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Table 1

Definitions of selected terms used in the European Stroke Action Plan


  • Stroke
    Unit:

    A dedicated geographically clearly defined area or ward in a hospital, where stroke patients are admitted and cared for by a multi-professional team (medical, nursing, and therapy staff) who have specialist knowledge of cerebral function, training and skills in stroke care with well-defined individual tasks, regular interaction withother disciplines, and stroke leadership. This team co-ordinates care through regular, multidisciplinary meetings.18
  • Stroke
    Centre:

    A hospital infrastructure and related processes of care that provide the full pathway of stroke unit care. A stroke centre is the co-ordinating body of the entire chain of care. This covers pre-hospital care, ongoing rehabilitation and secondary prevention, and access to neurosurgical and vascular intervention. A stroke unit is the most important component of a stroke centre. The Stroke Centre provides stroke unit services for the population of its own catchment area and serves as a referral centre for peripheral hospitals with stroke units in case their patients need services which are not available locally.18
  • Comprehensive
    stroke unit:

    A dedicated area where  acute stroke management is combined with early mobilization and rehabilitation and secondary prevention, according to the needs of the patient.
  • Early supported
    discharge:

    Early Supported Discharge (ESD) is designed to enable the accelerated discharge of Stroke patients to their home, providing specialist rehabilitation and social support in a home setting rather than an acute hospital ward. The Early Supported Discharge team comprises a variety of specialist therapists, social and support workers. The team visits patients in their home setting, enabling patients to undergo rehab in a familiar home setting and thus increasing patient flow and bed availability within the acute hospital.
  • Registry:

    A system for collecting process and outcome data at regional or national level that achieves near universal coverage.

Table 2

Recommendations for the investigation of incident or recurrent stroke


Stroke type
Aim
Investigation

All

Ischaemic vs. haemorrhagic

CT ± CTA, or MRI ± MRA, scanning immediately on admission to hospital

 

Vital measures

Blood pressure, weight/body mass index

 

Blood tests

Lipids, glucose, HbA1c, coagulation, markers for vasculitis and connective tissue disorders

 

Severe high BP

For secondary causes of hypertension

Ischaemic/TIA

Large artery stroke

Carotid ultrasound (extra-cranial)

   

CT and CTA, or MRI and MRA

 

Atrial fibrillation

ECG

   

Prolonged arrhythmia recording

 

Embolic stroke

Echocardiography, and bubble contrast transcranial Doppler if performed locally

Intracerebral haemorrhage

 

CTA or MRA; digital subtraction angiography if appropriate. Interval blood sensitive MRI

Subarachnoid haemorrhage

 

CT and CTA, lumbar puncture; digital subtraction angiography if appropriate. Delayed CTA or MRA

Note: Investigations may not be relevant or appropriate in all patients, e.g. those with dependent dementia or other causes of a reduced life-expectancy. BP: blood pressure; CT: computed tomography; CTA: computed tomography angiography; ECG: electrocardiogram; HbA1c: glycated haemoglobin; MRA: magnetic resonance angiography; MRI: magnetic resonance imaging

Table 3

Effective secondary prevention interventions and their targets according to type of stroke


Stroke type
Intervention

All

  • Primary prevention measures are applicable to secondary prevention
  • Government campaigns, e.g. promoting healthy lifestyle, reducing air pollution
  • Stop smoking (± nicotine replacement) and added salt, moderate alcohol intake and weight,59 and increase exercise60 and consumption of a cardioprotective diet including fruit and vegetables
  • Treat high blood pressure with angiotensin converting enzyme inhibitors or angiotensin receptor antagonists, calcium channel blockers and/or thiazide-like diuretics;61 usually needs ≥2 agents to reach target of <130/80 mmHg (if tolerated). Patients needing ≥3 drugs to reach target should be investigated for secondary causes of hypertension.
  • Glucose lowering in diabetes mellitus. Pioglitazone may provide prevention benefits beyond glucose control.
  • Sex-specific differences exist related to menopause and andropause, e.g. certain types of hormone-replacement therapy may increase the frequency and severity of stroke.
 
 
 
 
 

Ischaemic stroke/transient ischaemic attack

  • Antiplatelet for noncardioembolic stroke (e.g. AF).62 Dual therapy based on aspirin and clopidogrel for 3 weeks in acute minor stroke and TIA-, then mono-therapy Mono-therapy, or aspirin and dipyridamole, is relevant for lacunar infarction.

Large-artery disease

  • Lipid lowering with a statin, ideally at maximum dose.63 Fibrates, ezetimibe or PCSK9 inhibitors may be prescribed if statins cannot be tolerated or give insufficient response
 
  • Carotid endarterectomy (CEA) or carotid stenting for symptomatic severe ipsilateral carotid stenosis (NASCET score ≥70%) or in most high-risk patients with moderate stenosis (50-69%), as soon as the patient is stable and within 2 weeks.64 If CEA is not possible, or in younger patients, extracranial carotid artery stenting is an alternative for high-risk carotid stenosis.
 
  • In addition to best medical therapy, carotid endarterectomy may be appropriate in asymptomatic severe carotid stenosis in patients who also have symptomatic stenosis.

Cardio-embolic stroke

  • In atrial fibrillation, non-vitamin K oral anticoagulant (NOAC) rather than with warfarin or other vitamin K antagonists.65 Although currently on-patent and therefore more expensive, NOACs have no prothrombotic properties on initiation, provide more consistent anticoagulation, reduce the risk of intracranial haemorrhage, do not need monitoring, and have less interactions with food and other drugs
 
  • In patients with likely embolism (no lacunar or large artery features) cardiac echocardiography (or bubble transcranial Doppler) should be performed. Device closure of PFO66 with a moderate to large shunt or an atrial aneurysm reduces recurrent events in patients <60 years

Lacunar stroke

  • Optimise control of blood pressure, blood glucose and lipids, and mono-antiplatelet therapy

Other determined aetiology

  • These include cervical artery dissection, cerebral venous thrombosis, recreational drugs and genetic mutations, and require specific investigation and treatment (in addition to treatment as defined in ”All” above)

Intracerebral haemorrhage

  • Lower raised blood pressure (as above)

Subarachnoid haemorrhage

  • Stop smoking, moderate alcohol intake, and lower raised blood pressure (as above). Non-invasive screening for first degree family

Note: Interventions may not be relevant or appropriate in all patients, related to adverse events, concurrent conditions (e.g. dependent dementia).

AF: atrial fibrillation; CEA: carotid endarterectomy; NASCET: North American Symptomatic Carotid Endarterectomy Trial; NOAC: non-vitamin K oral anticoagulant; PCSK9: proprotein convertase subtilisin/kexin type 9; PFO: patent foramen ovale

Table 4

Distribution of neurological deficits after stroke*


Affected area
Frequency
Consequences
Treatment

Motor function

50-85 %

Impaired balance, transfer ability, walking and reduced upper extremity function

Task specific repetition training seems most beneficial

Cognition

≈ 1/2

Memory problems, reduced attention, executive dysfunction, and spatial neglect.

May affect the person’s ability to manage daily life.

No clear evidence of beneficial interventions. So far, often-compensatory strategies seem to work best.

Communication

≈ 1/3

Aphasia, ranging from occasional word-finding difficulties to having no effective means of verbal communication

Information to patient and family in the acute setting

*Many persons with stroke have more than one impairment. In addition, anxiety and depression are common after stroke.

Table 5

Life after stroke issues*


  • Health
    Issues:

    • Specific post-stroke disabilities e.g., arm function, vision, dysphagia, spasticity (need for ‘top up’ in rehabilitation; regular review; equipment)
    • Hidden post-stroke deficits e.g. psychological, cognitive, depression, anxiety, communication, fatigue, incontinence
    • Co-existing conditions including frailty and dementia (medication implications) and associated with old age e.g. hearing.
    • Need for links to secondary prevention in primary care e.g.  medication, diet and exercise
    • Emergence of sequelae over time e.g. epilepsy, depression
    • End of life care
  • Activity
    issues:

    • Meaningful activities including leisure, holidays and play
    •  Vocational support – getting back to work or education.
    • Mobility including driving, transportation and access
    • Vocational support – getting back to work/education.
    • Role in family and society (issues regarding relationships and divorce)
    • Friendships – making and keeping friends
    • Key life transitions e.g. entering school, , discharge from rehabilitation
    • Communication
  • Adjustment and
    Wellbeing Issues:

    • Coming to terms with new life
    • Specific individual issues such as  sex, sleep, fatigue, confidence
    • Happiness/life satisfaction/loneliness
    • Grief and adjustment of parents/carers for changed future prospects
    • Emotional, behavioural and psychosocial domains of wellbeing
    • Environmental including nursing home /residential care
  • Information and Support issues for individual and carers/ parents:

    • Self-management (includes parent education to support their child)
    • Advocacy Psychological and emotional support
    • Communication-including aphasia friendly and culturally sensitive literature
    • Cognitive support e.g. memory, concentration
    • Financial support including benefits. Issues re additional costs of stroke.
    • Long term support- groups, peer support, volunteering 
    • Community integration- loneliness/isolation
    • Practical help with specific tasks e.g. housework, shopping
    • Carer support (including children- parents and siblings; parents- siblings, relationship support for partners) and respite care.
    • Specific support e.g. around return to work.
    • IT access support ; web-based interventions, tele- rehabilitation, podcasts on Life after stroke/ audiobooks, virtual reality based support
    • Sharing of relevant information across health, education, work and social care with the appropriate consents of the patient and carers
    • Proactive review

*This is not an exhaustive list, but merely an indication of the breadth and depth of issues faced across the lifespan after stroke: many issues will overlap between categories.

Table 6

Proposed strategic steps for translational research in stroke, with related action points


Strategic step
Action points

Exploratory versus confirmatory studies

  • High quality basic research with:

–   state-of-the art, rigorous, methodology

–   transparency

–   data availability (e.g. deposition of protocols/data in public repositories)

–   avoidance of  publication bias

Preclinical confirmatory studies as an intermediate translational step

  • Separation of discovery and confirmation
  • Confirmation before undertaking clinical studies
  • Preregistration
  • Pre-planned study designs and analyses
  • Publication of all results (including negative results)

Improve experimental modelling

  • Reduce bias
  • Increase power
  • Include co-morbidities
  • Less standardization, more variability (e.g. genetics, different habitats, ageing, sex)

Change to a larger ‘team’ concept

  • Establishing “Team Science” in stroke research

Improve efficacy of early stage clinical trials

  • Regulations should be more proportionate to the risks of the trial
  • Carefully stratify patients for clinical trial inclusion, with the perspective of developing personalized treatment approaches

Note: Interventions may not be relevant or appropriate in all patients, related to adverse events, concurrent conditions (e.g. dependent dementia).

AF: atrial fibrillation; CEA: carotid endarterectomy; NASCET: North American Symptomatic Carotid Endarterectomy Trial; NOAC: non-vitamin K oral anticoagulant; PCSK9: proprotein convertase subtilisin/kexin type 9; PFO: patent foramen ovale

Figure 1

Range of support needed after stroke.92*


*N.B. This model was worded specifically for adults.

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