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Cardiovascular Neurological

Stroke and TIA

Last revised in June 2026

Stroke is a clinical syndrome characterised by sudden onset of rapidly developing focal or global neurological disturbance

Stroke and TIA: Summary

  • Stroke is a clinical syndrome of presumed vascular origin characterized by sudden-onset focal neurological deficit that lasts longer than 24 hours or leads to death.
    • Stroke may be ischaemic due to infarction following vascular occlusion or stenosis (about 86% of cases), haemorrhagic due to intracerebral haemorrhage or subarachnoid haemorrhage (about 14% of cases), or silent where there is radiological or pathological evidence of asymptomatic cerebral infarction or haemorrhage.
  • Transient ischaemic attack (TIA) is defined as transient sudden-onset focal neurological deficit, likely to be due to focal cerebral or ocular ischaemia, which lasts less than 24 hours.
  • Risk factors include lifestyle, established cardiovascular disease, other comorbidities including previous stroke or TIA, and demographic factors such as older age and family history of stroke.
  • About 100,000 people have strokes every year in the UK.
  • Stroke is the third most common cause of premature death in England. It may cause multiple complications affecting swallowing; nutrition; and hydration; communication; hearing and vision; continence and sexual function; cognition and mood; fatigue; pain; motor skills; and function.
  • Assessment of a person with suspected stroke or TIA includes:
    • Asking about symptoms (such as focal weakness, numbness, speech or visual disturbance) and time of onset; baseline cognitive and physical functioning; risk factors; comorbidities; and medications including anticoagulant or antiplatelet therapy.
    • Examination of consciousness level; vital signs; focused neurological examination including the Face Arm Speech Test (FAST) validated tool; cardiovascular system for arrhythmias or murmurs.
    • Checking finger-prick blood glucose to exclude hypoglycaemia as a cause for symptoms.
  • Management of suspected acute stroke or emergent TIA involves:
    • Arranging immediate emergency transfer to a hyperacute stroke centre and ensuring pre-alert notification to the stroke team.
  • Management of suspected TIA within the last 7 days involves:
    • Offering aspirin 300 mg immediately unless contraindicated.
    • Arranging emergency admission for urgent CT head to exclude intracranial haemorrhage if a person has a known bleeding disorder or is taking anticoagulant therapy.
    • Arranging urgent referral to a TIA clinic for assessment within 24 hours by a stroke specialist if emergency admission not needed. Note: if there is suspected TIA more than 7 days ago, referral to a TIA clinic should be arranged as soon as possible within 7 days.
    • Advising about how to recognise symptoms of acute stroke, and to call 999 immediately if suspected.
    • Advising not to drive until seen by a stroke specialist.
  • Follow-up in primary care following stroke or TIA includes:
    • Reviewing any health and social care unmet needs.
    • Advising the person and family members/carers about sources of information and support.
    • Advising about driving restrictions and returning to work.
    • Reviewing and managing any modifiable risk factors including lifestyle measures to reduce cardiovascular risk.
    • Managing any comorbidities and complications of stroke, and offering community stroke rehabilitation referral if needed.
    • Reviewing and optimizing secondary prevention drug treatment and ensuring vaccinations are up-to-date.
    • Offering advance care planning and supportive care if the person is at the end of life.

Have I got the right topic?

From age 16 years onwards.

This CKS topic covers the primary care assessment and management of adults presenting with suspected acute stroke or transient ischaemic attack (TIA), the secondary prevention of stroke and TIA, and management of stroke complications in primary care.

This CKS topic does not cover primary prevention of stroke, management of stroke in children, or secondary care management of stroke and TIA.

There are separate CKS topics on Adult malnutrition, Anticoagulation - oral, Antiplatelet treatment, Atrial fibrillation, Blackouts and syncope, CVD risk assessment and management, Depression, Delirium, Diabetes - type 1, Diabetes - type 2, Falls - assessment, Generalized anxiety disorder, Heart failure - chronic, Hypertension, Lipid modification - CVD prevention, Palliative care - general issues, Post-traumatic stress disorder, and Pressure ulcers.

The target audience for this CKS topic is healthcare professionals working within the NHS in the UK, and providing first contact or primary healthcare.

How up-to-date is this topic?

Changes

June 2026 — reviewed. A literature search was conducted in May 2026 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of this topic. The topic has been updated in line with the updated National Institute for Health and Care Excellence (NICE) guideline Stroke and transient ischaemic attack in over 16s: diagnosis and initial management [NICE, 2025] and the Intercollegiate Stroke Working Party (ICSWP) publication National clinical guideline for stroke for the United Kingdom and Ireland. Modified-release dipyridamole is no longer recommended as a drug option for antiplatelet therapy. The recommended indications, doses, and duration of use for dual antiplatelet therapy (DAPT) have been amended in line with current evidence in the literature.

Previous changes

November 2025 — minor update. The text about lipid modification management and secondary prevention recommendations have been aligned with the National Institute for Health and Care Excellence (NICE) guideline Cardiovascular disease: risk assessment and reduction and the Summary of national guidance for lipid management for primary and secondary prevention of CVD published by the Accelerated Access Collaborative. The previous version of this topic provided treatment advice on primary prevention targets for this population, which was incorrect. The advice on ezetimibe being reserved for the treatment of familial hypercholesterolaemia has also been deleted, as this was added in error to this topic. Links to the CKS topic Lipid modification - CVD prevention have also been added to this topic. 

May 2025 — minor update. QOF indicators updated in line with the NHS England Quality and Outcomes Framework guidance for 2025/26.

December 2023 — minor update. Further clarification made on the recommendation to avoid use of statins for secondary prevention in people with a history of intracerebral haemorrhage, as all people with stroke should be offered statins (unless contraindicated) in secondary care after a diagnosis of stroke is confirmed. 

October 2023 — minor update. The recommendation to avoid use of statins for secondary prevention in people with a history of intracerebral haemorrhage has been removed and information added to the basis of recommendation section to explain this change, based on a large trial which demonstrated no difference in adverse impact. The topic was also aligned with the recommendations contained in the updated NICE guideline [NG236] Stroke rehabilitation in adults [NICE, 2023]. 

April 2023 — minor update. Information on blood pressure targets has been removed and a link to the section on monitoring and treatment targets in the CKS topic on Hypertension has been added. 

August 2022 — minor update. Blood pressure targets reviewed with reference to the NICE guideline Hypertension in adults: diagnosis and management [NG136]. 

January 2022 — minor update. Typographical spelling error corrected. 

September 2021 — reviewed. A literature search was conducted in September 2021 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of the topic. A previous recommendation that people with suspected transient ischaemic attack (TIA) taking anticoagulants should not be given an immediate dose of aspirin 300 mg has been removed. NICE advises that a single dose of aspirin 300 mg is likely to carry a low risk of causing or aggravating bleeding (even in people taking anticoagulants).

August 2020 — minor update. New NICE quality standard QS194 added.

January to March 2017 — reviewed. A literature search was conducted in January 2017 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of the topic. The topic has undergone some restructuring. The recommendation on risk stratification of people with suspected TIA has changed, as all people presenting with suspected TIA within the last week should be referred urgently (to be seen within 24 hours) to a stroke physician without risk stratification.

December 2013 — reviewed. A literature search was conducted in September 2013 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of the topic. The structure of the topic was changed to improve clarity. Clopidogrel is preferred as the antiplatelet of choice for people who have had a transient ischaemic attack.

July 2013 — minor update. Links to the DVLA website have been updated.

June 2013 — minor update. The 2013 QOF options for local implementation have been added to this topic.

April  2012 — minor update. The 2012/2013 QOF indicators have been added to this topic. 

March 2011 — minor update. The new recommendations on alcohol consumption advising at least 2 alcohol-free days per week, based on guidelines from the House of Commons Science and Technology Committee, have been added. 

February 2012 — minor update. Amendment to referral information for a transient ischaemic attack, in line with the Quality and outcomes framework guidance for GMS contract 2011/12. 

January 2012 — minor update. Information from the manufacturer's Summary of Product Characteristics about the possible interaction between pantoprazole and warfarin has been added to drug interactions. Information from the British National Formulary about the potentially serious interaction between proton pump inhibitors and protease inhibitors (atazanavir and saquinavir) has also been added. 

September 2011 — minor update. Text added to include recommendations from the Scottish Intercollegiate Guidelines Network national clinical guideline 119 Management of patients with stroke: identification and management of dysphagia and national clinical guideline 118 Management of patients with stroke: Rehabilitation, prevention and management of complications, and discharge planning. 

June 2011 — minor update. The 2011/2012 QOF indicators have been added to this topic.

April 2011 — topic structure revised to ensure consistency across CKS topics. No changes to clinical recommendations have been made.

February 2011 — updated. The new recommendations from the NICE technology appraisal 210 Clopidogrel and modified-release dipyridamole for the prevention of occlusive vascular events have been incorporated into this topic. 

August 2010 — minor update. Text added to include NICE Quality Standards relating to Stroke.

July 2009 — minor update. The Medicines and Healthcare products Regulatory Agency (MHRA) has issued advice on the interaction between clopidogrel and proton pump inhibitors. Healthcare professionals are advised to avoid concomitant use of these drugs unless considered essential. 

May 2009 — updated to include the indicators related to stroke and transient ischaemic attack in the Quality and Outcomes Framework (QOF) of the General Medical Services (GMS) contract in the Goals and outcome measures section. 

September 2008 to February 2009 — converted from CKS guidance to CKS topic structure. The evidence-base on primary care treatments has been reviewed in detail, and recommendations are more clearly justified and transparently linked to the supporting evidence. The title has been changed from TIA — not in atrial fibrillation to Stroke and TIA, to reflect a wider scope, which now includes the primary care management of stroke. Changes to the sections on transient ischaemic attack (TIA) reflect new guidance from the National Institute for Health and Care Excellence (NICE) on using the FAST screening tool when diagnosing TIA, and on standards for referral for specialist assessment.

November 2008 — minor typographical correction to a citation. 

July 2006 — minor update to text. Details of the European/Australasian Stroke Prevention in Reversible Ischaemia Trial (ESPRIT) study included in Supporting evidence to further support recommendations. 

July to September 2005 — reviewed. Validated in December 2005 and issued in February 2006.

July 2005 — minor update to text to clarify dipyridamole formulations. 

October 2003 — minor revision. Inclusion of modified-release dipyridamole in the scenario for people intolerant of aspirin. Validated in December 2003, and issued in February 2004.

June 2003 — minor update. New advice from the British Heart Foundation on low-dose aspirin and ibuprofen added.

January 2002 — reviewed. Validated in March 2002 and issued in April 2002.

December 1998 — rewritten, replacing previous guidance called Transient cerebral ischaemia.

Update

New evidence

Evidence-based guidelines

No new evidence-based guidelines since 1 May 2026.

HTAs (Health Technology Assessments)

No new HTAs since 1 May 2026.

Economic appraisals

No new economic appraisals relevant to England since 1 May 2026.

Systematic reviews and meta-analyses

No new Systematic reviews and meta-analyses since 1 May 2026.

Primary evidence

No new primary evidence that reaches the CKS threshold for inclusion published since 1 May 2026.

New policies

No new national policies or guidelines since 1 May 2026.

New safety alerts

No new safety alerts since 1 May 2026.

Changes in product availability

No changes to product availability since 1 May 2026.

Goals and outcome measures

Goals

To support primary healthcare professionals to:

  • Promptly recognize the symptoms and signs of stroke and transient ischaemic attack (TIA).
  • Arrange immediate emergency transfer to a hyperacute stroke centre if a person has suspected acute stroke or emergent transient ischaemic attack (TIA) for specialist investigation and management.
  • Arrange urgent referral to a TIA clinic for assessment within 24 hours by a stroke specialist clinician if there is a history of suspected TIA, and start aspirin 300 mg immediately unless contraindicated.
  • Arrange review in primary care for people with stroke or TIA and advise about lifestyle and other secondary prevention measures to reduce risk of future stroke or cardiovascular event.
  • Advise on sources of information and support for the person and family members/carers.
  • Assess for and manage any complications of stroke if not already under the community stroke rehabilitation team.

Outcome measures

No outcome measures were found during the review of this topic.

Audit criteria

No audit criteria were found during the review of this topic.

QOF indicators

Table 1. Indicators related to stroke and transient ischaemic attack (TIA) in the Quality and Outcomes Framework (QOF) 2025–26.

IndicatorPointsAchievement threshold
CHOL003 Percentage of patients on the QOF Coronary Heart Disease, Peripheral Arterial Disease, Stroke/TIA or Chronic Kidney Disease Register who are currently prescribed a statin, or where a statin is declined or clinically unsuitable, another lipid-lowering therapy.2070-95%
CHOL004 Percentage of patients on the QOF Coronary Heart Disease (CHD), Peripheral Arterial Disease (PAD), or Stroke/ Transient Ischaemic Attack (TIA) Register, with the most recent cholesterol measurement in the preceding 12 months, showing as ≤ 2.0 mmol/L if it was an LDL (Low-density Lipoprotein) cholesterol reading or ≤ 2.6 mmol/L if it was a non-HDL (High-density Lipoprotein) cholesterol reading. For multiple readings on the latest date the LDL reading takes priority. 4420-50%
SMOK002 The percentage of patients with any or any combination of the following conditions: CHD, PAD, stroke or TIA, hypertension, diabetes, COPD, CKD, asthma, schizophrenia, bipolar affective disorder or other psychoses whose notes record smoking status in the preceding 12 months 2550-90%
STIA007 The percentage of patients with a stroke shown to be non-haemorrhagic, or a history of TIA, who have a record in the preceding 12 months that an anti-platelet agent, or an anticoagulant is being taken457-97%
CD001 The percentage of patients with coronary heart disease, stroke or TIA, aged 79 years or under, without moderate or severe frailty in whom the last blood pressure reading (measured in the preceding 12 months) is 140/90 mmHg or less, (or equivalent home blood pressure reading).4140-90%
CD002 The percentage of patients with coronary heart disease, stroke or TIA, aged 80 years or over, without moderate or severe frailty in whom the last blood pressure reading (measured in the preceding 12 months) is 150/90 mmHg or less, (or equivalent home blood pressure reading).2046-90%
Data from: [NHS England, 2026]

QIPP - Options for local implementation

No QIPP indicators were found during the review of this topic.

NICE quality standards

Stroke in adults

  • Adults presenting at an accident and emergency (A&E) department with suspected stroke are admitted to a specialist acute stroke unit within 4 hours of arrival.
  • Adults having stroke rehabilitation in hospital or in the community are offered at least 3 hours of rehabilitation covering a range of multidisciplinary therapy for a minimum of 5 days a week.
  • Adults who have had a stroke have access to a clinical psychologist or a clinical neuropsychologist with expertise in stroke rehabilitation who is part of the core multidisciplinary stroke rehabilitation team.
  • Adults who have had a stroke are offered early supported discharge if the core multidisciplinary stroke team assess that it is suitable for them.
  • Adults who have had a stroke are offered active management to return to work if they wish to do so.
  • Adults who have had a stroke have their rehabilitation goals reviewed at regular intervals.
  • Adults who have had a stroke have a structured health and social care review at 6 months and 1 year after the stroke, and then annually.

[NICE, 2023a]

Decision-making and mental capacity

  • People aged 16 and over who may lack capacity to make decisions are supported with decision-making in a way that reflects their individual circumstances and meets their particular needs.
  • People aged 16 and over at risk of losing capacity to make decisions, and those with fluctuating capacity, are given the opportunity to discuss advance care planning at each health and social care review.
  • People aged 16 and over who are assessed as lacking capacity to make a particular decision at the time that decision needs to be made, have a clear record of the reasons why they lack capacity and the practicable steps taken to support them.
  • People aged 16 and over who lack capacity to make a particular decision at the time that decision needs to be made have their wishes, feelings, values and beliefs accounted for in best interests decisions.

[NICE, 2020] 

Background information

What is it?

  • A stroke or transient ischaemic attack (TIA) is an acute neurological event presumed to be vascular in origin and causing cerebral ischaemia, cerebral infarction, or cerebral haemorrhage. It includes thrombotic and embolic events, and primary intracerebral haemorrhage of any cause, including venous thrombosis [NICE, 2025].
    • Stroke is a clinical syndrome of presumed vascular origin characterized by rapidly developing signs of focal or global disturbance of cerebral functions which lasts longer than 24 hours or leads to death.
      • Ischaemic stroke — an episode of neurological dysfunction caused by focal cerebral, spinal, or retinal cell death due to infarction following vascular occlusion or stenosis [NICE, 2025].
      • Haemorrhagic stroke — rapidly developing neurological dysfunction due to a focal collection of blood from within the brain parenchyma or ventricular system (intracerebral haemorrhage), or bleeding into the arachnoid space (subarachnoid haemorrhage) that is non-traumatic  [Steiner, 2025].
      • Silent stroke — radiological or pathological evidence of a cerebral infarction or haemorrhage not caused by trauma which is non-symptomatic [ICSWP, 2023].
    • TIA is defined as 'transient neurological symptoms, likely to be due to focal cerebral or ocular ischaemia, which last less than 24 hours' [Fonseca, 2021].

What causes it?

  • About 86% of strokes are ischaemic [HQIP, 2025]. 
    • Ischaemic strokes occur when large arteries (such as the extracranial carotid or vertebral arteries), intracranial arteries, or small penetrating arteries (lacunar) are occluded by [Hurford, 2020]: 
      • Thrombus (often as a complication of atherosclerosis), or
      • Embolus of fatty material from an atherosclerotic plaque or a clot in a larger artery or the heart (often as a complication of atrial fibrillation or atherosclerosis of the carotid arteries). 
    • Other causes include intracranial or extracranial vessel disease (for example, carotid or vertebral artery dissection [rare], which tends to occur in younger people and may be preceded by neck trauma). In addition, haematological conditions (such as sickle cell anaemia, antiphospholipid syndrome, or other prothrombotic conditions) may be associated with acute ischaemic stroke [ICSWP, 2023].
    • In about 25% of cases, no underlying cause is found (so-called 'cryptogenic stroke') [Rubiera, 2022].
  • About 14% of strokes are haemorrhagic [HQIP, 2025].
    • Intracerebral haemorrhage — the majority of spontaneous intracerebral haemorrhage is caused by cerebral small vessel disease, including hypertensive arteriopathy. More rarely, bleeding is caused by a macrovascular abnormality such as an arteriovenous malformation, dural arteriovenous fistula, intracranial aneurysm, cavernous malformation, or by cerebral venous thrombosis (rare) [ICSWP, 2023; Steiner, 2025].
    • Subarachnoid haemorrhage — rupture of an intracranial saccular aneurysm accounts for 80% of cases of non-traumatic subarachnoid haemorrhage. The remaining 20% are due to arteriovenous malformations, arterial dissections, use of anticoagulants, and other rare conditions [ICSWP, 2023].

What are the risk factors?

Risk factors for stroke and transient ischaemic attack (TIA) include:

How common is it?

  • The Sentinel Stroke National Audit Programme (SSNAP), based on 92,414 patients who were admitted across 250 hospitals, 195 community services, and 184 6-month follow-up providers in England, Wales and Northern Ireland with a stroke between April 2024 and March 2025, found [HQIP, 2025]:
    • There were 92,414 people admitted with stroke across the different care settings. This compares to 95,222 in 2023–24 and 92,143 in 2022–23.
    • 86% of patients admitted were diagnosed with cerebral infarction, 13.4% were diagnosed with intracerebral haemorrhage, and in 0.5% the type of stroke was unknown.
    • The median age of patients was 76 years, 15.5% of patients were aged less than 60 years, and 54% of patients were men.
    • 46.5% of people were directly admitted to a stroke unit within 4 hours of hospital arrival.
    • 74% of people spent at least 90% of their hospital stay on a specialist stroke unit.
    • 66.6% of patients were discharged to a stroke- or neurology-specific community rehabilitation service.
  • The World Stroke Organization Global Burden of Disease 2021 study on stroke cites evidence that the number of people who have a stroke, die from, or live with a disability after a stroke has risen substantially worldwide between 1990 and 2021 [Feigin, 2025]:
    • In 2021, there were 93.8 million prevalent and 11.9 million incident strokes worldwide.
    • Incident strokes increased by 70% over the study period.
    • Deaths from stroke increased by 44% over the study period.
    • Disability-adjusted life-years lost (DALYs) increased by 32% over the study period.
    • 10 modifiable risk factors were responsible for over 80% of stroke cases.
  • The European Stroke Organisation (ESO) and European Association of Neurosurgical Societies (EANS) joint guideline cites evidence that [Steiner, 2025]:
    • The global incidence of intracerebral haemorrhage was estimated at 3.41 million cases in 2019, accounting for 28.8% of all strokes, and the global prevalence was 20.6 million cases.
    • Spontaneous intracerebral haemorrhage resulted in 2.89 million deaths and was associated with 68.57 million DALYs.
  • The UK Stroke Association statistical data collection summarizes that [Stroke Association, 2021]:
    • About 100,000 people have strokes every year in the UK.
    • There are about 1.4 million stroke survivors in the UK.
  • A Public Health England (PHE) briefing document analysis of a general practice database provided first incidence of stroke estimates in England (2007–2016) and found [PHE, 2018]: 
    • About 57,000 people in England experienced a first stroke in 2016, with 51% occurring in men and 49% in women. This equated to the incidence rate increasing slightly from 1.03 strokes per 1000 population in 2013 to 1.13 strokes per 1000 population in 2016.
    • Stroke incidence increased with age, as 3% of the total estimated stroke incidence occurred in people aged under 40 years, 38% in people aged 40 to 69 years, and 59% in people aged over 70 years.
    • First-time stroke is occurring at an earlier age, with age at onset falling from 70.5 to 68.2 years in men and 74.5 to 73.0 years in women between 2007 and 2016. The median age of stroke in men was 70 years compared with 76 years in women. Peak incidence in men occurred in the 70–79 years age-group, compared with 80–89 years in women.
    • Increasing deprivation was associated with increasing stroke incidence rates.

What are the complications?

Potential complications of stroke include:
  • Early
  • Long-term
    • Swallowing, nutrition, hydration, and oral health
      • Dysphagia (swallowing difficulty associated with foods, fluids, and saliva) may affect 40–78% of people after acute stroke, depending on the diagnostic criteria, timing, and method of assessment. 11–50% of people may continue to have dysphagia at six months after stroke [Dziewas, 2021].
      • Up to 25% of people become malnourished and dehydrated in the weeks following acute stroke. Dehydration and malnutrition can occur due to swallowing problems, inability to self-feed, cognitive impairment, anxiety, depression, unfamiliar foods, and fatigue. Malnutrition is associated with functional impairment and increased mortality [ICSWP, 2023]. See the CKS topic on Adult malnutrition for more information.
      • Swallowing problems are associated with an increased risk of aspiration and subsequent pneumonia, disability, increased dependency, and increased mortality rates [Dziewas, 2021; ICSWP, 2023].
      • Poor oral hygiene can lead to dental caries, periodontitis, gingivitis, oral infections and ulceration due to increased bacterial load, and dry, painful lips [Dziewas, 2021; ICSWP, 2023; NICE, 2023 Stroke rehabilitation in adults]. See the CKS topic on Gingivitis and periodontitis for more information. Maintenance of oral health may be affected by cognitive impairment, dysphagia or arm weakness, inadequate control of saliva, and medication adverse effects such as dry mouth [ICSWP, 2023].
    • Communication problems
      • Aphasia — an impairment of language function that affects the ability to speak, understand, read, and write. It affects about one-third of people following stroke, and can impact mood, self-image and self-identity, relationships, employment, and social activities [ICSWP, 2023; NICE, 2023 Stroke rehabilitation in adults; Brady, 2025].
      • Dysarthria — motor speech impairment characterized by slow, weak, imprecise, and/or uncoordinated movements of the speech muscles. It may involve respiration, phonation, resonance, and/or oral articulation, and is often associated with dysphagia [ICSWP, 2023; NICE, 2023 Stroke rehabilitation in adults].
      • Apraxia of speech — difficulty in initiating and executing the voluntary movement needed to produce speech due to co-ordination problems, when there is no weakness of speech muscles  [Brady, 2025].
    • Hearing problems
    • Vision problems 
      • Vision problems after stroke may include loss or impairment of central and peripheral vision, including hemianopia, diplopia, eye movement disorders, visual neglect, and visual perception deficits such as impaired object recognition and loss of depth perception [Rowe, 2025]. Vision changes can affect the person's safety, including while driving, social interaction, and independence [ICSWP, 2023; NICE, 2023 Stroke rehabilitation in adults].
    • Continence problems 
      • Urinary and faecal incontinence are common and can persist long-term, affecting mood, self-image, self-confidence, participation in rehabilitation, and may contribute to carer stress. In addition, urinary incontinence increases the risk of skin breakdown and pressure areas. Urinary and faecal incontinence can be exacerbated by constipation [ICSWP, 2023]. See the CKS topics on Constipation, Faecal incontinence in adults, Incontinence - urinary, in women, and Pressure areas for more information.
    • Cognitive impairment
      • Cognitive impairment is associated with poor prognosis after stroke, including prolonged hospital stay and reduced independence [ICSWP, 2023]. Cognitive impairments may vary over time after stroke, and in different care settings [NICE, 2023 Stroke rehabilitation in adults].
      • Attention impairments may persist in the longer term and may be specific (such as focusing, dividing or sustaining attention), or more generalized, affecting alertness and speed of processing. Attention problems may lead to fatigue, low mood, and difficulty with functional tasks and living independently, including mobility, dressing, eating, and using a wheelchair, for example [ICSWP, 2023; NICE, 2023 Stroke rehabilitation in adults].
      • Memory problems after stroke can lead to longer hospital stay, poorer outcomes, risks to personal safety, difficulties engaging with rehabilitation, and can cause distress to the person and carers. In addition, dementia affects about 20% of people after stroke [ICSWP, 2023]. See the CKS topic on Dementia for more information.
      • Neglect refers to the reduced and impaired ability to process spatial information, which may affect reasoning, memory retrieval, and impaired interaction with the person's environment. It may have implications for functional tasks such as dressing, mobility and safety, crossing roads, driving, or work [ICSWP, 2023].
      • Apraxia is difficulty performing purposeful actions due to disturbance of the conceptual ability to organise actions to achieve a goal, causing difficulties with dressing or using everyday objects correctly, for example [ICSWP, 2023].
      • Impairment in executive function affects the ability to plan and execute a series of tasks, regulate emotional responses, foresee the consequences of actions, problem solve, organise, and assess risk [ICSWP, 2023].
    • Emotional wellbeing and mood 
      • Mood disorders such as anxiety and depression are common after stroke, as well as increased levels of emotional agitation and lability, including uncontrolled crying or laughter, and emotional distress including anger, frustration, and hopelessness. People with aphasia are twice as likely to develop depression after stroke than people without aphasia. Anxiety and depression affect about 25% and 30% of people after stroke, respectively [ICSWP, 2023; NICE, 2023 Stroke rehabilitation in adults]. See the CKS topics on Depression and Generalized anxiety disorder for more information.
      • Psychological distress may impact on daily activities, engagement in rehabilitation, assessing risk and safety, and decision-making [ICSWP, 2023].
      • Apathy affects about one-third of people after stroke, and may affect motivation, social engagement, functional recovery, and emotional responsiveness [ICSWP, 2023].
    • Fatigue 
      • Post-stroke fatigue is typically not relieved by rest and can cause considerable morbidity. It may affect 35–92% of people following stroke [ICSWP, 2023].
      • It can impact a person's ability to engage with rehabilitation, return to work, mobilise and perform physical and social activities, mood, and cognitive function. It is likely to be multifactorial, impacted by pain type and severity, sleep disturbance including obstructive sleep apnoea, mood disturbance, physical demands, medication adverse effects, the person's coping style, and level of social support [ICSWP, 2023; NICE, 2023 Stroke rehabilitation in adults].
    • Pain
      • Neuropathic pain or central post-stroke pain is estimated to affect 5–20% of people with stroke. It may impact lifestyle, sleep, mood, activities, and participation [ICSWP, 2023]. See the CKS topic on Neuropathic pain - drug treatment for more information.
      • Musculoskeletal pain can occur following stroke due to prolonged immobility, abnormal posture, or due to exacerbation of pre-existing conditions such as osteoarthritis [ICSWP, 2023]. In particular, musculoskeletal shoulder pain is often associated with glenohumeral joint subluxation, motor weakness, muscle spasticity, nerve impingement, and/or soft tissue injury [NICE, 2023 Stroke rehabilitation in adults]. It affects 30–65% of people following stroke, and may cause reduced functional recovery, affect participation in rehabilitation, and increase the risk of depression and reduced quality of life [ICSWP, 2023]. 
    • Motor skills 
      • Hemiparesis or hemiplegia — affects about 80% of people with stroke. About 40% of people have persistent altered arm function, which may involve shoulder subluxation, pain, and spasticity. Muscle weakness is the strongest factor influencing dexterity and upper limb function, activities of daily living, balance, and walking. The degree of weakness is mainly determined by stroke severity, location, and pre-morbid strength. Muscle and joint stiffness may develop due to inactivity and deconditioning, and further inactivity limits opportunities for rehabilitation, social participation, and increases the risk of recurrent stroke [ICSWP, 2023].
      • Ataxia — occurs in about 3% of ischaemic strokes, and may be a complication of posterior circulation stroke. It may present as gait and limb ataxia, dysarthria, and nystagmus, with a risk of associated balance problems and falls [ICSWP, 2023].
      • Falls — up to 73% of people with severe stroke fall within the first year after acute stroke. Contributory factors include lower limb weakness, limited trunk control, and altered sensation and visuospatial perception. Further complications include hip fracture, reduced physical activity, loss of confidence and independence, and social isolation [ICSWP, 2023]. See the CKS topic on Falls - assessment for more information.
      • Spasticity and contractures — spasticity can lead to pain, restricted activities, and difficulties for carers, and affects up to 40% of people with severe weakness after stroke. Contractures can develop in limbs affected by spasticity due to shortening of surrounding tissues, and can cause pain and restricted movement [ICSWP, 2023].
      • Loss of independence and ability to perform activities of daily living — activities such as washing, dressing, bathing, toileting, eating, and drinking usually depend on the ability to transfer and the use of at least one hand [ICSWP, 2023].
    • Functional impairment
      • Physical and cognitive impairment can lead to difficulties with personal care, driving, work and loss of income, leisure activities, and living independently. One in 12 people in the UK have to move into a care home following stroke as a result [ICSWP, 2023].
    • Sexual dysfunction 
      • The physical and psychological impact of stroke can affect role identity and relationships with sexual partners, which may lead to sexual dysfunction. It is typically multifactorial, and causes include peripheral arterial disease, altered sensation, limited mobility, medication adverse effects, mood changes, and fear of precipitating further stroke [ICSWP, 2023]. See the CKS topic on Erectile dysfunction for more information.

What is the prognosis?

  • A Public Health England (PHE) briefing document analysis of a general practice database provided first incidence of stroke estimates in England (2007–2016) and found [PHE, 2018]:
    • Stroke is the third most common cause of premature death in England.
    • There are about 30,000 stroke-related deaths each year, and more than 25% of people leaving hospital experience moderate-to-severe disability following a stroke.
  • In the UK, analysis of health equality indicators found that 30-day mortality after admission to hospital for [OECD, 2021]:
    • Ischaemic stroke decreased from 18.3 per 100 patients in 2007 to 11.9 per 100 patients in 2020.
    • Haemorrhagic stroke decreased from 37.1 per 100 patients in 2008 to 30.5 per 100 patients in 2020.
  • Among non-communicable disorders, stroke remains the second leading cause of death and the third leading cause of death and disability combined (as expressed by disability-adjusted life-years lost [DALYs]) in the world [Feigin, 2025].
  • The UK national clinical guideline for stroke states that [ICSWP, 2023]:
    • Of stroke survivors, 1 in 12 have to move into a care home because of the effects of their stroke.
    • About one in 20 people with acute stroke will receive end-of-life care within 72 hours of onset, and one in seven people with acute stroke will die in hospital. 10–15% of people with intracerebral haemorrhage and subarachnoid haemorrhage die before reaching hospital, and the overall survival rate is about 70%.
  • The European Stroke Organisation (ESO) guideline on secondary prevention cites evidence that recurrent stroke may affect 9–15% of people within 1 year of first stroke and 27–40% of people at 10 years, depending on the underlying aetiology [Dawson, 2022].
  • A systematic review and meta-analysis of 13 studies (n = 9115 stroke survivors) of the risk of longer-term recurrent stroke in people surviving a first stroke estimated the pooled cumulative risk of stroke recurrence to be [Mohan, 2011]:
    • 3.1% (95% CI 1.7 to 4.4) at 30 days.
    • 11.1% (95% CI 9.0 to 13.3) at 1 year.
    • 26.4% (95% CI 20.1 to 32.8) at 5 years.
    • 39.2% (95% CI 27.2 to 51.2) at 10 years.
  • The ESO guideline on transient ischaemic attack (TIA) notes that a TIA precedes a stroke in about 25% of people with a history of stroke [Fonseca, 2021].
    • It cites evidence that the pooled risk of stroke following a TIA at 7 days is estimated to be 2.06%, with about 50% of events occurring in the first 48 hours.
    • Clinical features suggesting a high risk of early stroke in people with a history of TIA include weakness or speech disturbance lasting more than five minutes; a history of recurrent TIAs; and significant ipsilateral large artery disease, such as carotid stenosis or intracranial stenosis.
  • In a retrospective population-based cohort study from 1984–2017, people with a history of TIA had a greater risk of subsequent stroke than matched controls without TIA. The risk of stroke after TIA fell during the study period (2000–2017) [Lioutas, 2021]: 
      • 5.9% in 90 days.
      • 7.6% in 1 year.
      • 16.1% in 5 years.
      • 20.3% in 10 years.

Diagnosis of stroke and TIA

When should I suspect TIA or stroke?

Stroke and transient ischaemic attack (TIA) typically present with sudden-onset focal neurological deficits, the nature of which depends on the territory of the brain affected. Widespread cerebral hypoperfusion (for example due to subarachnoid or intracranial haemorrhage or massive infarction) may present with non-focal or global neurological deficits.

  • Suspect a diagnosis of TIA if a person presents with:
    • Sudden-onset focal neurological deficit which has completely resolved within 24 hours of onset and cannot be explained by another condition, such as hypoglycaemia (most TIAs resolve within 1 hour but can persist for up to 24 hours). Focal neurological deficits may include:
      • Unilateral weakness or sensory loss. See the CKS topic on Sensory neuropathy for more information.
      • Aphasia.
      • Ataxia, vertigo, or loss of balance. See the CKS topic on Vertigo for more information.
      • Syncope. See the CKS topic on Blackouts and syncope for more information.
      • Sudden transient loss of vision in one eye (amaurosis fugax), diplopia, or homonymous hemianopia.
      • Cranial nerve deficits.
  • Suspect a diagnosis of stroke if a person presents with:
    • Sudden-onset, focal neurological deficit that is ongoing or has persisted for longer than 24 hours and cannot be explained by another condition, such as hypoglycaemia. The clinical features of stroke vary depending on the causative mechanism and the area of the cerebral blood vessels affected, and may include:
      • Confusion, altered level of consciousness, and coma. See the CKS topic on Delirium for more information.
      • Headache — usually of insidious onset and gradually increasing in intensity if intracranial haemorrhage. There may be sudden, severe occipital headache and neck stiffness with subarachnoid haemorrhage. Sentinel headache(s) may occur in the preceding weeks. See the CKS topic on Headache - assessment for more information.
      • Unilateral weakness or paralysis in the face, arm, or leg.
      • Sensory loss (paraesthesia or numbness). See the CKS topic on Sensory neuropathy for more information.
      • Ataxia.
      • Aphasia. 
      • Dysarthria.
      • Visual disturbance (homonymous hemianopia, diplopia).
      • Gaze paresis — this is often horizontal and unidirectional. 
      • Photophobia.
      • Dizziness, vertigo, or loss of balance — isolated dizziness is not usually a symptom of stroke. Note: posterior circulation stroke may be challenging to diagnose and should be suspected if a person presents with symptoms of acute vestibular syndrome such as acute, persistent, continuous vertigo or dizziness with nystagmus, nausea or vomiting, head motion intolerance, and new gait unsteadiness. See the CKS topic on Vertigo for more information.
      • Cranial nerve deficits such as unilateral tongue weakness or Horner’s syndrome (miosis, ptosis, and facial anhidrosis).
      • Difficulty with fine motor coordination and gait. 
      • Neck or facial pain (associated with arterial dissection).

Basis for recommendation

The information about diagnosis of suspected stroke and transient ischaemic attack (TIA) is based on the National Institute for Health and Care Excellence (NICE) guideline Stroke and transient ischaemic attack in over 16s: diagnosis and initial management [NICE, 2025], the UK Intercollegiate Stroke Working Party publication National clinical guideline for stroke for the United Kingdom and Ireland [ICSWP, 2023], and expert opinion in a review article on ischaemic stroke [Hurford, 2020]. It is also pragmatic, based on what CKS considers to be good clinical practice.

When to suspect stroke

  • The ICSWP guideline notes that some people with symptoms of stroke will not be identified by the Face Arm Speech Test (FAST), such as people with sudden-onset visual disturbance and/or lateralizing cerebellar dysfunction. In addition, rare causes of acute stroke such as cerebral venous thrombosis may present with headache, seizures, and sometimes bilateral neurological deficits [ICSWP, 2023].
  • The ICSWP guideline states that if a person has a negative FAST but stroke is still suspected, they should be treated as if they have stroke until the diagnosis has been excluded by a specialist stroke clinician [ICSWP, 2023].
  • The information about clinical features suggesting intracranial haemorrhage is based on the ICSWP guideline [ICSWP, 2023] and is also extrapolated from the NICE guideline on stroke and TIA [NICE, 2025].

How should I assess a person with suspected stroke or TIA?

Assess the person promptly if there is a suspected diagnosis of stroke or emergent transient ischaemic attack (TIA) to ensure timely emergency hospital transfer and treatment. A brief telephone assessment may be sufficient.

  • Take a focused history from the person and, if possible, a collateral history from witnesses or family members/carers. Ask about:
    • The clinical features suggesting stroke or TIA, including focal neurological deficits and associated symptoms such as headache, vomiting, or decreased level of consciousness.
    • The time of onset, speed of onset (sudden or gradual), duration, intensity, and fluctuation of symptoms.
      • Time from stroke onset is essential to determine eligibility for acute stroke treatments such as intravenous thrombolysis or mechanical thrombectomy.
      • If time of onset is not clear, ask what time the person was last known to be well (at their previous baseline or symptom-free).
      • If the person awoke with symptoms, the time of onset is defined as when the person was last awake and symptom-free.
      • In general, symptoms will have completely resolved within 24 hours in people with TIA and will be persisting in people with suspected stroke.  
    • The person's baseline level of cognitive and physical functioning pre-stroke.
    • Any other clinical features that may indicate an alternative diagnosis such as history of fever, rash, head trauma or head injury, or repetitive stereotyped events.
    • Any risk factors for stroke or TIA including any comorbidities such as ischaemic heart disease, atrial fibrillation, anxiety, depression, or dementia.
    • Any past history of stroke or TIA, bleeding disorder, miscarriage, or thromboembolic events suggesting inherited or acquired thrombophilia. See the CKS topics on Miscarriage and Platelets - abnormal counts and cancer for more information.
    • Recent trauma or surgery.
    • Family history of stroke (may indicate familial hyperlipidaemia or prothrombotic state). See the CKS topics on CVD risk assessment and management and Platelets - abnormal counts and cancer for more information.
    • Any medication such as anticoagulant or antiplatelet therapy, insulin, or antihypertensives.
  • Examine the person (if clinically appropriate):
    • Assess level of consciousness using the Glasgow Coma Scale.
    • Assess vital signs including blood pressure, heart rate and rhythm, pulse oximetry, and temperature.
    • Perform a focused neurological examination to assess for clinical signs of stroke or TIA, such as unilateral weakness, visual or speech disturbance, ataxia, and nystagmus. Use the Face Arm Speech Test (FAST) validated tool for rapid assessment (this also may be used by relatives/carers if using telephone assessment). Suspect stroke if one or more of the following are present:
      • New facial weakness (asymmetry such as the mouth or eye drooping).
      • Arm or leg weakness.
      • Speech disturbance (such as slurring or difficulty in finding names for commonplace objects).
    • Perform a cardiovascular examination to assess for murmurs, pulmonary oedema, other signs of heart failure, and arrhythmias (such as atrial fibrillation). See the CKS topics on Atrial fibrillation, Heart failure - chronic, and Palpitations for more information.
    • Assess for general signs of disorientation, trauma, coagulopathy, or other risk factors.
  • Perform appropriate investigations in primary care if immediately available and appropriate training, if this does not delay emergency hospital transfer:
    • Check finger-prick blood glucose to rule out hypoglycaemia (blood glucose less than 4.0 mmol/L).
    • An electrocardiogram (ECG) to exclude arrhythmias. See the CKS topic on Palpitations for more information.

Basis for recommendation

These recommendations are largely based on the National Institute for Health and Care Excellence (NICE) guidelines Stroke and transient ischaemic attack in over 16s: diagnosis and initial management [NICE, 2025] and Stroke rehabilitation in adults [NICE, 2023 Stroke rehabilitation in adults], the UK Intercollegiate Stroke Working Party publication National clinical guideline for stroke for the United Kingdom and Ireland [ICSWP, 2023], a European Academy of Neurology (EAN) and European Stroke Organisation (ESO) consensus statement on the pre-hospital management of stroke [Kobayashi, 2017], an ESO guideline on screening for subclinical atrial fibrillation (AF) [Rubiera, 2022], and expert opinion in a review article on ischaemic stroke [Hurford, 2020]. They are also pragmatic, based on what CKS considers to be good clinical practice.

Clinical features on history-taking

  • Taking a collateral history from witnesses or family members/carers can help provide valuable information about presenting symptoms and context to aid diagnosis, as well as the person's pre-stroke baseline level of physical functioning, mood, and cognitive function which may help guide the person's rehabilitation needs and subsequent prognosis [ICSWP, 2023]. The information that a brief telephone assessment may be sufficient is pragmatic, based on what CKS considers to be safe clinical practice. It is also supported by the EAN/ESO consensus statement on pre-hospital management, which notes that any reduction of delay between symptom onset and hospital arrival and adequate pre-hospital care of people with acute stroke are important for improving the chances of a favourable prognosis [Kobayashi, 2017].
  • The recommendation to ask about the time of onset of stroke symptoms and the person's pre-stroke functional status can help in specialist decision-making about treatment options such as thrombectomy and intravenous thrombolysis in acute ischaemic stroke, and decisions about surgical intervention in people with acute intracerebral haemorrhage [NICE, 2025].
  • The recommendations to ask about risk factors and comorbidities are based on the fact that the risk of recurrent vascular event will vary according to the person's comorbidities and lifestyle factors, for example [ICSWP, 2023].
  • Factors such as anticoagulant medication or history of haematological bleeding tendency may affect the choice of urgent brain imaging arranged in a hospital setting [NICE, 2025].

Clinical features on examination

  • The recommendation to assess consciousness level using a tool such as the Glasgow Coma Scale is extrapolated from the NICE guideline on stroke and transient ischaemic attack (TIA), which notes that a low score may affect the decision to offer medical and/or surgical intervention, depending on the balance of perceived risks and benefits, the person's pre-stroke functional status, and their wishes and preferences, for example [NICE, 2025].
  • The recommendation to assess vital signs is extrapolated from the ESO guideline on screening for atrial fibrillation (AF), which notes that identification of AF is critical as oral anticoagulation is highly effective for the prevention of ischaemic stroke recurrence. In addition, ischaemic strokes due to AF tend to be more severe compared with strokes due to other aetiologies [Rubiera, 2022]. This approach is supported by the ICSWP guideline [ICSWP, 2023].
  • The recommendation to use a validated tool such as the Face Arm Speech Test (FAST) is based on the NICE guideline on stroke and TIA [NICE, 2025] and the ICSWP guideline [ICSWP, 2023].
  • The recommendation to perform a cardiovascular examination is extrapolated from the ESO guideline on screening for AF [Rubiera, 2022]. It is also pragmatic, based on what CKS considers to be good clinical practice.
  • The NICE guideline on stroke rehabilitation recommends to assess for general signs of disorientation [NICE, 2023 Stroke rehabilitation in adults].

Investigations in primary care (if appropriate)

  • The recommendation to perform an electrocardiogram (ECG) if immediately available is extrapolated from the ESO guideline on screening for AF [Rubiera, 2022]. It is also pragmatic, based on what CKS considers to be good clinical practice.

What else might it be?

Alternative conditions which may present similarly to stroke or transient ischaemic attack (TIA) include:

Basis for recommendation

The information about differential diagnosis of stroke is based on the National Institute for Health and Care Excellence (NICE) guideline Stroke and transient ischaemic attack in over 16s: diagnosis and initial management [NICE, 2025], the UK Intercollegiate Stroke Working Party publication National clinical guideline for stroke for the United Kingdom and Ireland [ICSWP, 2023], the European Stroke Organisation (ESO) guideline on transient ischaemic attack (TIA) [Fonseca, 2021], and expert opinion in review articles [Fernandes, 2013; Yew, 2015; Hurford, 2020]. It is also pragmatic, based on what CKS considers to be good clinical practice.

  • The ESO guideline on transient ischaemic attack (TIA) notes that it is often difficult to distinguish TIA from other transient neurological attacks, and up to 60% of people with suspected TIA may have a 'mimic syndrome' [Fonseca, 2021].

Management

Scenario: Suspected acute stroke

From age 16 years onwards.

How should I manage a person with suspected acute stroke?

If a person has ongoing focal neurological deficit suggestive of acute stroke or transient ischaemic attack (TIA), manage as suspected stroke until the diagnosis is confirmed.

  • Arrange immediate emergency transfer to a hyperacute stroke centre if a person has suspected acute stroke or emergent TIA symptoms.
    • Be aware that a person may have ongoing focal neurological deficit despite a negative Face Arm Speech Test (FAST) assessment tool and should be managed as acute stroke if this is the case.
    • Monitor and manage any clinical deterioration (airway, breathing, and circulation) using clinical judgement. Give supplemental oxygen if the oxygen saturation level is less than 95% on air and there are no contraindications.
    • Ensure a pre-alert notification is given to the admitting stroke team — this should include details of time of onset, symptom evolution, clinical stability, comorbidities, and any medications (especially anticoagulants).
  • Do not start anticoagulation (for example in people with atrial fibrillation) or antiplatelet treatment in people following ischaemic stroke until intracerebral haemorrhage has been excluded with brain imaging.

Basis for recommendation

These recommendations are largely based on the National Institute for Health and Care Excellence (NICE) guideline Stroke and transient ischaemic attack in over 16s: diagnosis and initial management [NICE, 2025], the UK Intercollegiate Stroke Working Party publication National clinical guideline for stroke for the United Kingdom and Ireland [ICSWP, 2023], a European Academy of Neurology (EAN) and European Stroke Organisation (ESO) consensus statement on the pre-hospital management of stroke [Kobayashi, 2017], the (ESO) guideline on transient ischaemic attack (TIA) [Fonseca, 2021], the Sentinel Stroke National Audit Programme (SSNAP) publication State of the nation report 2025. Stroke care received between April 2024 to March 2025 [HQIP, 2025], and the NHS England document National Stroke Service Model. Integrated Stroke Delivery Networks [NHS England, 2021].

Arranging emergency transfer to a hyperacute stroke centre
  • The recommendation to manage a person with ongoing focal neurological deficit as suspected stroke is based on the fact that transient ischaemic attack (TIA) cannot be confidently diagnosed unless the symptoms have resolved within 24 hours [Fonseca, 2021].
  • The ICSWP guideline notes that 95% of people with acute stroke have their first symptoms outside a hospital setting. It states 'there is strong evidence that specialised stroke unit care initiated as soon as possible after the onset of stroke provides effective treatments that reduce long-term brain damage, disability and healthcare costs', and highlights the time-critical nature of interventions to improve outcomes. It cites evidence that people with stroke who receive organized inpatient care in a stroke unit are more likely to be alive, independent, and living at home one year after stroke. Stroke units should provide multidisciplinary care for diagnosis, hyperacute and acute treatments, early rehabilitation, prevention of complications, and secondary prevention measures. In particular, people with suspected stroke need immediate and timely access to brain imaging including CT or MR angiography and perfusion when necessary to maximize the potential benefit from revascularisation treatments and to identify acute intracerebral haemorrhage [ICSWP, 2023].
    • People with acute ischaemic stroke, regardless of age or stroke severity, should be considered for thrombolysis with alteplase or tenecteplase if it can be started within 4.5 hours of known onset. People who are more than 4.5 hours from acute ischaemic stroke onset, with unknown time of onset, or with 'wake-up' stroke may be considered for thrombolysis with alteplase if certain clinical criteria are met [ICSWP, 2023].
    • If a person has carotid artery stenosis and is a candidate for carotid intervention, carotid imaging with carotid duplex ultrasound or either CT angiography or MR angiography should be performed within 24 hours of assessmen [ICSWP, 2023].
  • Similarly, the NICE guideline on stroke and TIA outlines that acute stroke units provide access to specialist stroke multidisciplinary teams with equipment and expertise to monitor and provide rehabilitation for people with acute stroke [NICE, 2025].
  • The SSNAP report also reiterates that 'early admission to a stroke unit ensures that patients have the best possible opportunity for receiving timely interventions and key multidisciplinary assessments, such as the safe management of an unsafe swallow'. In addition, advances in reperfusion therapy have resulted in the need for time-critical access to multi-modal imaging such as CT angiography and CT perfusion. Furthermore, people presenting with intracerebral haemorrhage may need hyperacute interventions, including rapid blood pressure lowering and anticoagulant reversal [HQIP, 2025].
  • The ICSWP guideline notes that some people with symptoms of stroke will not be identified by the Face Arm Speech Test (FAST), such as people with sudden-onset visual disturbance, and/or lateralizing cerebellar dysfunction). In addition, rare causes of acute stroke such as cerebral venous thrombosis may present with headache, seizures, and sometimes bilateral neurological deficits [ICSWP, 2023].
  • The recommendation to monitor and manage any clinical deterioration and to correct hypoxia is based on the NICE guideline on stroke and TIA, which states that supplemental oxygen should be given if oxygen saturation levels fall to below 95% [NICE, 2025]. This is supported by very low-quality evidence in the EAN/ESO consensus statement on the pre-hospital management of stroke, which notes that hypoxia should be avoided as it may worsen ischaemic brain damage and patient outcomes [Kobayashi, 2017].
  • The recommendation to ensure hospital pre-arrival notification is extrapolated from the EAN/ESO consensus statement on the pre-hospital management of stroke, which found moderate-quality evidence to recommend that all emergency medical services implement a stroke protocol, including highest priority dispatch, pre-hospital notification, and rapid transfer to the closest ‘stroke-ready’ centre, to improve the prognosis of people with suspected stroke [Kobayashi, 2017]. This is supported by the NHS England document, which states that a pre-alert system is needed to communicate patient characteristics and ensure all people with suspected stroke are met by the stroke team on arrival [NHS England, 2021]. It is also pragmatic, based on what CKS considers to be good clinical practice.
Not starting anticoagulation or antiplatelet therapy until intracerebral haemorrhage excluded
  • This recommendation is extrapolated from the ICSWP guideline, which states that anticoagulation should not be given if brain imaging has identified significant intracerebral haemorrhage [ICSWP, 2023].

Scenario: Suspected transient ischaemic attack

From age 16 years onwards.

How should I manage a person with suspected TIA?

  • If a person has had a suspected transient ischaemic attack (TIA) within the last 7 days:
    • Offer aspirin 300 mg immediately unless contraindicated.
    • Offer a proton-pump inhibitor to anyone with dyspepsia associated with aspirin use. See the CKS topic on Antiplatelet treatment for more information.
      • If aspirin is contraindicated, liaise with a stroke specialist for advice.
      • If the person is already taking low-dose aspirin regularly, advise to continue this dose (do not offer aspirin 300 mg).
    • Arrange urgent referral to a TIA clinic for assessment within 24 hours by a stroke specialist clinician in a neurovascular clinic or an acute stroke unit.
      • If the person with suspected TIA has a known bleeding disorder or is taking an anticoagulant, arrange emergency admission for urgent CT head to exclude intracranial haemorrhage.
    • Do not use scoring systems, such as ABCD2, to assess risk of subsequent stroke or to inform the urgency of referral if there is suspected or confirmed TIA.
    • Be aware that a person may have ongoing focal neurological deficit despite a negative Face Arm Speech Test (FAST) assessment tool. If this is the case, manage the person for suspected acute stroke rather than TIA. See the section on Management of acute stroke for more information.
  • If a person has had a suspected TIA more than 7 days ago: 
    • Refer to a TIA clinic for specialist assessment as soon as possible within 7 days.
  • Advise the person and family members/carers about how to recognise stroke and TIA symptoms, and advise them to call 999 immediately if new symptoms occur suggesting acute stroke.
  • Advise the person not to drive until they have been seen by a stroke specialist (when definitive guidance should be given).

Basis for recommendation

These recommendations are largely based on the National Institute for Health and Care Excellence (NICE) guideline Stroke and transient ischaemic attack in over 16s: diagnosis and initial management [NICE, 2025], the UK Intercollegiate Stroke Working Party publication National clinical guideline for stroke for the United Kingdom and Ireland [ICSWP, 2023], the European Stroke Organisation (ESO) guideline on transient ischaemic attack (TIA) [Fonseca, 2021], and the Driver and Vehicle Licensing Agency (DVLA) publication Assessing fitness to drive: a guide for medical professionals [DVLA, 2025].

Managing suspected TIA within the last 7 days
  • The recommendation to offer aspirin 300 mg immediately unless contraindicated is based on the NICE guideline on stroke and TIA committee's knowledge and experience, together with indirect evidence from studies. These found benefit of aspirin in the early management of confirmed TIA or 'minor stroke' to reduce the risk of stroke or recurrent stroke in secondary care. The guideline states that the earlier aspirin is given, the better patient outcomes are for people with TIA, with an associated low risk of complications such as gastrointestinal or other haemorrhage [NICE, 2025]. Similarly, the ESO guideline on TIA states that 'the benefits of antiplatelet therapy are greatest (in both relative and absolute terms) within the first 24 hours following a TIA'. It recommends that in people with suspected TIA, antiplatelet monotherapy should be started before brain imaging if a wait of more than 24 hours to planned imaging is expected, and a delay is judged to increase the risk of further ischaemic events, above the risk of starting antiplatelet medication, compared to not starting antiplatelet monotherapy [Fonseca, 2021].
  • The recommendation to seek specialist advice if aspirin is contraindicated is pragmatic, based on what CKS considers to be good clinical practice.
  • The NICE guideline does not make a specific recommendation for people already taking low-dose aspirin, and there is a lack of evidence in the literature on the effectiveness of increasing the aspirin dose in this clinical scenario. The recommendation to continue low-dose antiplatelet therapy is therefore pragmatic, based on what CKS considers to be good clinical practice. It is also in line with expert opinion from previous external reviewers of this CKS topic.
  • The recommendation to arrange immediate referral if a person has had a suspected TIA for specialist assessment and investigation, to be seen within 24 hours of symptom onset, is based on the NICE guideline on stroke and TIA [NICE, 2025]. This approach is supported by the ICSWP guideline [ICSWP, 2023] and the ESO guideline, which stresses that timely assessment and treatment of people with suspected TIA can help prevent subsequent stroke and impact prognosis [Fonseca, 2021].
  • The NICE guideline on stroke and TIA states that MRI brain imaging may be arranged following assessment in the TIA clinic, to determine the territory of ischaemia or to detect haemorrhage or other pathology causing symptoms. In addition, urgent carotid imaging is needed for any person who is felt to be a candidate for carotid endarterectomy, following specialist assessment [NICE, 2025].
  • The ICSWP guideline notes that people with suspected TIA are at substantial risk of further vascular events and stroke in the first few days, and therefore need urgent specialist assessment. It states that any person with fully resolved acute-onset neurological deficit that might be due to stroke disease needs urgent specialist assessment, to establish the diagnosis and to determine whether the cause is vascular, as about 50% of cases have an alternative diagnosis. It recommends MRI brain imaging first-line to detect the presence and/or distribution of brain ischaemia if this is suspected. Brain imaging may help reduce diagnostic uncertainty, and confirm the territory of ischaemia before making a decision about carotid artery surgery or before commencing dual antiplatelet therapy (DAPT) [ICSWP, 2023].
  • The recommendation to arrange emergency admission for an urgent unenhanced CT head to exclude intracranial haemorrhage if a person has a bleeding disorder or is taking an anticoagulant is extrapolated from the ICSWP guideline [ICSWP, 2023].
  • The recommendation not to use risk predictive scoring tools is based on the ICSWP guideline, which notes that people with suspected TIA are at high risk of stroke within the first 7 days, and need a full diagnostic assessment urgently without further risk stratification. It cites study evidence that risk predictive scoring tools such as ABCD2, ABCD2-I, and ABCD3-I did not discriminate sufficiently between low- and high-risk patients in both short-term and long-term follow-up, for determining the urgency of assessment or subsequent treatment options, and they are no longer recommended [ICSWP, 2023]. This approach is supported by the NICE guideline on stroke and TIA, which found evidence that risk prediction scores such as ABCD2 and ABCD3 used in isolation are poor at discriminating low and high risk of stroke after TIA. It concluded that 'arranging specialist assessment less urgently for some people based on a tool with poor discriminative ability for stroke risk has the potential for harm', and therefore recommends that risk scores are not used in this context. Instead, all cases of suspected TIA should be considered as potentially high-risk for stroke and be referred for urgent specialist assessment, to allow rapid initiation of secondary prevention treatments if a diagnosis of TIA is confirmed [NICE, 2025].
  • The ESO guideline on TIA also recommends against using risk prediction tools such as the ABCD2 score alone to identify high-risk TIA patients, due to their low sensitivity and low specificity for identifying 7-day stroke risk following TIA [Fonseca, 2021].
  • The ICSWP guideline notes that some people with symptoms of stroke will not be identified by the Face Arm Speech Test (FAST), such as people with sudden-onset visual disturbance, and/or lateralizing cerebellar dysfunction). In addition, rare causes of acute stroke such as cerebral venous thrombosis may present with headache, seizures, and sometimes bilateral neurological deficits [ICSWP, 2023].
Manging suspected TIA more than 7 days ago
  • This recommendation is based on the ICSWP guideline, which states that people presenting with suspected TIA symptoms more 7 days previously can be considered at lower risk of stroke and therefore do not need specialist assessment within 24 hours [ICSWP, 2023].
Advising when to call 999 if suspected acute stroke
  • This recommendations are based on the ICSWP guideline [ICSWP, 2023]. They are also pragmatic, based on what CKS considers to be good clinical practice.
Advising not to drive until seen by stroke specialist
  • This recommendation is extrapolated from the DVLA publication on medical fitness to drive, which states that following TIA the person must not drive for one month [DVLA, 2025]. It is supported by the ICSWP guideline [ICSWP, 2023].

Scenario: Follow-up in primary care

From age 16 years onwards.

How should I follow up a person with stroke or TIA in primary care?

If a person has had a confirmed stroke or transient ischaemic attack (TIA) following specialist stroke clinician assessment, arrange follow-up in primary care on hospital discharge, at 6 months, and then at least annually, depending on the person's needs and clinical judgement.

  • Review any health and social care unmet needs of the person and family members/carers at least 6-monthly, such as ability to wash, dress, toilet, eat/drink, and communicate; carer training and support to reduce carer stress; the person's adjustment to stroke and how they are coping; housing including safety and risk management; participation in daily and community activities; and access to transport and benefits, for example.
    • A person with stroke should be supported to develop their own self-management plan, based on their individual needs, goals, preferences, and circumstances.
  • Advise the person and family members/carers about sources of information and support about stroke, TIA, and vascular risk factors, taking into account any cognitive or communication issues, such as:
    • The Stroke Association (website www.stroke.org.uk) provides patient information including local support groups and stroke services, life after stroke, healthy lifestyle, the effects of stroke, and sources of carer support.
    • The UK charity Different strokes (website www.differentstrokes.co.uk) provides peer support for working age stroke survivors and their families, and provides various information booklets covering topics such as physical impact of stroke; spasticity; cognitive, emotional and social impact of stroke; fatigue; sex and relationships; advocacy and rights after stroke.
  • Advise about driving restrictions and the person’s responsibility to notify the Driver and Vehicle Licensing Agency (DVLA) after a stroke or TIA.
    • The DVLA publication Assessing fitness to drive: a guide for medical professionals has detailed information about driving restrictions and when to notify the DVLA.
    • If a person has persisting cognitive, language, or motor function impairment after stroke and wishes to return to driving, offer referral for an on-road screening and evaluation.
    • If a person is safe to drive after stroke, provide information about eligibility for disability concessions, such as the 'Blue Badge scheme', if clinically appropriate.
  • Provide advice about returning to work (including paid employment, vocational training, voluntary work, and adult education) if needed, such as financial support, opportunities for vocational rehabilitation (if available), assessment by an Occupational Health team, and/or statutory employment support, if appropriate.
    • Workplace interventions may include vocational counselling and coaching; emotional support; adaptation of the working environment, work patterns and tasks; strategies to compensate for functional limitations (such as communication, cognition and memory problems, mobility and arm function); and anxiety and fatigue management.
  • Review any modifiable risk factors for stroke or TIA, and advise about lifestyle modification to reduce cardiovascular risk. See the CKS topic on CVD risk assessment and management for more information.
    • Encourage regular physical activity and engagement with any stroke rehabilitation team individualized exercise programme, if offered. See the section on Management of stroke complications for more information.
    • Advise smokers to stop smoking and non-smokers to avoid passive smoking. See the CKS topic on Smoking cessation for more information.
    • Advise the person to eat a healthy balanced diet to reduce cardiovascular disease (CVD) risk and maintain a healthy weight. See the CKS topic on Obesity for more information.
    • Advise people who drink alcohol to drink within recommended limits. See the CKS topic on Alcohol - problem drinking for more information.
  • Screen for and manage any comorbidities, such as new-onset atrial fibrillation (AF), diabetes mellitus, heart failure, obesity, obstructive sleep apnoea, falls, and sickle cell disease. See the CKS topics on Atrial fibrillation, Diabetes - type 1, Diabetes - type 2, Falls - assessment, Heart failure - chronic, Obesity, Obstructive sleep apnoea syndrome, and Sickle cell disease.
  • Review the person's medication for secondary prevention of CVD, including rationale, how and when to take it, common adverse effects, and the need for any medication compliance aids. Be aware that medications for secondary prevention should be started by the specialist stroke team at diagnosis.
    • If there is a diagnosis of ischaemic stroke or TIA without paroxysmal or permanent AF, prescribe antiplatelet therapy.
      • Dual antiplatelet therapy (DAPT) with either aspirin 75 mg once daily (for 21 days) plus clopidogrel 75 mg once daily ongoing, or aspirin 75 mg once daily (for 30 days) plus ticagrelor 90 mg twice daily followed by ticagrelor 90 mg twice daily ongoing or clopidogrel 75 mg once daily ongoing, may be started by the stroke team if a person presents within 24 hours of onset of TIA or minor ischaemic stroke.
      • For other people, clopidogrel 75 mg once daily (or aspirin 75 mg once daily if clopidogrel is not tolerated) may be recommended by the stroke team.
      • A person with haemorrhagic transformation following ischaemic stroke may be started on long-term antiplatelet therapy by a stroke specialist if the potential benefits outweigh the risks.
      • See the CKS topic on Antiplatelet treatment for detailed prescribing information including contraindications and cautions, adverse effects, and potential drug interactions.
    • If there is a diagnosis of ischaemic stroke or TIA, prescribe high-intensity lipid-lowering therapy with atorvastatin 80 mg daily unless contraindicated.
      • Consider prescribing a lower statin dose or alternative statin therapy at the maximum tolerated dose if there is a potential drug interaction, adverse effects, or if the person prefers this.
      • Note: if there is a history of intracerebral haemorrhage, assess the need for lipid-lowering therapy based on the person's overall cardiovascular risk and the underlying cause of haemorrhage. Seek specialist advice if needed.
      • See the CKS topic on Lipid modification - CVD prevention for detailed information on assessing response to treatment, treatment targets for secondary prevention, adverse effects and managing statin intolerance, contraindications and cautions, potential drug interactions, and treatment optimization strategies (such as increasing the statin dose or adding in other lipid-lowering therapy such as ezetimibe).
    • If there is a diagnosis of stroke or TIA, prescribe antihypertensive drug treatment if clinically indicated.
      • Aim to lower blood pressure to a target of less than 130/80 mm Hg in most people after ischaemic stroke or TIA, unless the potential risks outweigh benefits.
      • Treatment options include a thiazide-like diuretic, long-acting calcium-channel blocker, angiotensin-converting enzyme inhibitor, or angiotensin-II receptor blocker. See the CKS topic on Hypertension for detailed information on management, blood pressure targets, and prescribing information for different antihypertensive drugs.
      • Seek specialist advice from a stroke specialist if the person's blood pressure remains above target despite optimal drug treatment in primary care.
    • If there is a diagnosis of non-disabling ischaemic stroke or TIA, prescribe an anticoagulant if there is concomitant paroxysmal, persistent, or permanent AF or atrial flutter, intracardiac thrombus, or valvular heart disease, once intracerebral haemorrhage and other contraindications, such as uncontrolled hypertension, have been excluded. The choice of anticoagulant drug should be made by a stroke specialist. See the CKS topic on Atrial fibrillation for more information.
      • A person with TIA should start anticoagulant treatment immediately on diagnosis once imaging has excluded intracerebral haemorrhage.
      • A person with ischaemic stroke and AF or atrial flutter should start anticoagulation treatment within 14 days of stroke onset, the exact timing as recommended by a stroke specialist.
      • Prescribe a direct oral anticoagulant (DOAC) first-line for people with ischaemic stroke or TIA due to non-valvular AF. Prescribe adjusted-dose warfarin for people with valvular AF, a mechanical heart valve replacement, or contraindications or intolerance to DOAC treatment. See the CKS topic on Anticoagulation - oral for more detailed prescribing information including contraindications and cautions, adverse effects, potential drug interactions, and drug monitoring information.
      • Do not prescribe anticoagulation for people with stroke or TIA who are in sinus rhythm unless there are other indications, such as a cardiac source of embolism, cerebral venous thrombosis, or arterial dissection, as directed by a specialist.
      • Do not prescribe antiplatelet treatment as an alternative to anticoagulation in people with ischaemic stroke and a contraindication to anticoagulation, such as undiagnosed bleeding.
  • Screen for any long-term stroke complications, and offer management and/or onward referral to the community stroke rehabilitation team depending on clinical judgement. See the section on Management of stroke complications for more information.
  • Advise about safe contraception and/or hormone replacement therapy (HRT) options, if needed.
    • Do not offer pre- or perimenopausal women with a diagnosis of stroke or TIA combined hormonal contraception. Offer progestogen-only and non-hormonal contraception instead. See the CKS topic on Contraception - assessment for more information.
    • Advise perimenopausal and post-menopausal women with ischaemic stroke or TIA who wish to start or continue taking HRT about the relative risks and benefits of treatment. See the CKS topic on Menopause for more information.
  • Offer COVID-19 and influenza vaccinations in line with the national immunization programme. See the CKS topics on Coronavirus - COVID-19 and Immunizations - seasonal influenza for more information.

Basis for recommendation

These recommendations are based on the National Institute for Health and Care Excellence (NICE) guidelines Stroke and transient ischaemic attack in over 16s: diagnosis and initial management [NICE, 2025], Stroke rehabilitation in adults [NICE, 2023 Stroke rehabilitation in adults], Cardiovascular disease: risk assessment and reduction, including lipid modification [NICE, 2023b], and Hypertension in adults: diagnosis and management [NICE, 2026]; the UK Intercollegiate Stroke Working Party publication National clinical guideline for stroke for the United Kingdom and Ireland [ICSWP, 2023], a EAN/ERS/ESO/ESRS joint consensus statement on sleep disorders [Bassetti, 2020], various European Stroke Organisation (ESO) guidelines on transient ischaemic attack (TIA) [Fonseca, 2021], on blood pressure management after stroke [Sandset, 2021], on secondary prevention drug treatment after stroke [Dawson, 2022], on antithrombotic treatment in non-valvular atrial fibrillation (AF) [Klijn, 2019], and on stroke in women [Kremer, 2022]; the Sentinel Stroke National Audit Programme (SSNAP) publication State of the nation report 2025. Stroke care received between April 2024 to March 2025 [HQIP, 2025], the College of Sexual and Reproductive Healthcare (CoSRH) publication UK Medical Eligibility Criteria for Contraceptive Use (UKMEC) 2025   [CoSRH, 2025], the UK Health Security Agency (HSA) publication Immunisation against infectious disease [UKHSA, 2025], and the Driver and Vehicle Licensing Agency (DVLA) publication Assessing fitness to drive: a guide for medical professionals [DVLA, 2025].

Arranging regular follow-up in primary care
  • These recommendations are based on the NICE guideline on stroke rehabilitation, the ICSWP guideline [ICSWP, 2023], and the SSNAP publication [HQIP, 2025]. They are also pragmatic, based on what CKS considers to be good clinical practice.
Reviewing any health and social care needs
  • These recommendations are extrapolated from the NICE guideline on stroke rehabilitation, which highlights the importance of ensuring a person with stroke has a safe and enabling home environment, including provision of necessary equipment and adaptations, and that carers have the support they need to allow a person with stroke to live and self-care as independently as possible [NICE, 2023 Stroke rehabilitation in adults].
  • The SSNAP report highlights that patient outcome measures record significant levels of physical and psychological morbidity at 6 months which need to be identified as an ongoing need, in order to provide appropriate support to promote recovery and rehabilitation [HQIP, 2025]. 
    • The information about stroke self-management plans is based on the ICSWP guideline [ICSWP, 2023].
Advising about sources of information and support
  • The ICSWP guideline highlights that patient organisations and support groups may offer a valuable source of social, emotional, and psychological support for a person after stroke or transient ischaemic attack (TIA) and their family members/carers. A person's needs are likely to evolve and change over time. Overall, engagement in community activity is associated with improved quality of life, and should be encouraged and facilitated wherever possible [ICSWP, 2023].
  • The NICE guideline on stroke rehabilitation also stresses the importance of information for the person with stroke and family members/carers, including the voluntary sector and stroke support groups. In particular, it highlights the need to take into account any specific issues such as aphasia and other communication and/or cognitive impairments. Information provision should be paced to allow time for the person to make emotional adjustments [NICE, 2023 Stroke rehabilitation in adults].
Advising about driving restrictions
  • These recommendations are based on the DVLA publication about medical fitness to drive [DVLA, 2025], the The NICE guideline on stroke rehabilitation [NICE, 2023 Stroke rehabilitation in adults].
  • The ICSWP guideline recommends offering referral for an on-road screening and evaluation, and advises about eligibility for disability concessions in certain clinical scenarios. It highlights the importance of driving for some people for practical reasons and maintaining independence, as well as the potential positive impact of driving on self-esteem and mood [ICSWP, 2023].
Advising about returning to work
  • The ICSWP guideline highlights that not being in work after stroke is associated with health risks, reduced quality of life, and poorer psychosocial outcomes. The potential benefits of returning to work include improvements in quality of life, better perceived general health, reduced pain and depression, and higher perceived participation and autonomy compared to those not returning to work. It notes a lack of evidence to inform recommendations on returning to work after a stroke [ICSWP, 2023].
  • The NICE guideline on stroke rehabilitation stresses the importance of identifying any physical, cognitive, communication, and psychological demands of the person's job including multi-tasking, identifying any problems that may affect work performance, and ensuring reasonable adjustments such as provision of equipment and phased return to work are arranged if needed [NICE, 2023 Stroke rehabilitation in adults].
Advising about lifestyle modification
  • The recommendations about lifestyle modification are extrapolated from the ICSWP guideline, which notes a lack of high quality research evidence for specific lifestyle interventions in the secondary prevention of stroke and TIA. Available evidence on lifestyle interventions relates mainly to primary prevention of vascular events [ICSWP, 2023].
    • The recommendations about physical activity are based on the fact that people with stroke are at risk of physical deconditioning, with low cardiorespiratory fitness, muscle strength and power, which can impact functional activity and independence [ICSWP, 2023]. The NICE guideline on stroke rehabilitation recommends cardiorespiratory and resistance training for people who can walk and are medically stable after stroke [NICE, 2023 Stroke rehabilitation in adults].
    • The recommendation about smoking is based on the ICSWP guideline [ICSWP, 2023].
    • The recommendation about maintaining a healthy weight is based on the fact that overweight and obesity is a significant risk factor for the development of cardiovascular disease and ischaemic stroke, and is associated with an increase in all-cause mortality [ICSWP, 2023].
    • The recommendation about alcohol intake is based on limited study evidence showing that low alcohol intake (below 15 g/day) is associated with a reduced risk of total stroke, ischaemic stroke, and stroke mortality with no significant effect on haemorrhagic stroke [ICSWP, 2023].
Managing any comorbidities
  • The ICSWP guideline recommends that pulse rhythm is checked at each clinical contact to help detect non-symptomatic atrial fibrillation (AF), which is a risk factor for recurrent stroke and other vascular events. It also recommends screening for obstructive sleep apnoea (OSA) and optimally managing any coexisting ischaemic heart disease, hypertension, and diabetes mellitus, to reduce the risk of future vascular events [ICSWP, 2023].
  • The ESO guideline on secondary prevention drug treatment recommends aiming for an HbA1c level of less than 53mmol/mol in people with diabetes mellitus, to reduce the risk of microvascular and macrovascular complications. It notes that this target may need to be individualized based on the person's duration of diabetes, age, and other comorbidities [Dawson, 2022].
  • The EAN/ERS/ESO/ESRS joint consensus statement on sleep disorders states that continuous positive airway pressure (CPAP) treatment may reduce stroke risk in people with confirmed OSA [Bassetti, 2020].
Reviewing secondary prevention medications
  • The ICSWP guideline notes that the greatest risk of a vascular event is early after stroke or TIA, and therefore secondary prevention measures to reduce the risk of recurrence should be started as soon as possible after the initial event. It notes that risk of recurrent events will vary according to the underlying pathology, comorbidities, and lifestyle factors. It highlights that medications for secondary prevention should be started by a stroke specialist at diagnosis. It also states that the need for medication compliance aids should be assessed for each person, depending on their level of manual dexterity, cognitive impairment, personal preference, and any safety issues in the home environment [ICSWP, 2023].
  • The NICE guideline on stroke and TIA also recommends to offer secondary prevention, in addition to aspirin, as soon as possible after a diagnosis of TIA is confirmed [NICE, 2025].
Prescribing antiplatelet therapy
  • The ICSWP guideline states that antiplatelet therapy is one of the most important interventions for reducing the risk of recurrent vascular events including stroke. It cites evidence which supports the early use of dual antiplatelet therapy (DAPT) in people with TIA or minor ischaemic stroke as it has resulted in a significant reduction in ischaemic stroke, with no increased incidence of haemorrhagic stroke, in some studies. It provides recommendations on specific antiplatelet drug combinations and the optimal duration of treatment with DAPT [ICSWP, 2023].
  • The NICE guideline on stroke and TIA recommends to continue aspirin 300 mg daily until two weeks after the onset of stroke symptoms, at which time long-term antithrombotic treatment should be started. Long-term treatment may be started earlier by a stroke specialist if a person is being discharged from hospital before two weeks [NICE, 2025].
  • The ESO guideline on TIA recommends use of DAPT with aspirin and clopidogrel short-term in high-risk non-cardioembolic patients with TIA. It cites high-quality study evidence that short-term DAPT can reduce the risk of stroke recurrence compared with antiplatelet monotherapy, but found no net benefit from continuing DAPT beyond three weeks. It concluded that about 50 people with high-risk TIA need to be treated with aspirin and clopidogrel for three weeks instead of monotherapy to avoid one stroke, and in about 500 people treated with DAPT there will be one case of moderate-to-severe extracranial bleed [Fonseca, 2021].
  • The ESO guideline on secondary prevention drug treatment cites moderate-quality evidence supporting the use of longterm antiplatelet therapy to reduce the risk of recurrent stroke [Dawson, 2022].
Prescribing lipid-lowering therapy
  • Raised lipid levels, especially hypercholesterolaemia, are an important modifiable risk factor for cardiovascular events including stroke and myocardial infarction. The benefit of lipid-lowering therapy with statins to reduce cardiovascular events and mortality has been confirmed in trial evidence, both for people with cardiovascular disease and stroke disease [ICSWP, 2023]. This approach is supported by the ESO guideline on secondary prevention drugs, which found high-quality evidence supporting the use of statins to reduce the risk of recurrent ischaemic stroke and major cardiovascular events in people with previous ischaemic stroke or TIA [Dawson, 2022].
  • The recommendation if there is a history of intracerebral haemorrhage is based on the ICSWP guideline [ICSWP, 2023]. It is also pragmatic, based on what CKS considers to be good clinical practice.
  • The ICSWP guideline recommends to aim to reduce fasting LDL-cholesterol to below 1.8 mmol/L (equivalent to a non-HDL-cholesterol below 2.5 mmol/L in a non-fasting sample) in people with a history of ischaemia stroke or TIA, to reduce the risk of major cardiovascular events [ICSWP, 2023]. This approach is supported by moderate-quality evidence in the ESO guideline on secondary prevention drug treatment [Dawson, 2022]. CKS notes that these lipid treatment targets for secondary prevention of stroke are tighter than those recommended in the NICE guideline on cardiovascular disease and lipid modification, which recommends to aim for LDL-cholesterol levels of 2.0 mmol/L or less, or non-HDL-cholesterol levels of 2.6 mmol/L or less [NICE, 2023b].
  • The recommendation to consider adding ezetimibe to statin lipid-lowering therapy if clinically indicated is based on the ICSWP guideline [ICSWP, 2023]. Similarly, the ESO guideline on secondary prevention drug treatment found indirect evidence supporting an expert consensus recommendation for add-on therapy with ezetimibe to reduce the risk of recurrent stroke in people who do not achieve the recommended LDL-cholesterol targets despite taking a maximally tolerated dose of a statin for at least six weeks [Dawson, 2022].
Prescribing antihypertensive treatment
  • The ICSWP guideline cites high-quality study evidence that blood pressure reduction after stroke or TIA prevents further vascular events including recurrent ischaemic and haemorrhagic stroke. It recommends that antihypertensive medication should generally be started before transfer of care out of hospital or at 2 weeks, whichever is sooner. It states that blood pressure targets for people with stroke or TIA are the same as for people without a history of CVD, aiming for a clinic systolic blood pressure below 130 mmHg, with the exception of people with severe bilateral carotid artery stenosis, where a systolic blood pressure of 140–150 mmHg is acceptable [ICSWP, 2023]. The ESO guideline on secondary prevention drug treatment also cites moderate-quality evidence to recommend a blood pressure lowering target of less than 130/80 mmHg in people with ischaemic stroke and TIA to reduce the longterm risk of recurrent stroke, except in subgroups of people at increased risk of harm such as those with severe bilateral carotid artery stenosis, older age, cognitive impairment, or pre-existing kidney disease, where risks such as worsening kidney function or hypotension need to be balanced against potential benefits of intensive blood pressure lowering [Dawson, 2022]. CKS notes that these blood pressure treatment targets are tighter than those recommended in the NICE guideline on hypertension, which recommends to aim for a clinic blood pressure below 140/90 mmHg for people aged under 80 years [NICE, 2026].
  • People 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, aiming to achieve a systolic BP of 130–139 mmHg within one hour and sustained for at least 7 days [ICSWP, 2023]. The ESO guideline on blood pressure management similarly recommend that people with hyperacute intracerebral haemorrhage have systolic blood pressure lowered to 110–140 mmHg to reduce the risk of haematoma expansion. This guideline notes that optimal blood pressure management in acute ischaemic stroke and acute intracerebral haemorrhage remains controversial, but is vital to reduce the risk of stroke recurrence, cerebral oedema, reperfusion haemorrhage after reperfusion therapies for acute ischaemic stroke, to reduce haematoma expansion and cerebral oedema in intracranial haemorrhage, and to avoid impairment of cerebral perfusion [Sandset, 2021].
Prescribing anticoagulant therapy
  • The ICSWP guideline notes that direct oral anticoagulants (DOACs) are largely replacing vitamin K antagonists such as warfarin for secondary stroke prevention in people with non-valvular AF. DOACs have the advantage of a rapid onset of action, fewer potential drug interactions, do not need regular blood monitoring, are more user-friendly, and have a reduced risk of intracranial haemorrhage compared with warfarin in studies [ICSWP, 2023]. Similarly, the ESO guideline on antithrombotic treatment for non-valvular AF states that 'in patients with atrial fibrillation and previous stroke or transient ischemic attack, oral anticoagulants reduce the risk of recurrence over antiplatelets or no antithrombotic treatment. Non-vitamin K antagonist oral anticoagulants are preferred over vitamin K antagonists because they have a lower risk of major bleeding and death'. It found a lack of strong evidence to provide recommendations about the management of specific patient subgroups such as older people, those with cognitive impairment, kidney disease, or small vessel disease [Klijn, 2019].
  • The ICSWP guideline states that people with ischaemic stroke and AF or flutter should be considered for anticoagulation within 5 days of onset for mild stroke, and may be considered for anticoagulation from 5–14 days of onset for moderate-to-severe stroke. It cites strong evidence for the use of anticoagulation for long-term secondary prevention of stroke in people with permanent AF. It states that anticoagulant treatment is not more effective than antiplatelet therapy in people with non-cardioembolic ischaemic stroke or TIA and anticoagulation carries a greater risk of bleeding. It notes potential strategies available to reduce the bleeding risk in some people, such as optimizing blood pressure control, reviewing medications and improving medication adherence, managing comorbidities, and reducing falls risk [ICSWP, 2023]. Similarly, the NICE guideline on stroke and TIA recommends that anticoagulation treatment is not used routinely for the treatment of acute ischaemic stroke [NICE, 2025].
  • The recommendation not to prescribe anticoagulation for people in sinus rhythm unless there are other indications is extrapolated from the ICSWP guideline [ICSWP, 2023] and the NICE guideline on stroke and TIA [NICE, 2025].
  • The recommendation not to prescribe antiplatelet therapy as an alternative to anticoagulation in people with contraindications is based on the ICSWP guideline [ICSWP, 2023].
Advising about contraception and HRT
  • The recommendations about use of combined hormonal contraception and hormone replacement therapy (HRT) are extrapolated from expert consensus opinion in the ICSWP guideline. It cites limited study evidence that oestrogen increases the risk of cardiovascular events including ischaemic stroke both when used by younger women as the combined oral contraceptive (COC) and by post-menopausal women as HRT [ICSWP, 2023].
    • The information if a woman has a stroke while using different contraception methods is based on the CoSRH publication on medical eligibility criteria for contraceptive use [CoSRH, 2025].
  • The ESO guideline on stroke in women notes that pregnancy, postpartum, and menopause are key time periods in a woman's life when they are more vulnerable to ischaemic events. It notes conflicting evidence in the literature regarding stroke risk and hormone replacement therapy (HRT) during menopause, but found that prior HRT has no impact on mortality in postmenopausal women with an acute stroke [Kremer, 2022].
Offering COVID-19 and influenza vaccinations
  • These recommendations are based on the UK HSA publication on immunisation against infectious disease [UKHSA, 2025].

Scenario: Management of stroke complications

From age 16 years onwards.

How should I manage long-term complications of stroke in primary care?

If a person with stroke has longterm complications following hospital discharge, arrange review in primary care.

  • Arrange referral or support self-referral to the multidisciplinary community stroke rehabilitation team if they have ongoing rehabilitation needs that cannot be fully managed in primary care.
    • Ensure the person and family members/carers have a named contact who is responsible for co-ordinating care and providing information and advice following hospital discharge.
    • The duration and intensity of any rehabilitation intervention should be based on the person's self-management plan and their clinical needs, goals, and preferences.
    • If there is any uncertainty about the management of stroke complications or the person has complex or atypical health and/or social care needs, seek advice or arrange referral to a stroke specialist and/or community stroke rehabilitation team.
  • Offer assessment and management of potential complications after stroke, depending on clinical judgement and the person's wishes and preferences.
    • Swallowing, nutrition, and hydration
      • Monitor the person's dietary intake, hydration and fluid balance, and nutritional status.
      • People with swallowing difficulties after acute stroke should only be given food, fluids, and medications in a form that can be swallowed without aspiration. Review the need for medication, its formulation, and route of administration if a person is unable to swallow medication.
      • Refer to a dietician and/or speech and language therapist (SLT) for a swallow and nutritional assessment if a person's oral intake of nutrition and fluids is inadequate, or food or fluid consistency needs modification to optimize nutrition and hydration and reduce the risks of aspiration and choking. See the CKS topic on Adult malnutrition for more information.
      • Ensure that people who have difficulty self-feeding after stroke have access to appropriate equipment and assistance to facilitate independent and safe feeding.
      • Ensure that family members/carers know what to do if a person has difficulties while eating and drinking, including coughing and choking.
    • Communication  
      • Assess the person's communication, including their ability to understand and follow instructions, and to express their needs and wishes.
      • If the person has aphasia or unclear or unintelligible speech after stroke, offer re-referral to SLT if not already under their care, for ongoing assessment, treatment, and provision of communication aids and other supportive technologies, if needed.
      • Advise family members and/or carers about the use of communication skills for people with aphasia after stroke (such as slowing down, not interrupting the person, and using communication props, gestures, or drawings).
    • Oral health 
      • Aim to maintain the health of the mouth, teeth, gums, cheeks, and palate. Advise that mouth care, including brushing teeth and cleaning gums using mouthwash and/or oral gels with antibacterial or antifungal properties should be performed at least twice a day.
      • Advise people who have dentures to clean them regularly and have regular dental check-ups and replacement dentures if they are ill-fitting, damaged, or lost.
      • Ensure that a suitably trained healthcare professional, family member, or carer provides or supervises mouth care for people after stroke who cannot, or find it difficult to, follow a mouth care regimen.
    • Motor skills and function
      • Arrange referral to physiotherapy if a person has muscle weakness, sensory disturbance, and/or balance problems after stroke that affect movement, for cardiorespiratory and resistance training, and group-based physical exercise, if available and clinically appropriate. Mobility or walking aids and postural equipment to help with seating may be helpful if there are issues with standing balance or confidence.
      • Arrange referral to an occupational therapist with experience in neurological disability if a person has limitations of activities of daily living after stroke, for consideration of adaptations and equipment.
      • Arrange referral to orthotics if there are issues with ankle dorsiflexion or instability causing balance problems and falls risk, for consideration of ankle or foot orthoses, and for consideration of hand and wrist splints if there are issues with hand weakness or high tone.
      • Consider arranging referral for a falls risk assessment and/or vestibular rehabilitation if there are balance problems and/or risk of falls. See the CKS topic on Falls - assessment for more information.
    • Spasticity and contractures
      • Advise on measures to reduce spasticity such as adapting positioning, passive and active movement and stretching, and/or pain control to improve symptoms and reduce the risk of pressure areas. See the CKS topic on Pressure ulcers for more information.
      • Arrange referral to orthotics for consideration of hand and wrist splints if there are issues with hand weakness or high tone.
      • Consider arranging referral to the community stroke rehabilitation team or specialist spasticity service if there are ongoing symptoms, depending on local service provision and referral pathways.
    • Hearing
      • Refer people with hearing difficulties after stroke for an audiology assessment.
    • Vision
      • Refer people with vision problems after stroke to an orthoptist, ophthalmologist, optometrist, and/or low vision service for further assessment and provision of vision aids, depending on the person's needs and clinical judgement.
      • If there are vision problems after stroke, offer referral  to an occupational therapist to assess its impact on the person's ability to carry out functional tasks independently, their self-confidence, and safety.
    • Continence
      • Advise that management options for continence issues depend on the underlying cause and may include timed toileting, prompted voiding, review of caffeine intake, bladder retraining, pelvic floor exercises, and in some cases drug treatment(s).
      • Do not insert an indwelling urethral catheter unless indicated for relief of urinary retention or if monitoring of fluid balance is critical.
      • If there is associated constipation or urinary tract infection, see the CKS topics on Constipation, Urinary tract infection (lower) - men, and Urinary tract infection (lower) - women for more information.
      • Offer referral to the local continence service for further assessment and provision of continence aids, if clinically appropriate.
    • Sexual function 
      • Assess for reversible causes of sexual dysfunction (including medication adverse effects), and reassure the person that sexual activity is not contraindicated and is very unlikely to precipitate a further stroke. Offer referral for psychosexual counselling if clinically indicated.
      • If a man reports erectile dysfunction, discuss available treatment options. Advise that phosphodiesterase type-5 inhibitors should not be used for three months after stroke (and blood pressure must be controlled). See the CKS topic on Erectile dysfunction for more information on management options including drug treatments.
    • Cognition
      • Refer people with suspected cognitive impairment for neuropsychological assessment, depending on clinical judgement. See the CKS topics on Delirium and Dementia for more information.
      • Offer information about compensatory techniques if a person has memory problems, such as use of electronic reminders, medication compliance aids and alarms, diaries, calendars, lists, or use of goal-setting if there is impairment of executive function.
      • Ensure that decisions made with or on behalf of people with stroke are in line with the principles of the Mental Capacity Act (2005). See the CKS topic on Delirium for more information.
    • Emotional wellbeing and mood
      • If the person has a severe or persistent mood disorder such as depression or anxiety, post-traumatic stress disorder, behavioural changes, or complex or atypical symptoms after stroke including increased risk of suicide, consider referral to a clinical psychology/neuropsychology or psychiatry team for specialist assessment and treatment.
      • If the person has depression and /or anxiety after stroke, see the CKS topics on Depression, Generalized anxiety disorder, and Post-traumatic stress disorder for more information about management options.
      • If a person's motivation and engagement with rehabilitation appears reduced, assess for changes in self-esteem, self-efficacy, identity, or mood. Offer opportunities for increased social interaction and participation, increased exercise, or other psychosocial interventions.
    • Fatigue
      • Assess for and manage any reversible causes or exacerbating factors for fatigue, such as depression and anxiety, sleep disorders, pain, or medication adverse effects. See the CKS topics on Chronic pain, Depression, Generalized anxiety disorder, Hypothyroidism, Insomnia, and Obstructive sleep apnoea syndrome for more information.
      • Provide the person and their family members/carers with information, reassurance, and support to identify signs and triggers for fatigue, and to develop individualized strategies to anticipate and manage it, including rest, adjustment, goal-setting, pacing, prioritising activities, and relaxation techniques. See the CKS topic on Tiredness/fatigue in adults for more information.
    • Pain — neuropathic (central post-stroke pain)
      • Consider prescribing drug treatment for neuropathic pain, and arrange regular reviews monitoring for treatment response and adverse effects. Consider gradually reducing drug doses over time if symptom improvement is sustained. See the CKS topic on Neuropathic pain - drug treatment for more information on management options.
      • Consider referral to a specialist pain management service if clinically indicated.
    • Pain — musculoskeletal
      • Advise about simple analgesia options such as paracetamol, topical nonsteroidal anti-inflammatory drugs (NSAIDs), or transcutaneous electrical nerve stimulation (TENS) first-line. See the CKS topics on Analgesia - mild-to-moderate pain and NSAIDs - prescribing issues for more information.
      • Advise that therapeutic positioning, whether in the bed, chair or wheelchair, aims to reduce skin pressure damage, limb swelling, shoulder pain or subluxation, discomfort, contractures, and to maximize function. Good positioning may also help to reduce respiratory complications and help to maintain adequate hydration and nutrition.
      • Consider arranging referral to physiotherapy, occupational therapy, and/or orthotics, depending on clinical judgement. See the CKS topic on Chronic pain for more information.
    • End of life care
      • Ensure people with stroke with limited life expectancy, and family members/carers where appropriate, are offered advance care planning and have access to timely specialist palliative care services if needed. See the CKS topic on Palliative care - general issues for more information.
      • Discuss end of life and supportive care issues for people with stroke, including an explicit decision not to have burdensome restrictions that may exacerbate suffering. This may involve a decision, taken together with the person with stroke, their family members/carers, and the multidisciplinary team including a stroke specialist and the palliative care team, for example, to allow oral food or fluid intake despite risks including aspiration and choking.
      • Decisions to withhold or withdraw life-prolonging treatments after stroke, including artificial nutrition and hydration should, whenever possible, take the person’s prior expressed wishes and preferences into account, and should be taken in the best interests of the person with stroke.

Basis for recommendation

These recommendations are largely based on the National Institute for Health and Care Excellence (NICE) guidelines Stroke and transient ischaemic attack in over 16s: diagnosis and initial management [NICE, 2025] and Stroke rehabilitation in adults [NICE, 2023 Stroke rehabilitation in adults], the UK Intercollegiate Stroke Working Party publication National clinical guideline for stroke for the United Kingdom and Ireland [ICSWP, 2023], the European Stroke Organisation (ESO) and European Academy of Neurology (EAN) joint guidelines on post-stroke cognitive impairment  [Quinn, 2021], the ESO and European Society for Swallowing Disorders (ESSD) joint guideline on post-stroke dysphagia [Dziewas, 2021], and the ESO guidelines on visual impairment after stroke [Rowe, 2025], on speech problems after stroke [Brady, 2025], and on motor rehabilitation after stroke [Murphy, 2025].

Supporting referral to the community stroke rehabilitation team
  • These recommendations are based on the NICE guideline on stroke rehabilitation [NICE, 2023 Stroke rehabilitation in adults] and the ICSWP guideline [ICSWP, 2023].
    • The ICSWP guideline states that a stroke rehabilitation unit should have a multidisciplinary team including access to physiotherapy, occupational therapy, speech and language therapy, dietetics, clinical psychology or neuropsychology, orthotics, and social work. Community rehabilitation may be delivered by combined stroke and neuro-therapy teams. It states that hospital inpatients with stroke who have mild-to-moderate disability may be offered 'early supported discharge', with treatment at home beginning within 24 hours of discharge. It notes that people with stroke should be considered to have the potential to benefit from rehabilitation at any point after stroke, based on expert group consensus. Rehabilitation delivered later after stroke may prevent regression of physical or cognitive gains achieved in the earlier stages of recovery, and prevent physical deconditioning.
    • The NICE guideline on stroke rehabilitation cites evidence that early supported discharge may reduce physical dependency and psychological distress as well as cost of care, and may improve health-related quality of life. It similarly highlights that stroke care and rehabilitation should be offered and continued for as long as it helps the person achieve their treatment goals.
    • The recommendation if there is any uncertainty in management of complications or complex or atypical health and social care needs is extrapolated from the ICSWP guideline. It is also pragmatic, based on what CKS considers to be good clinical practice.
Swallowing, nutrition, and hydration 
  • These recommendations are based on the NICE guidelines on stroke and TIA [NICE, 2025] and on stroke rehabilitation [NICE, 2023 Stroke rehabilitation in adults], the ICSWP guideline [ICSWP, 2023], and the ESO/ESSD joint guideline on post-stroke dysphagia [Dziewas, 2021].
    • The NICE guideline on stroke and TIA notes that factors such as dysphagia, poor oral health, and reduced ability to self-feed will affect the risk of malnutrition in people with stroke.
    • The recommendation about reviewing the need for medication, its formulation, and route of administration is based on the NICE guidelines on stroke and TIA and on stroke rehabilitation, and the ICSWP guideline.
    • The ICSWP guideline notes that a dietitian may offer nutritional support and/or oral nutritional supplements if clinically indicated. Similarly, the ESO/ESSD joint guideline found low-to-moderate quality evidence for a variety of treatment options to improve swallowing physiology and safety. These included dietary and nutritional interventions such as use of texture-modified diets and/or thickened liquids to reduce the risk of pneumonia, the use of speech and language therapy (SLT) swallowing exercises and manoeuvres, the use of oral nutritional supplementation if there is evidence of malnutrition, and oral healthcare interventions to reduce the risk of aspiration pneumonia.
    • The recommendation if a person has difficulty self-feeding is based on the ICSWP guideline.
    • The recommendation about educating family members/carers if a person has coughing or choking while eating and drinking is based on the NICE guideline on stroke rehabilitation.
Communication
  • These recommendations are based on the NICE guideline on stroke rehabilitation [NICE, 2023 Stroke rehabilitation in adults], the ICSWP guideline [ICSWP, 2023], and the ESO guideline on speech problems after stroke [Brady, 2025].
    • The recommendation to assess the person's communication is based on the NICE guideline on stroke rehabilitation.
    • The recommendation to offer re-referral to the SLT team is based on the ICSWP guideline and the NICE guideline on stroke rehabiliation, which notes that technologies such as apps or computer-based programmes tailored to individual goals and circumstances may help support word-finding difficulties, in addition to face-to-face SLT. Other methods of communicating, such as gestures, writing, and using communication props may also help.
    • The ESO guideline on speech problems after stroke highlights that SLT should be tailored to the person with aphasia so that it is functionally relevant, and at the right level of language difficulty for the peron's specific rehabilitation needs.
Oral health
  • These recommendations are based on the NICE guideline on stroke rehabilitation [NICE, 2023 Stroke rehabilitation in adults], the ICSWP guideline [ICSWP, 2023], and the ESO/ESSD joint guideline on post-stroke dysphagia [Dziewas, 2021].
    • The NICE guideline on stroke rehabilitation highlights the importance of good oral health for people with stroke, and notes that an effective mouth care regimen is important to decrease the risk of aspiration pneumonia. This is supported by the ICSWP guideline and the ESO/ESSD joint guideline on post-stroke dysphagia.
    • The recommendations about denture care are extrapolated from the ICSWP guideline.
    • The recommendation about supporting a regular mouth care regimen is based on the NICE guideline on stroke rehabilitation.
Motor skills and function
  • These recommendations are based on the NICE guideline on stroke rehabilitation [NICE, 2023 Stroke rehabilitation in adults], the ICSWP guideline [ICSWP, 2023], and the ESO guideline on motor rehabilitation [Murphy, 2025].
    • The ICSWP guideline highlights the importance of encouraging early mobility, exercise, motor retraining, and practice of functional tasks. It states that any intervention to promote motor recovery should be delivered at the appropriate intensity and 'dose' to achieve optimal outcomes, at the right point in the person’s recovery programme. In particular, rehabilitation programmes should be individualized taking into account the person's comorbidities, baseline activity levels, post-stroke fatigue, tolerance, goals, and preferences Exercise is key to reducing muscle weakness and maximizing cardiorespiratory fitness, which is an important target for rehabilitation to optimize recovery and reduce the risk of stroke recurrence. In addition, as well as the physical benefits, exercise helps to build confidence, reduce boredom, and increases autonomy and independence. Muscle weakness typically benefits from task-specific, repetitive, intensive exercises or activities to increase strength.
    • Similarly, the ESO guideline on motor rehabilitation found very low-quality evidence to support the use of repetitive upper limb practice to improve arm capacity, moderate-quality evidence to support high-intensity gait training to improve walking endurance in people with stable cardiovascular disease, low-quality evidence to improve walking speed, moderate-quality evidence to support sit-to-stand training to improve balance, and an expert consensus recommendation to use walking practice to improve walking capacity.
    • The NICE guideline on stroke rehabilitation also recommends use of repetitive task training on a range of activities and strength training if there is muscle weakness after stroke, for example sit-to-stand repetitions, weights, and progressive resistance exercise. It notes that potential benefits of 'community participation programmes' and group-based physical exercise include improved quality of life for the person with stroke, and reduced carer stress.
    • The ICSWP guideline states that an occupational therapist with experience in neurological disability may provide equipment and adaptations that increase the person's independence safely. The NICE guideline on stroke rehabilitation notes that occupational therapy may provide advice on restorative strategies (such as using both arms to dress) or compensatory strategies (such as dressing one-handed or using bathing and dressing aids).
    • The recommendation to consider referral to orthotics for ankle or foot orthoses is based on the ICSWP guideline. Similarly, the recommendation about hand and wrist splints is based on the NICE guideline on stroke rehabilitation, which notes that these may maintain joint range, soft tissue length, and alignment, reducing the risk of contractures and spasticity, and may assist hand grip and function.
    • The ICSWP guideline notes that if there is a high risk of falls, the person should be advised to do regular physical exercise including balance and co-ordination activities.
Spasticity and contractures
  • These recommendation are based on the NICE guideline on stroke rehabilitation [NICE, 2023 Stroke rehabilitation in adults] and the ICSWP guideline [ICSWP, 2023].
    • The recommendation about measures to reduce spasticity are largely based on the NICE guideline on stroke rehabilitation, and are supported by the ICSWP guideline.
    • The recommendation about hand and wrist splints is based on the NICE guideline on stroke rehabilitation, which notes that these may maintain joint range, soft tissue length, and alignment, reducing the risk of contractures and spasticity, and may assist hand grip and function.
    • People with persistent or progressive focal spasticity after stroke that affects one or two areas may be offered botulinum toxin by a specialist team as well as rehabilitation therapy and/or splinting or casting for up to 12 weeks after the injections. People with generalized or diffuse spasticity may be offered muscle relaxants for symptom relief [ICSWP, 2023]. The NICE guideline on stroke rehabilitation notes that limb stretching, splints, neuromuscular electrical stimulation (NMES) or transcutaneous electrical nerve stimulation (TENS), and botulinum toxin A may be offered by the stroke rehabilitation service for people with focal spasticity of the upper limb, and the muscle relaxant baclofen may be offered for people with generalized spasticity with careful monitoring for adverse effects.
Hearing
Vision
  • These recommendations are based on the NICE guideline on stroke rehabilitation [NICE, 2023 Stroke rehabilitation in adults], the ICSWP guideline [ICSWP, 2023], and the ESO guideline on visual impairment after stroke [Rowe, 2025].
    • The ESO guideline on visual impairment in stroke states that vision screening should be offered to all people with stroke to improve the detection of vision problems. It highlights the importance of close collaboration between stroke teams including occupational therapy, neuropsychology, and eye care teams (including orthoptics, ophthalmology, and optometry) for the targeted management of visual impairment. It recommends interventions such as use of visual scanning/visual search to aid adaptation to visual field loss after stroke, and other specialist interventions may be needed to help manage visual neglect or visual perception deficits. Referral to specialist eye services is needed for the targeted management of eye movement disorders, for example.
    • The recommendation about referral to occupational referral is also based on the ICSWP guideline.
Continence
  • These recommendations are based on the NICE guideline on stroke rehabilitation [NICE, 2023 Stroke rehabilitation in adults] and the ICSWP guideline [ICSWP, 2023].
    • The information about the potential range of management options is based on the ICSWP guideline.
    • The information about possible indications for an indwelling urethral catheter is based on the ICSWP guideline.
    • The recommendation about referral to the local continence service is based on the NICE guideline on stroke rehabilitation and the ICSWP guideline.
Sexual function
  • The ICSWP guideline highlights that regaining sexual intimacy with partners can have a positive impact on the person's self-esteem, quality of life, and can help to strengthen relationships. It recommends assessing for potential reversible causes and offering psychosexual counselling if indicated [ICSWP, 2023].
  • The recommendations on management of erectile dysfunction in men are largely based on the ICSWP guideline, which found little evidence on the risks and benefits of phosphodiesterase type-5 inhibitors after stroke, suggesting no reason to suspect that people are at increased risk of adverse effects after stroke. It recommends waiting for three months after stroke before prescribing these drugs, once blood pressure is controlled, based on expert consensus opinion of the working party group [ICSWP, 2023].
Cognition
  • These recommendations are based on the NICE guideline on stroke rehabilitation [NICE, 2023 Stroke rehabilitation in adults], the ICSWP guideline [ICSWP, 2023], and the ESO/EAN joint guidelines on post-stroke cognitive impairment [Quinn, 2021].
    • The ESO/EAN joint guidelines advise that due to a lack of relevant trials in people with stroke, there is uncertainty over the relative risks and benefits of routine cognitive screening to improve stroke care. There was expert consensus that cognitive screening should be considered as part of the comprehensive assessment of stroke survivors, although there were insufficient data to make recommendations around the optimal timing and content of cognitive screening for the person.
    • The recommendation to refer people with suspected cognitive impairment for specialist assessment is based on the ICSWP guideline. This notes that assessment of the person's pre-stroke baseline level of physical functional abilities, mood, and cognitive function may help inform the person's rehabilitation needs and subsequent prognosis. It may also contribute to mental capacity or safeguarding decisions, and the assessment and management of people returning to cognitively demanding roles such as managing their finances, work, and/or driving.
    • The information about use of compensatory techniques if there are memory problems is based on the NICE guideline on stroke rehabilitation, the ICSWP guideline, and the ESO/EAN joint guidelines on cognitive impairment, which cite limited emerging evidence for the beneficial effect of cognitive rehabilitation based on re-learning of compensatory strategies, particularly in the context of meaningful functional tasks for the person.
    • The recommendation about decision-making in line with the Mental Capacity Act (2005) is extrapolated from the ICSWP guideline.
Emotional wellbeing and mood
  • These recommendations are based on the NICE guidelines on stroke and TIA [NICE, 2025] and on stroke rehabilitation [NICE, 2023 Stroke rehabilitation in adults], and the ICSWP guideline [ICSWP, 2023].
    • The ICSWP guideline acknowledges that assessment and management of mood disorders can be challenging and complex, as a person's clinical presentation may be affected by mood, apathy, fatigue, communication difficulties, and/or cognitive impairment. Clinical psychology and/or neuropsychology assessment can help to determine the relative contributions and impact of different factors, to help guide management. The NICE guideline on stroke rehabilitation highlights that people with complex or atypical symptoms after stroke including increased risk of suicide may benefit from clinical psychology or neuropsychology assessment. The NICE guideline on stroke and TIA notes that psychiatry input may be needed for some people with signs of a severe or persistent mood disorder.
    • The recommendation about arranging assessment and possible psychosocial interventions if a person presents with reduced motivation and engagement with rehabilitation is based on the ICSWP guideline, which notes that reduced goal-directed behaviour, decreased emotional responsiveness, and persistent apathy can impact on a person's functional recovery.
Fatigue
  • These recommendations are largely based on the NICE guideline on stroke rehabilitation [NICE, 2023 Stroke rehabilitation in adults] and the ICSWP guideline [ICSWP, 2023].
    • The NICE guideline on stroke rehabilitation notes that fatigue may impact on engagement with stroke rehabilitation, goal-setting, and therapy session planning.
    • The recommendations to assess for and manage any reversible causes, and to provide information about individualized strategies to manage fatigue are based on the ICSWP guideline.
Pain
  • The recommendations about neuropathic pain are based on the ICSWP guideline, which notes there is very little study evidence available specific to the management of neuropathic or central post stroke pain. It bases its recommendations largely on the NICE guideline on neuropathic pain [ICSWP, 2023].
  • The recommendations about musculoskeletal pain are also based on the ICSWP guideline, which did not find any study evidence on musculoskeletal pain specific to stroke. Its recommendations are based on the NICE guideline on osteoarthritis and the expert consensus opinion of the working party group [ICSWP, 2023]. The recommendation to consider referral to physiotherapy, occupational therapy, and/or orthotics is also pragmatic, based on what CKS considers to be good clinical practice.
End of life care
  • The ICSWP guideline notes the risk of aspiration and choking at the end of life, but states that 'rigid adherence to recommendations ... on access to oral food or fluids could, in palliative care, result in burdensome restrictions that may exacerbate suffering'. It adds that 'in the presence of dysphagia, eating and drinking with acknowledged risks should be considered. This is recognised as a complex and personalised decision' [ICSWP, 2023].
  • The other recommendation about end of life care are based on the ICSWP guideline [ICSWP, 2023]. They are also pragmatic, based on what CKS considers to be good clinical practice.

Supporting evidence

This CKS topic is largely based on the National Institute for Health and Care Excellence (NICE) guidelines Stroke and transient ischaemic attack in over 16s: diagnosis and initial management [NICE, 2025] and Stroke rehabilitation in adults [NICE, 2023 Stroke rehabilitation in adults], the UK Intercollegiate Stroke Working Party publication National clinical guideline for stroke for the United Kingdom and Ireland [ICSWP, 2023], various European Stroke Organisation (ESO) guidelines and consensus statements, and expert opinion in review articles. The rationale for individual recommendations is discussed in the relevant basis for recommendation sections.

How this topic was developed

This section briefly describes the processes used in developing and updating this topic. Further details on the full process can be found in the About Us section and on the Clarity Informatics website.

Search strategy

A literature search was conducted for guidelines, systematic reviews and randomized controlled trials on primary care management of stroke and TIA.

Search dates

September 2021 - May 2026

Key search terms

Various combinations of searches were carried out. The terms listed below are the core search terms that were used for Medline.

  • Exp Ischemic Attack, Transient/
  • Exp Stroke/
  • exp Cerebral Hemorrhage/
  • ((mini or minor or mild or acute) adj2 (stroke or strokes)).ti,ab.
  • (stroke or strokes or cva or poststroke* or apoplexy or “cerebrovascular accident”).ti,ab.
  • ((cerebro* or brain or brainstem or cerebral*) adj3 (infarct* or accident*)).ti,ab.
  • ((transient (isch?aemic adj2 attack*) or TIA)).ab,ti.
  • “brain attack*.ti,ab.

Sources of guidelines

Sources of systematic reviews and meta-analyses

  • The Cochrane Library:
    • Systematic reviews
    • Protocols
    • Database of Abstracts of Reviews of Effects
  • Medline (with systematic review filter)
  • EMBASE (with systematic review filter)

Sources of health technology assessments and economic appraisals

Sources of randomized controlled trials

  • The Cochrane Library:
    • Central Register of Controlled Trials
  • Medline (with randomized controlled trial filter)
  • EMBASE (with randomized controlled trial filter)

Sources of evidence based reviews and evidence summaries

Sources of national policy

Patient experiences

Sources of medicines information

The following sources are used by CKS pharmacists and are not necessarily searched by CKS information specialists for all topics. Some of these resources are not freely available and require subscriptions to access content.

Stakeholder engagement

Our policy

The external review process is an essential part of CKS topic development. Consultation with a wide range of stakeholders provides quality assurance of the topic in terms of:

  • Clinical accuracy.
  • Consistency with other providers of clinical knowledge for primary care.
  • Accuracy of implementation of national guidance (in particular NICE guidelines).
  • Usability.

Principles of the consultation process

  • The process is inclusive and any individual may participate.
  • To participate, an individual must declare whether they have any competing interests or not. If they do not declare whether or not they have competing interests, their comments will not be considered.
  • Comments received after the deadline will be considered, but they may not be acted upon before the clinical topic is issued onto the website.
  • Comments are accepted in any format that is convenient to the reviewer, although an electronic format is encouraged.
  • External reviewers are not paid for commenting on the draft topics.
  • Discussion with an individual or an organization about the CKS response to their comments is only undertaken in exceptional circumstances (at the discretion of the Clinical Editor or Editorial Steering Group).
  • All reviewers are thanked and offered a letter acknowledging their contribution for the purposes of appraisal/revalidation.
  • All reviewers are invited to be acknowledged on the website. All reviewers are given the opportunity to feedback about the external review process, enabling improvements to be made where appropriate.

Stakeholders

  • Key stakeholders identified by the CKS team are invited to comment on draft CKS topics. Individuals and organizations can also register an interest to feedback on a specific topic, or topics in a particular clinical area, through the Getting involved section of the Clarity Informatics website.
  • Stakeholders identified from the following groups are invited to review draft topics:
    • Experts in the topic area.
    • Professional organizations and societies (for example, Royal Colleges).
    • Patient organizations, Clarity has established close links with groups such as Age UK and the Alzheimer’s Society specifically for their input into new topic development, review of current topic content and advice on relevant areas of expert knowledge.
    • Guideline development groups where the topic is an implementation of a guideline.
    • The British National Formulary team.
    • The editorial team that develop MeReC Publications.
  • Reviewers are provided with clear instructions about what to review, what comments are particularly helpful, how to submit comments, and declaring interests.

Patient engagement

Clarity Informatics has enlisted the support and involvement of patients and lay persons at all stages in the process of creating the content which include:

  • Topic selection
  • Scoping of topic
  • Selection of clinical scenarios
  • First draft internal review
  • Second draft internal review
  • External review
  • Final draft and pre-publication

Our lay and patient involvement includes membership on the editorial steering group, contacting expert patient groups, organizations and individuals.

Evidence exclusion criteria

Our policy

Scoping a literature search, and reviewing the evidence for CKS is a methodical and systematic process that is carried out by the lead clinical author for each topic. Relevant evidence is gathered in order that the clinical author can make fully informed decisions and recommendations. It is important to note that some evidence may be excluded for a variety of reasons. These reasons may be applied across all CKS topics or may be specific to a given topic.

Studies identified during literature searches are reviewed to identify the most appropriate information to author a CKS topic, ensuring any recommendations are based on the best evidence. We use the principles of the GRADE and PICOT approaches to assess the quality of published research. We use the principles of AGREE II to assess the quality of published guidelines.

Standard exclusions for scoping literature:

  • Animal studies
  • Original research is not written in English

Possible exclusions for reviewed literature:

  • Sample size too small or study underpowered
  • Bias evident or promotional literature
  • Population not relevant
  • Intervention/treatment not relevant
  • Outcomes not relevant
  • Outcomes have no clear evidence of clinical effectiveness
  • Setting not relevant
  • Not relevant to UK
  • Incorrect study type
  • Review article
  • Duplicate reference

Organizational, behavioural and financial barriers

Our policy

The CKS literature searches take into consideration the following concepts, which are discussed at the initial scoping of the topic.

  • Feasibility
    • Studies are selected depending on whether the intervention under investigation is available in the NHS and can be practically and safely undertaken in primary care.
  • Organizational and Financial Impact Analysis
  • Studies are selected and evaluated on whether the intervention under investigations may have an impact on local clinical service provision or national impact on cost for the NHS. The principles of clinical budget impact analysis are adhered to, evaluated and recorded by the author. The following factors are considered when making this assessment and analysis.
    • Eligible population
    • Current interventions
    • Likely uptake of new intervention or recommendation
    • Cost of the current or new intervention mix
    • Impact on other costs
    • Condition-related costs
    • In-direct costs and service impacts
    • Time dependencies
  • Cost-effectiveness or cost-benefit analysis studies are identified where available. 

We also evaluate and include evidence from NICE accredited sources which provide economic evaluations of recommendations, such as NICE guidelines. When a recommended action may not be possible because of resource constraints, this is explicitly indicated to healthcare professionals by the wording of the CKS recommendation.

Declarations of interest

Our policy

Clarity Informatics requests that all those involved in the writing and reviewing of topics, and those involved in the external review process to declare any competing interests. Signed copies are securely held by Clarity Informatics and are available on request with the permission of the individual. A copy of the declaration of interest form which participants are asked to complete annually is also available on request. A brief outline of the declarations of interest policy is described here and full details of the policy is available on the Clarity Informatics website. Declarations of interests of the authors are not routinely published, however competing interests of all those involved in the topic update or development are listed below. Competing interests include:

  • Personal financial interests
  • Personal family interest
  • Personal non-financial interest
  • Non-personal financial gain or benefit

Although particular attention is given to interests that could result in financial gains or losses for the individual, competing interests may also arise from academic competition or for political, personal, religious, and reputational reasons. An individual is not obliged to seek out knowledge of work done for, or on behalf of, the healthcare industry within the departments for which they are responsible if they would not normally expect to be informed.

Who should declare competing interests?

Any individual (or organization) involved in developing, reviewing, or commenting on clinical content, particularly the recommendations should declare competing interests. This includes the authoring team members, expert advisers, external reviewers of draft topics, individuals providing feedback on published topics, and Editorial Steering Group members. Declarations of interest are completed annually for authoring team and editorial steering group members, and are completed at the start of the topic update and development process for external stakeholders.

Competing interests declared for this topic:

None.

References

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