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Stroke and transient ischaemic attack in over 16s: diagnosis and initial management


  • Stroke is a major health problem in the UK. It accounts for around 11% of deaths, results in significant morbidity in people who survive, and represents a substantial health and resource burden. Symptoms of stroke include numbness, weakness or paralysis, slurred speech, blurred vision, confusion and severe headache. A transient ischaemic attack (TIA) is defined as stroke symptoms and signs that resolve within 24 hours
  • This guideline covers interventions in the acute stage of a stroke (‘acute stroke’) or TIA. Most of the recommendations relate to interventions in the first 48 hours after onset of symptoms, although some interventions up to 2 weeks are covered. There is evidence that rapid diagnosis, admission to a specialist stroke unit, and immediate brain imaging and use of thrombolysis where indicated can all contribute to a better outcome for patients. For people who have had a TIA, rapid assessment for risk of subsequent stroke allows appropriate treatment to be initiated to reduce the likelihood of stroke occurring

Patient-centred care

  • Treatment and care should take into account peoples' needs and preferences. People with acute stroke or TIA should have the opportunity where possible to make informed decisions about their care and treatment, in partnership with their healthcare professionals. However, the person's consent may be difficult to obtain at the time of an acute episode, or where the stroke or TIA results in communication problems. If the person does not have the capacity to make decisions, healthcare professionals should follow the Department of Health's advice on consent and the code of practice that accompanies the Mental Capacity Act. In Wales, healthcare professionals should follow advice on consent from the Welsh Government

Key priorities for implementation

Rapid recognition of symptoms and diagnosis

  • In people with sudden onset of neurological symptoms a validated tool, such as FAST (Face Arm Speech Test), should be used outside hospital to screen for a diagnosis of stroke or TIA
  • People who have had a suspected TIA who are at high risk of stroke (that is, with an ABCD2 score of 4 or above) should have:
    • aspirin (300 mg daily) started immediately
    • specialist assessment and investigation within 24 hours of onset of symptoms
    • measures for secondary prevention introduced as soon as the diagnosis is confirmed, including discussion of individual risk factors
  • People with crescendo TIA (two or more TIAs in a week) should be treated as being at high risk of stroke, even though they may have an ABCD2 score of 3 or below

Specialist care for people with acute stroke

  • All people with suspected stroke should be admitted directly to a specialist acute stroke unit following initial assessment, either from the community or from the A&E department
  • Brain imaging should be performed immediately for people with acute stroke if any of the following apply:
    • indications for thrombolysis or early anticoagulation treatment
    • on anticoagulant treatment
    • a known bleeding tendency
    • a depressed level of consciousness (Glasgow Coma Score below 13)
    • unexplained progressive or fluctuating symptoms
    • papilloedema, neck stiffness or fever
    • severe headache at onset of stroke symptoms

Nutrition and hydration

  • On admission, people with acute stroke should have their swallowing screened by an appropriately trained healthcare professional before being given any oral food, fluid or medication

full guideline available from…
National Institute for Health and Care Excellence, Level 1A, City Tower, Piccadilly Plaza, Manchester, M1 4BT

National Institute for Health and Care Excellence. Stroke and transient ischaemic attack in over 16s: diagnosis and initial management. Quick Reference Guide. July 2008
First included: October 2008.