National Clinical Guidelines For Stroke Research Articles

191 Intermittent: an audit of venous thromboembolism prophylaxis on our stroke unit

Abstract Background The National Clinical Guideline for Stroke for the United Kingdom and Ireland recommends immobile stroke patients receive Intermittent Compression Stockings (IPCs) to prevent Venous Thromboembolism (VTE) from days 3 to 30 of admission. We set out to audit IPC usage on the stroke unit in our hospital. Methods Data was collected for all 31 stroke unit patients on a single day by two NCHDs. We documented age, gender, length of stay, and mobility status. We recorded completion of the VTE risk section of the medication chart, and if the patient was prescribed single antiplatelet (SAPT), dual antiplatelet (DAPT), direct oral anticoagulant (DOAC) or IPCs. We also noted if the patient’s stroke was ischaemic or haemorrhagic. Results 16 patients were male (52%). Mean age was 72 years old. Median length of stay was 29 days. 23 patients had ischaemic strokes (74%), 8 had haemorrhagic strokes (26%). 21 patients had their VTE risk section completed (68%). 9 ischaemic stroke patients were on DOAC, 9 on SAPT, 4 on DAPT, and 1 was on no therapy. 19 patients (61%) were immobile (assistance of one or higher dependency). Of these, 9 had been admitted for between 3 and 30 days. None had IPCs prescribed and only 1 (11%) had them in situ. 3 were on DOAC therapy (33%). One other patient (admitted 41 days prior) had IPCs in situ but not prescribed. Conclusion 89% of appropriate stroke patients did not have IPCs in situ, and 56% had no VTE prophylaxis at all. The VTE risk section of the medication chart was blank in 32% of cases. Based on these results we are conducting a root cause analysis as to why guidelines are not adhered to. This will guide a planned quality improvement initiative.

304 Increasing the intensity of physiotherapy in a subacute stroke rehabilitation unit—results of audit and intervention

Abstract Background The National Clinical Guideline for Stroke (2023) recommend the delivery of high intensity therapy to optimise physical recovery post-stroke. Previous guidelines suggested 45 minutes but now suggest a total of 3 hours daily. The aim of this intervention was to review current practice and implement the stroke guidelines aiming to augment the dosage of therapy sessions. Methods Given the guidelines’ recommendation to improve the reporting of exercise prescription, a chart audit was completed comparing the dosage of physiotherapy from 2020–2022 on a random sample of 10 charts per year. Strategies to increase intensity included a restructure of the stroke exercise class, run twice weekly. The class structure moved towards a circuit class of 5x 6-minute stations followed by group outdoor mobility. Use of tally counters, increased semi-supervised practice and introduction of a ‘champions board’ to celebrate individuals’ achievements also contributed to a culture of high intensity therapy. Results The chart audit showed an improvement in the recording of repetitions each year. The average recorded repetitions per week for stroke survivors increased from 77.9 repetitions in 2020 to a weekly average of 1,043 in 2022 (2020 range 0–288 repetitions; 2022 range 245–2095 repetitions). The average repetitions in the stroke exercise class in 2022 was 462 and was previously not measured. A review of annual patient statistics from 2021 and 2022 showed that stroke survivors spent more time in physiotherapy in 2022. This was likely affected by variables such as staffing allocation and COVID-19 restrictions limiting the ability to provide gym-based therapy or group classes. Conclusion The measurement and recording of intensity has improved and increased in 2022 although this may have been affected by factors outside of this intervention. Future iterations of this project would be to increase dosage of upper limb therapy, and to increase physical activity outside therapy, such as use of pedometers outside therapy hours.

National Clinical Guideline for Stroke for the United Kingdom and Ireland: Part I – An overview of the updated recommendations

National Clinical Guideline for Stroke for the United Kingdom and Ireland: Part I – An overview of the updated recommendations

National Clinical Guideline for Stroke for the UK and Ireland: Part ll – The challenges and opportunities posed for occupational therapists

National Clinical Guideline for Stroke for the UK and Ireland: Part ll – The challenges and opportunities posed for occupational therapists

230 DEVELOPMENT AND IMPLEMENTATION OF A STROKE PASSPORT IN THE HYPER-ACUTE STROKE UNIT: SUPPORTING PEOPLE POST-STROKE

Abstract Background A Multi-Disciplinary Team (MDT) approach is instrumental to post-stroke management in the Hyper Acute Stroke Unit (HASU). There is strong evidence highlighting the importance of patients’ social needs post-stroke (UK National Clinical Guideline for Stroke, 2016) and the need for a clear plan and resource combining both health and social care. This is outlined in the National Stroke Strategy (2020-2025). Stroke care involves a cohesive multi-disciplinary approach. In 2021, members of the MDT in HASU identified a service gap and implemented a unified tool. The aim of this project was to develop a user-friendly resource “Stroke Passport” to ensure the patient was central to their own stroke journey. Methods National and international guidelines were reviewed and benchmarking of other acute services was completed. The Stroke Passport was specialised to the HASU to include key stakeholders including stroke Consultant, stroke MDT and stroke Nursing Staff. Key stakeholders contributed to the development and adjustments were made after feedback. A sample of stroke patients piloted the passport (n=10). Education was provided for staff and patients through information sessions. Results This project resulted in the development of a resource that captured the following key areas:(i)Causes of Stroke (ii) Risk Factors (iii) Stroke Team (iv) Rehabilitation Goals (v) Useful Contacts (vi) and Medication List (vii). Qualitative feedback from the pilot study included: consistent awareness into stroke type, rehabilitation goals and discharge plan. The passport was successfully implemented to meet the organisational demands of the service while including the patient’s voice and is now embedded into standard practice in the HASU. Conclusion The development and implementation of a Stroke Passport ensured inclusion of the patient central to rehabilitation goal setting and discharge planning. The project supports an integrated approach to care and allows for patient centred care from admission to safe discharge.

146 GOLD STANDARD GOAL-SETTING: ARE WE HITTING THE MARK? IMPLEMENTING AN INTERDISCIPLINARY GOAL-SETTING PATHWAY IN STROKE REHABILITATION

Abstract Background The cornerstone of rehabilitation is effective and realistic interdisciplinary goal-setting with patient and family engagement across the continuum of recovery. The Royal College of Physicians National Clinical Guidelines for Stroke (2016) highlights the importance of encouraging self-management and self-efficacy to support a more person-orientated approach. This quality improvement initiative aimed to introduce a structured interdisciplinary goal-setting pathway on a post-acute 14-bed stroke unit. Methods An interdisciplinary working group was established comprising of Physiotherapy, Occupational Therapy, Speech & Language Therapy, Medical Social Work and Nursing. Quality improvement methodology was used to sequentially implement change over a 6-month period. The restructure included the introduction of an initial and review goal-focused family meeting. An interdisciplinary tool was developed based on the East Kent Outcome System (EKOS). A series of workshops was delivered to support implementation. Results An interdisciplinary goal-setting pathway is currently being piloted for 6 months on the stroke unit. To date, 22 staff have been trained and 9 patients have progressed through the updated pathway. Analysis has provided useful clinical insights and qualitative feedback has been collated regarding the benefits of the early opportunity to meet the team, establishing patient’s personal goal priorities and clear timeframes.Furthermore, repeat trials followed by reflections have enabled the team to develop consistency and confidence in person-centred, interdisciplinary goal-setting. It is acknowledged that this initiative has been a significant change process for the team and that adjustments are being made, in line with the principles of quality improvement. Conclusion This person-orientated interdisciplinary process is evidence-based and in line with national standards and guidelines for stroke rehabilitation. Formal training in EKOS is planned and a clinical audit will follow the pilot phase to systematically evaluate the change in practice.

Hub-and-spoke model for thrombectomy service in UK NHS practice

Mechanical thrombectomy is a highly effective but time dependent treatment for acute ischaemic stroke due to large vessel occlusion. In the UK, the national clinical guidelines for stroke and National Institute for Health and Care Excellence guidance endorses thrombectomy as an acute stroke treatment, and NHS England commissioned thrombectomy services. However, there are no UK 'real-world' data to verify the efficacy of the hub-and-spoke model in thrombectomy. There are currently 24 tertiary neuroscience centres in the UK that can provide thrombectomy treatment and many of these operate only within working hours. This study is the first to demonstrate that a hub-and-spoke thrombectomy service in routine UK 24/7 clinical practice is as effective and safe as in the setting of randomised controlled clinical trials. However, there are 9.3% of patients accepted for transfer to the thrombectomy centre who did not proceed to thrombectomy, mostly due to delays. Fifty-three per cent of thrombectomy cases were performed outside of standard working hours when transfer delays were increased. A 24/7 thrombectomy service is needed to maximise the benefit to all suitable patients. Measures, including improving workflow and optimising work forces, are needed to minimise the delays and continue to improve the service.

81 A Review of the Referrals to a Daily TIA Service and Subsequent Specialist Diagnosis

Abstract Background Current guidelines highlight the need for all patients experiencing transient ischaemic attacks (TIA) within the previous 7 days to be seen by a specialist service within 24 hours. (RCP National Clinical Guideline for Stroke 2016) Risk stratification tools are no longer recommended.(Lavallee 2007;Wardlaw, 2014) We reviewed the referrals to such a service to assess the proportion of patients who received a diagnosis of TIA and the time taken for assessment. Methods We used a retrospective review of 131 patients coded under the daily TIA clinic in 2018 and analysed the clinic letter from the attendance. We assessed the time taken from referral to clinic review and the percentage of patients diagnosed with TIA by the specialist service. Results Of 131 patients seen only 33.6% were diagnosed TIA by the stroke specialist team. Other frequently seen diagnoses were migraine (22.9%), presyncope (12.2%), transient global amnesia (4.6%). ‘Other’ diagnoses such as peripheral nerve palsy, cervical root impingement and delirium made up the remainder. Referrals from the emergency department only received TIA diagnosis in 25.3%, GP referrals (34.9%) and eye casualty (83.3%). The time from referral to review was a mean of 2.45 days. The patients diagnosed with TIA were seen with average of 2.14 days, non TIAs were 2.6 days. Conclusion Evidence shows that patients suffering TIA should be seen urgently within 24hrs. The degree of non TIA symptoms being reviewed risks these services being overrun. A review of our service has shown that the average time of referral to review is longer than desired, however only a third of patients seen were felt to have a TIA. Unless there is a change in the standard of referral it will continue to be difficult to see all true TIAs within 24hrs. This will require further education for our colleagues and a more robust triaging system.

Ten Years On - A Survey of Orthoptic Stroke Services in the UK and Ireland.

Aim:In 2007 a national orthoptic survey identified poor provision of vision assessment for stroke survivors. The purpose of this study is to report a 10-year update of this survey to identify changes in clinical practice over recent years.Methods:An online practice survey of registered orthoptists (British and Irish Orthoptic Society, BIOS) was undertaken to scope vision services for stroke survivors.Results:At the time of this survey, there were 223 orthoptic departments and 227 stroke units in the UK and Ireland. 317 responses were received representing 178 orthoptic departments – an 80% response rate for orthoptic departments. Of the respondents, 92% reported having a stroke unit in their hospital. A stroke/vision service was provided by 98% of responding orthoptic departments for 77% of stroke units but with only half providing a vision service on the stroke unit. Only 33% of vision services were funded and funding remains the primary barrier to providing a stroke/vision service. About 85% of respondents were aware of the national clinical guidelines for stroke and the BIOS extended practice guidelines for stroke.Conclusions:There has been a positive increase in awareness of stroke-related visual impairment and a steady improvement in provision of eye care for stroke survivors. However, there remains a lack of provision of specialist vision services specifically on stroke units which infers a health inequality for stroke survivors who have visual impairment. Their visual impairments can remain undetected and thus undiagnosed and unmanaged due to unsatisfactory patient care.

WED 259 The challenge of mood and cognition screening in hasu

The National Clinical guideline for stroke, recommends that services for people with stroke should provide screening for mood and cognition within six weeks of stroke using validated tools. In HASU assessing mood and cognition in a timely fashion has been challenging. In 2013 a previous audit showed cognitive screening at 48% and mood screening at only 7%. We instituted a number of measures to improve compliance including education events for MDT staff, a bespoke stroke clerking proforma, to include data collection boxes. We also introduced the briefer ‘YALE questionnaire’ for mood, and the Montreal Cognitive Assessment Tool (MOCA). We also piloted occupational therapy staff using a ‘screening sticker’ in patient notes. A daily MDT was also introduced, primarily to improve patient flow, but also to prompt action planning. Mood screening improved to 92% and cognition screening to 95% on detailed notes audit. These high compliance figures were however not fully reflected on SSNAPP although compliance has improved. SSNAP data input is completed by a single coder, non clinical staff member. We plan to employ a second data clerk and further revise the stroke proforma.

Research protocol: investigating the feasibility of a group self-management intervention for stroke (the GUSTO study)

BackgroundLife after stroke can be an ongoing struggle with over half of all survivors reporting unmet emotional and social needs. In the United Kingdom’s (UK) national clinical guidelines for stroke, self-management is suggested as one approach which can support long-term needs. In the UK NHS, self-management interventions are delivered in various ways. Regardless of the delivery mechanism, a tailored approach and ways to integrate peer support are advocated. Group delivery offers a platform for peer support and has the potential to remain individualised. However, before the efficacy of a group self-management intervention can be tested, the feasibility must be explored. This research investigates the feasibility of a GroUp Self-management intervention for sTrOke (GUSTO).MethodsA randomised waitlist control design will be used to investigate the feasibility of a group self-management intervention adapted from an existing one-to-one intervention called Bridges. A mixed methods approach will be used. Qualitative work will capture participant experience, while quantitative work will allow preliminary comparison between the intervention and waitlist groups (between subjects) and pre-post intervention measures (within subjects). Interviews will be conducted with stroke survivors and focus groups with family and friends to assess acceptability of the intervention.DiscussionThere is a growing interest in group-based self-management interventions for stroke as a method of supporting stroke survivors’ ongoing unmet needs. This is an area with limited research to date. This study will inform design of a fully powered trial which would assess the efficacy of a group self-management intervention following stroke.Trial registrationISRCTN19867168

Veldig tidlig mobilisering ved akutt hjerneslag

Since the first stroke units were established in the 1990s, early mobilisation has formed a key part of the acute treatment. In the context of an updating of national clinical guidelines for stroke, the Norwegian Directorate of Health commissioned the Institute of Public Health to prepare a systematic review of the efficacy and safety of very early mobilisation (within 24 hours) after stroke, compared with current practice, which is early mobilisation (within 48 hours). We have written a systematic review based on a previous review from the Cochrane Collaboration published in 2009. We performed literature searches for randomised controlled studies in MEDLINE, EMBASE and CENTRAL. Three randomised controlled studies were included. Very early mobilisation showed no statistically significant difference in mortality or functional level compared with early mobilisation. We have very little confidence in the results and are therefore uncertain of the efficacy of the intervention. Very early mobilisation, when prolonged and given regularly, can most likely result in increased mortality and poorer functional level. Early mobilisation is useful for many patients, but very early mobilisation, when frequent and prolonged, may also cause injury. Based on current research, we are uncertain of the optimal time to initiate mobilisation after stroke.

Advances in nursing assessment and management of urinary incontinence for stroke survivors

Urinary incontinence (UI) affects up to 60% of patients following stroke. National clinical guidelines in the UK, Australia and New Zealand recommend that people with stroke who have confirmed difficulties, once assessed, should have a continence management plan. Despite this, management is suboptimal, with less than two thirds of stroke units in the UK having a documented plan to promote continence. National clinical guidelines for stroke in the UK also recommend patients with stroke who have continued loss of bladder control 2 weeks after diagnosis should be reassessed to identify the cause of incontinence and have an ongoing treatment plan involving both patients and carers. Despite these guidelines, there is low reported use of assessment tools to screen, assess and manage UI in the acute setting, and the ongoing care and management of UI in rehabilitation and long-term care facilities is inconsistent. This review of the literature highlights the evidence base available and recommends that health professionals looking after stroke survivors should be urged to complete training and education to improve their understanding of the need for assessment and management of UI in stroke survivors for better patient care and recovery.

The latest national clinical guideline for stroke

Editor – There is lack of clarity in the latest National clinical guideline for stroke on cardiac monitoring if a cardio-embolic stroke is suspected.[1][1] It is estimated that between 25 and 60% of atrial fibrillations are paroxysmal (PAF) and approximately one third of the patients affected are

The latest national clinical guideline for stroke

The Intercollegiate Stroke Working Party (ICSWP) published the 5th edition of the National clinical guideline for stroke in October 2016.[1][1] It provides the most up to date and comprehensive overview of the management of stroke available, covering the whole of the pathway from acute care to

Integrated oral health care for stroke patients - a scoping review.

To identify current evidence on the role of nurses and allied health professionals in the oral health management of stroke patients, detailing their current knowledge, attitudes and practices and the potential benefits of an integrated oral care programme. Stroke has disabling oral health effects, such as dysphagia and hindered brushing due to upper limb hemiparesis. Together, these can increase bacterial load, increasing risk of pneumonia. In general management of stroke, nurses play a key role in early identification, assessment and referral, while occupational therapists, dieticians and speech pathologists are important in rehabilitation. While this should logically apply to the oral care of stroke patients, there is currently limited information, especially in Australia. Scoping review. A literature search was conducted using multiple databases regarding the oral health management of stroke patients by nondental professionals, and 26 articles were reviewed. The Australian National Clinical Guidelines for Stroke accentuate the need for oral care following stroke and suggest how hospital staff need to be involved. Currently, there are no Australian studies. However, international literature suggests that lack of oral health knowledge by nurses and poor patient attitude are reflected in infrequent assistance with stroke patient oral hygiene. There is limited information regarding the benefits of nursing-driven oral hygiene programme in reducing pneumonia incidence, and only few studies show that involving nurses in assisted oral care reduces plaque. There are some suggestions that involving nurses and speech pathologists in oral rehabilitation can improve dysphagia outcomes. Managing oral health poststroke is vital, and there is a need for an appropriate integrated oral care service in Australia. Nondental professionals, especially nurses, can play a key role in the poststroke oral health management of stroke patients to reduce complications, especially pneumonia.

The top ten: best practice recommendations for aphasia

ABSTRACTBackground: The move from nationally focused health services towards healthcare globalisation is apparent with the hope that healthcare services will ultimately follow similar quality standards and guidelines throughout the world. Aphasia United, an organisation representing a broad range of professionals and others interested in improving the lives of those with aphasia, undertook a project to gain consensus on best practices to guide aphasia rehabilitation across multiple countries.Aims: To develop and gain multinational consensus on an initial set of best practice recommendations for aphasia.Methods & Procedures: The project entailed three phases: (1) crafting a draft set of recommendations for aphasia management drawing from research evidence and stroke guidelines, (2) obtaining consensus on recommendations from healthcare experts across multiple countries and (3) creating a strategic plan to facilitate dissemination, revision, further development and uptake of best practices. This article reports on the first two phases of this process. Phase 1 entailed reviewing existing research reviews, national clinical guidelines for stroke and/or aphasia and evidence websites to identify recommendations based on high-quality evidence. Nine national stroke and/or aphasia guidelines were identified to serve as the primary source documents. A qualitative theme analysis was used to extract recommendations from these documents. An auditing reviewer examined the source documents and extracts to ensure that results were consistent with sources. Finally, the recommendations were circulated to an expert panel for input. Phase 2 involved a multiple stage consensus process: (1) discussion of draft recommendations by an expanded panel of experts, (2) cycles of revision by an expert working group, (3) an online survey soliciting agreement from a broader panel of experts and (4) an open-ended online survey soliciting consensus from professionals across multiple countries.Outcomes & Results: The cycles of revision and the final consensus of 500 aphasia experts across multiple countries resulted in 10 best practice recommendations for aphasia including screening, assessment, intervention and discharge recommendations.Conclusions: The top 10 recommendations achieved very strong consensus among participants. These results provide an initial set of recommendations that might serve as a basis for translating evidence into practice to improve aphasia services. Future efforts should be directed at determining barriers to implementation. In addition, individual countries or groups (whether represented in the consensus process or not) will necessarily need to consider the applicability of recommendations to their own cultural and ethnic traditions and national practices.

Updated Korean Clinical Practice Guidelines on Decompressive Surgery for Malignant Middle Cerebral Artery Territory Infarction.

Clinical practice guidelines (CPGs), which provide systemic reviews of accumulated scientific evidence, are used by clinicians to choose optimal treatment modalities. In Korea, the Clinical Research Center for Stroke (CRCS) published the first version of its CPGs for stroke in October 2009; it was based on articles that had been reported before June 2007 [1]. Since then, major trials of decompressive surgery for malignant middle cerebral artery (MCA) have been published, and the CRCS and Korean Society of Cerebrovascular Surgeons (KSCVS) therefore decided to revise the CPGs to reflect this new evidence. To select source papers for the revision, we searched Pubmed for English-language articles published between July 2007 and May 2014 that contained the word “stroke,” plus any one of the following terms or phrases: “malignant MCA infarction,” “hemicraniectomy,” and “decompressive surgery.” We retrieved 122 articles with the key words “stroke” and “malignant MCA infarction,” 136 articles with “stroke” and “hemicraniectomy,” and 225 articles with “stroke” and “decompressive surgery.” We then narrowed this pool of articles down by limiting the search to prospective, randomized clinical trials, pooled analyses, and meta-analyses and found five such articles that were published during this period. We reviewed a total of five randomized, clinical trials [2-6], one pooled analysis [7], and one meta-analysis [4], including three studies [2,3,7] that were mentioned in the first edition. The revised versions of the CPGs for decompressive surgery from the European Stroke Organization (ESO) (May 2008) [8], the Scottish Intercollegiate Guidelines Network (December 2008) [9], the National Clinical Guidelines for Stroke of the Royal College of Physicians (July 2008) [10], and the American Heart Association (AHA)/American Stroke Association (ASA) guidelines (published, respectively, in 2013 and 2014) [11,12] were also considered. After we reviewed these articles and described new evidence in guidelines, each piece of evidence and recommendation was given a strength based on a definition of evidence level and recommendation grade used in the KSCVS and the CRCS guidelines (Table 1). Table 1. Evidence levels and recommendation grades used by the Korean Society of Cerebrovascular Surgeons and the Clinical Research Center for Stroke

WHAT ARE THE PATTERNS OF DYING IN ACUTE STROKE?

IntroductionImplementation of stroke professionals' palliative care role outlined in the UK National Clinical Guidelines for stroke is challenged by uncertainty about prognosis. Understanding the patterns of dying in acute stroke may help stroke clinicians improve implementation.Aim(s) and method(s)To identify the patterns of dying in acute stroke services, and explore patient and family carer experiences. Over a six month period, biographical and clinical data, including the type of dying trajectory for deceased patients, were collected from admissions to four acute stroke services. Death trajectories were classified as sudden; rapid; episodic; slow decline; or other. Interviews were conducted with a sample of patients, family carers and bereaved relatives, exploring narratives of experience and initiation of end of life care.Results686 admissions were screened; with 627 (91.4%) eligible for inclusion. Six patients, nine family members and two bereaved family members took part in interviews. There were 91 deaths during the study period (14.5% of stroke patients) with dying trajectories classified for 72 deceased patients. Five (7.3%) were classed as sudden deaths; 64 (88.6) as rapid; 2 (3.3%) as episodic and 1 (0.8%) as slow decline. Interviews highlighted the significance that patients and families attach to clinical geography, including the type of care setting, in making sense of prognosis, and helpful messages that staff could use around planning for end of life care.Conclusion(s)The pattern of dying that acute stroke service staff encounter most is a rapid decline in a patient's condition, with a distinct terminal phase, although not set within a context of deterioration.

Raising stroke awareness among young women

British Journal of Neuroscience NursingVol. 10, No. 6 CommentsRaising stroke awareness among young womenDawn Good, Tracy PalmerDawn GoodSearch for more papers by this author, Tracy PalmerSearch for more papers by this authorDawn Good; Tracy PalmerPublished Online:16 Dec 2014https://doi.org/10.12968/bjnn.2014.10.6.266AboutSectionsView articleView Full TextPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookTwitterLinked InEmail View article References Intercollegiate Stroke Working Party (2012) National Clinical Guideline for Stroke. 4th edn, Royal College of Physicians, London. http://tinyurl.com/oowvlnn (accessed 21 November 2014) Google ScholarNational Institute for Health and Care Excellence (2006) NICE clinical guideline 36. The management of atrial fibrillation. http://tiny.cc/0yzvpx (accessed 25 November 2014) Google ScholarNational Institute for Health and Care Excellence (2008) NICE clinical guideline 68. Diagnosis and initial management of acute stroke and transient ischaemic attack. http://tiny.cc/nyzvpx (accessed 25 November 2014) Google ScholarSolenski N (2004) Transient Attacks: part1 diagnosis and evaluation. The American Family Physician http://www.aafp.org/afp/2004/0401/p1665.html (accessed 25 November 2014) Google ScholarStroke Association (2012) Women and Stroke fact sheet. http://tiny.cc/kvzvpx (accessed 25 November 2014) Google ScholarStroke Association (2014a) World Stroke Day 2014: women and stroke. http://tiny.cc/zrnx-px (accessed 26 November 2014) Google ScholarStroke Association (2014b) UK women unaware of their stroke risk, new poll reveals. http://tiny.cc/pz0dqx (accessed 4 November 2014) Google ScholarTowfighi A1, Saver JL, Engelhardt R, Ovbiagele B (2007) A midlife stroke surge among women in the United States. Neurology 69(20): 1898–1904 Crossref, Google ScholarTouzé E1, Rothwell PM (2007) Heritability of ischaemic stroke in women compared with men:genetic epidemiological study. The Lancet Neurology 6(2): 125–33 Crossref, Google Scholar FiguresReferencesRelatedDetails 2 December 2014Volume 10Issue 6ISSN (print): 1747-0307ISSN (online): 2052-2800 Metrics History Published online 16 December 2014 Published in print 2 December 2014 Information© MA Healthcare LimitedPDF download