac rhythm and rate.	2016
C	Patients with acute stroke should only receive supplemental oxygen if their oxygen saturation is below 95% and there is no contraindication.	2016
D	Patients with acute stroke should have their hydration assessed using a standardised approach within four hours of arrival at hospital, and should be reviewed regularly and managed so that normal hydration is maintained.	2016
E	Patients with acute stroke should have their swallowing screened, using a validated screening tool, by a trained healthcare professional within four hours of arrival at hospital and before being given any oral food, fluid or medication.	2016
F	Until a safe swallowing method is established, patients with dysphagia after acute stroke should: Be immediately considered for alternative fluids; Have a comprehensive specialist assessment of their swallowing; Be considered for nasogastric tube feeding within 24 hours; Be referred to a dietitian for specialist nutritional assessment, advice and monitoring; Receive adequate hydration, nutrition and medication by alternative means; Be referred to a pharmacist to review the formulation and administration of medication.	2023
G	Patients with swallowing difficulties after acute stroke should only be given food, fluids and medications in a form that can be swallowed without aspiration.	2016
H	Patients with acute stroke should be treated to maintain a blood glucose concentration between 5 and 15 mmol/L with close monitoring to avoid hypoglycaemia.	2016
I	Patients with acute ischaemic stroke should only receive blood pressure-lowering treatment if there is an indication for emergency treatment, such as: Systolic blood pressure above 185 mmHg or diastolic blood pressure above 110 mmHg when the patient is otherwise eligible for treatment with thrombolysis; Hypertensive encephalopathy; Hypertensive nephropathy; Hypertensive cardiac failure or myocardial infarction; Aortic dissection; Pre-eclampsia or eclampsia.	2016
J	Patients with acute stroke admitted on antihypertensive medication should resume oral treatment once they are medically stable and as soon as they can swallow medication safely.	2016
K	Patients with acute ischaemic stroke should receive high-intensity statin treatment with atorvastatin 20-80 mg daily as soon as they can swallow medication safely.	2016
L	Patients with primary intracerebral haemorrhage should only be started on statin treatment based on their cardiovascular disease risk and not for secondary prevention of intracerebral haemorrhage.	2016

3.11 Positioning

Following a stroke many patients are left with varying degrees of physical impairment which can reduce their ability to change position and posture. Therapeutic positioning, whether...

A	Description	Year
A	Patients with acute stroke should have an initial specialist assessment for positioning as soon as possible and within 4 hours of arrival at hospital.	2016
B	Patients admitted to hospital with acute stroke should be allowed to adopt either a sitting-up or lying-flat head position in the first 24 hours, according to comfort. Stroke units should not have a policy or practice that favours either head position.	2023
C	Healthcare professionals responsible for the initial assessment of patients with acute stroke should be trained in how to position patients appropriately, taking into account the degree of their physical impairment after stroke.	2016
D	When lying or sitting, patients with acute stroke should be positioned to minimise the risk of aspiration and other respiratory complications, shoulder pain and subluxation, contractures and skin pressure ulceration.	2016

3.12 Early mobilisation

Immobility and/or bed rest are well-documented to have detrimental effects on hospital patients in general. Early mobilisation (e.g. activities such as sitting out of bed, transferring...

A	Description	Year
A	Patients with difficulty moving after stroke should be assessed as soon as possible within the first 24 hours of onset by an appropriately trained healthcare professional to determine the most appropriate and safe methods of transfer and mobilisation.	2016
B	Patients with difficulty moving early after stroke who are medically stable should be offered frequent, short daily mobilisations (sitting out of bed, standing or walking) by appropriately trained staff with access to appropriate equipment, typically beginning between 24 and 48 hours of stroke onset. Mobilisation within 24 hours of onset should only be for patients who require little or no assistance to mobilise.	2016

3.13 Deep vein thrombosis and pulmonary embolism

Deep vein thrombosis (DVT) and pulmonary embolism (PE) are common complications of hemiplegic stroke with up to 50% of patients having thrombus in either the calf or thigh of the p...

A	Description	Year
A	Patients with immobility after acute stroke should be offered intermittent pneumatic compression within 3 days of admission to hospital for the prevention of deep vein thrombosis. Treatment should be continuous for 30 days or until the patient is mobile or discharged, whichever is sooner.	2016
B	Patients with immobility after acute stroke should not be routinely given low molecular weight heparin or graduated compression stockings (either full-length or below-knee) for the prevention of deep vein thrombosis.	2016
C	Patients with ischaemic stroke and symptomatic deep vein thrombosis or pulmonary embolism should receive anticoagulant treatment provided there are no contraindications.	2016
D	Patients with intracerebral haemorrhage and symptomatic deep vein thrombosis or pulmonary embolism should receive treatment with a vena caval filter.	2016