Anthony Rudd

• King's College London

This chapter briefly describes some of the less common causes of stroke and some of the less common groups of patients who have stroke. It is not an exhaustive list and does not describe in much detail each of the individual conditions. References to review articles are included where further information is needed. It is important to be aware of th...

The number of drugs which a physician needs to be familiar with when managing stroke is fairly small. In Vietnam, there are several drugs in common use that are not used much in Europe and the USA. The evidence for some of the commonly used drugs will be reviewed in this chapter. Much of the information will overlap with information elsewhere in th...

Making a diagnosis of stroke is only the first stage in offering effective treatment and secondary prevention. Stroke is a syndrome made up of many different pathologies. Understanding basic neuroanatomy is essential for all clinicians treating stroke to be able to effectively assess patients clinically and to understand the results of their invest...

Most stroke services have an unrelenting workload. But up to 50% of referrals have final diagnoses that are not stroke. This does not mean that they are necessarily inappropriately managed, but a significant proportion with good management by dispatchers, paramedics, emergency medical staff could result in more appropriate use of limited resources....

ICH is a common problem in Vietnam and other parts of South Asia. Until recently, intracerebral haemorrhage (ICH) was thought to be untreatable and either patients survived or they died. Recent research identifying signs predictive of rebleeding, management of raised blood pressure, reversal of anticoagulation, surgery and the implementation of urg...

Acute stroke is commonly followed by dehydration, partly because the patient may have been unwell for some time before being taken to hospital and partly because once in hospital hydration may not be the first thing that gets dealt with. There may also be dysphagia and cannot swallow or they have reduced thirst sensation or reduced conscious levels...

This is often the most neglected part of the stroke pathway but one that managed effectively has some of the greatest potential to enable effective treatment. Successful acute stroke care requires that treatment is started very early. Whether it is intravenous thrombolysis, endovascular thrombectomy, reversal of anticoagulation or control of high b...

Stroke is a significant public health concern in Vietnam due to a high incidence and prevalence of death and disability in the population. Since early 2008 in Vietnam, cerebrovascular diseases have been a major concern by both the Vietnam Association of Cardiology and the Vietnam Association of Neurology. The Vietnam Association of Stroke was estab...

As presented in this chapter on Stroke Units, one of the important components for effective specialist stroke care is that units should have clear protocols for the management of common problems affecting acute stroke patients. While it is important that there are always staff on duty with expertise in stroke, there will inevitably be many situatio...

Worldwide vascular disease is the most common cause of death and one of the most important causes of adults developing long-term disability. Ischaemic heart disease is the number one cause with cerebrovascular disease taking second position. The Global Burden of Disease (GBD) study data [1] are summarised in Fig. 7.1 showing that as a cause of disa...

Rapid accurate diagnosis of TIA is essential to reduce the risk of development of stroke. This chapter reviews how TIA is defined and its epidemiology. The importance of a skilled history from the patient and any witnesses is emphasised with the key clinical features described. The key investigations are described and the evidence for management re...

Background Stroke registers are recommended as a key priority by the Lancet Neurology World Stroke Organisation Commission for Stroke, 2023, and the African Stroke Leaders’ Summit, 2022. Aims This scoping review aims to map where stroke registers have been implemented in SSA. The article then compares and critiques the methods and definitions used...

Background: HIV infection rates are relatively low in Sierra Leone and in West Africa but the contribution of HIV to the risk factors for stroke and outcomes is unknown. In this study, we examined stroke types, presentation, risk factors and outcome in HIV stroke patients compared with controls. Methods: We used data from the Stroke in Sierra Le...

Background: Prehospital care including recognition of stroke symptoms by the public and professionals combined with an efficient and effective emergency medical service (EMS) is essential to increase access to effective acute stroke care. We undertook a survey to document the status of stroke prehospital care globally. Methods: A survey was dist...

Background: There is limited information on long term outcomes after stroke in Sub-Saharan Africa (SSA). Current estimates of case fatality rate (CFR) in SSA are based on small sample sizes with varying study design and report high heterogeneity. Aims: We report CFR and functional outcomes from a large, prospective, longitudinal cohort of stroke pa...

Background: Limited data are available on sex-related disparities in long-term outcomes after stroke. We estimated sex differences in various stroke long-term outcomes among survivors after stroke in a prospective 25-year follow-up study. Methods: Individuals recruited to the South London Stroke Register, an ongoing multi-ethnic urban-based popu...

Background In England, the provision of early supported discharge is recommended as part of an evidence-based stroke care pathway. Objectives To investigate the effectiveness of early supported discharge services when implemented at scale in practice and to understand how the context within which these services operate influences their implementat...

Introduction: Stroke is the second most common cause of adult death in Africa. This study reports the demographics, stroke types, stroke care and hospital outcomes for stroke in Freetown, Sierra Leone. Methods: A prospective observational register recorded all patients 18 years and over with stroke between May 2019 and April 2020. Stroke was define...

Background and purpose: The coronavirus disease 2019 (COVID-19) pandemic has potentially caused indirect harm to patients with other conditions via reduced access to health care services. We aimed to describe the impact of the initial wave of the pandemic on admissions, care quality, and outcomes in patients with acute stroke in the United Kingdom...

Objectives: To guide policy when planning reperfusion thrombolysis (IVT) and thrombectomy (MT) services for acute stroke in England, focussing on the choice between ‘mothership’ (direct conveyance to an MT centre) and ‘drip-and-ship' (secondary transfer for MT after local IVT) provision and the impact of bypassing local acute stroke centres.Methods...

Objective The first observational study to investigate the impact of early supported discharge (ESD) on length of hospital stay in real-world conditions. Design Using historical prospective Sentinel Stroke National Audit Programme (SSNAP) data (1 January 2013–31 December 2016) and multilevel modelling, cross-sectional (2015–2016; 30 791 patients n...

Background Acute stroke impairments often result in poor long-term outcome for stroke survivors. The aim of this study was to estimate the trends over time in the prevalence of these acute stroke impairments. Methods and findings All first-ever stroke patients recorded in the South London Stroke Register (SLSR) between 2001 and 2018 were included...

Background Seven-day working in hospitals is a current priority of international health research and policy. Previous research has shown variability in delivering evidence-based clinical interventions across different times of the day and week. We aimed to identify factors influencing such variations in London hyperacute stroke units. Objectives T...

The Changing Role of the Hospital in European Health Systems - edited by Martin McKee July 2020

Background Implementation of stroke early supported discharge (ESD) services has been recommended in many countries’ clinical guidelines, based on clinical trial evidence. This is the first observational study to investigate the effectiveness of ESD service models operating in real-world conditions, at scale. Methods AND RESULTS Using historical p...

Background and purpose Machine learning (ML) has attracted much attention with the hope that it could make use of large, routinely collected datasets and deliver accurate personalised prognosis. The aim of this systematic review is to identify and critically appraise the reporting and developing of ML models for predicting outcomes after stroke. M...

Background and Purpose— Care homes provide care to many stroke survivors, yet little is known about changes in care home use over time. We aim to determine trends in discharge to care homes, to explore the characteristics of stroke survivors over time (1995–2018), and to identify the associations between these characteristics and discharge to care...

Objective To investigate variations in quality of acute stroke care and outcomes by day and time of admission in London hyperacute stroke units compared with the rest of England. Design Prospective cohort study using anonymised patient-level data from the Sentinel Stroke National Audit Programme. Setting Acute stroke services in London hyperacute...

Objectives Seven-day working in hospitals is a current priority of international health research and policy. Previous research has shown variability in delivering evidence-based clinical interventions across different times of day and week. We aimed to identify factors influencing such variations in London hyperacute stroke units (HASUs). Design I...

In the original publication [1] figures S1 and S2 should have been part of the main text rather than additional files.

Background: The benefit of statins on stroke incidence is well known. However, data on the relationship between pre- and post-stroke statin use, recurrence, and survival outcomes are limited. We aim to investigate the short- and long-term relationships between statin prescription, stroke recurrence, and survival in patients with first-ever ischemi...

Background: Stroke Early Supported Discharge (ESD) is a service innovation that facilitates discharge from hospital and delivery of specialist rehabilitation in patients' homes. There is currently widespread implementation of ESD services in many countries, driven by robust clinical trial evidence. In England, the type of ESD service patients rece...

Stroke remains one of the most important causes of death and disability worldwide. Effective prevention could reduce the burden of stroke dramatically. The management of stroke has undergone a revolution over the last few decades, particularly with the development of techniques for revascularisation of patients with ischaemic stroke. Advanced imagi...

Background: Randomized controlled trials provide high-level evidence, but the necessity to include selected patients may limit the generalisability of their results. Methods: Comparisons were made of baseline and outcome data between patients with acute ischemic stroke (AIS) recruited into the alteplase-dose arm of the international, multi-center,...

Background and purpose: There is limited information on factors, trends, and outcomes in return to work at different time-points post-stroke; this study aims to identify these in a multi-ethnic urban population. Methods: Patterns of return to work were identified in individuals in paid work prior to first-ever stroke in the population-based Sout...

Background Stroke care and outcomes have improved significantly over the past decades. It is unclear if patients who had a stroke in hospital (in-hospital stroke, IHS) experienced similar improvements to those who were admitted with stroke (community-onset stroke, COS). Methods Data from the South London Stroke Register were analysed to estimate t...

Background Centralising acute stroke services is an example of major system change (MSC). ‘Hub and spoke’ systems, consisting of a reduced number of services providing acute stroke care over the first 72 hours following a stroke (hubs), with a larger number of services providing care beyond this phase (spokes), have been proposed to improve care an...

Objectives To investigate whether further centralisation of acute stroke services in Greater Manchester in 2015 was associated with changes in outcomes and whether the effects of centralisation of acute stroke services in London in 2010 were sustained. Design Retrospective analyses of patient level data from the Hospital Episode Statistics (HES) d...

Background Depression is a common neuropsychiatric consequence of stroke. We identified trajectories of depression symptoms in men and women and examined their associations with 10‐year all‐cause mortality. Methods Data were obtained from the South London Stroke Register (1998‐2016). Socio‐demographic, stroke severity and clinical measures were co...

Background: Results of small trials indicate that fluoxetine might improve functional outcomes after stroke. The FOCUS trial aimed to provide a precise estimate of these effects. Methods: FOCUS was a pragmatic, multicentre, parallel group, double-blind, randomised, placebo-controlled trial done at 103 hospitals in the UK. Patients were eligible...

Background As the average life expectancy increases, more people are predicted to have strokes. Recent studies have shown an increasing incidence in certain types of cerebral infarction. We aimed to estimate time trends in incidence, prior risk factors, and use of preventive treatments for ischaemic stroke (IS) aetiological subtypes and to ascertai...

Introduction: The purpose of this study is to investigate which factors are associated with physiotherapy provision to hospitalised stroke patients. Methods: Data were analysed for stroke patients admitted to hospital in England and Wales between April 2013 and March 2017 recorded on the Sentinel Stroke National Audit Programme (SSNAP) national...

Background and Purpose— Well-organized stroke care is associated with better patient outcomes, but the most important organizational factors are unknown. Methods— Data were extracted from the Sentinel Stroke National Audit Programme of adults with acute stroke treated in stroke hospitals in England and Wales between April 2013 and March 2015. Mult...

Purpose: Both intravenous thrombolysis (IVT) and intra-arterial endovascular thrombectomy (ET) improve the outcome of patients with acute ischaemic stroke, with endovascular thrombectomy being an option for those patients with large vessel occlusions. We sought to understand how organisation of services affects time to treatment for both intraveno...

Over the last 20 years, England, Wales and Northern Ireland have developed an audit programme that now encompasses nearly all patients admitted to hospital with a stroke. This article records and reviews some questions that have been answered using data from the audit: Is the rate of institutional care after rehabilitation a possible measure of out...

Stroke has multiple etiologies but the underlying genes and pathways are largely unknown. We conducted a multi-ancestry genome-wide association meta-analysis in 521,612 individuals (67,162 cases and 454,450 controls) and discovered 22 novel stroke risk loci bringing the total to 32. We further found shared genetic variation with related vascular tr...

Background: The economic implications of major system change are an important component of the decision to implement health service reconfigurations. Little is known about how best to report the results of economic evaluations of major system change to inform decision-makers. Reconfiguration of acute stroke care in two metropolitan areas in Englan...

Background: We aimed to estimate socioeconomic disparities in the incidence of hospitalisation for first-ever stroke, quality of care, and post-stroke survival for the adult population of England. Methods: In this cohort study, we obtained data collected by a nationwide register on patients aged 18 years or older hospitalised for first-ever acut...

Background and purpose: Intravenous thrombolysis with alteplase is one of the few approved treatments for acute ischemic stroke; nevertheless, little is known about its long-term effects on survival and recovery because clinical trials follow-up times are limited. Methods: Patients registered between January 2005 and December 2015, to the popula...

Background: Few interventions are proven to increase recruitment in clinical trials. Recruitment to RESTART, a randomised controlled trial of secondary prevention after stroke due to intracerebral haemorrhage, has been slower than expected. Therefore, we sought to investigate an intervention to boost recruitment to RESTART. Methods/design: We co...

This chapter describes the epidemiology of stroke, a major cause of disability and premature death worldwide. The accurate classification of strokes is critical in conducting research and guiding clinical management. There are a number of classifications in clinical use, although a precise delineation of stroke subtypes requires the integration of...

Introduction Stroke registries are used in many settings to measure stroke treatment and outcomes, but rarely include data on health economic outcomes. We aimed to extend the Sentinel Stroke National Audit Programme registry of England, Wales and Northern Ireland to derive and report patient-level estimates of the cost of stroke care. Methods An i...

Compelling evidence indicates that the organization and delivery of stroke care makes a difference in the chances of patients surviving, their level of disability, and the chances of further strokes. Most evidence-based interventions do not require expensive high-technology medicine but rather need well-organized basic care delivered by people with...

Introduction Stroke is a leading cause of adult disability and death worldwide. The neurological impairments associated with stroke prevent patients from performing basic daily activities and have enormous impact on families and caregivers. Practical and accurate tools to assist in predicting outcome after stroke at patient level can provide signif...

Background and aims Clinical predictive models for stroke recovery could offer the opportunity of targeted early intervention and more specific information for patients and carers. In this study, we developed and validated a patient-specific prognostic model for monitoring recovery after stroke and assessed its clinical utility. Methods Four hundr...

Background Previous studies have found low use of anticoagulation prior to stroke, in people with atrial fibrillation (AF). This study examined data on patients with AF-related stroke from a population-based stroke register, and sought to examine changes in management of AF prior to stroke, and reasons for suboptimal treatment, in those who were kn...

Factors associated with anticoagulant prescription in high-risk patients (CHA2DS2-VASc≥2); results of multivariable logistic regression analysis. (DOCX)

Background Recruitment to randomised prevention trials is challenging, not least for intracerebral haemorrhage (ICH) associated with antithrombotic drug use. We investigated reasons for not recruiting apparently eligible patients at hospital sites that keep screening logs in the ongoing REstart or STop Antithrombotics Randomised Trial (RESTART), wh...

Background Research into methods to boost recruitment has been identified as the highest priority for randomised controlled trial (RCT) methodological research in the United Kingdom. Slow recruitment delays the delivery of research and inflates costs. Using electronic patient records has been shown to boost recruitment to ongoing RCTs in primary ca...

Background and purpose: Despite guidelines for specialist assessment in hospital for stroke, it is important to identify patient characteristics, trends, and outcome in patients not admitted to hospital compared with patients admitted to hospital. Methods: Population-based stroke register of first in a life time strokes between 1995 and 2012 wer...

Background The global epidemiological shift of disease burden towards long-term conditions means understanding long-term outcomes of cardiovascular disease is increasingly important. More people are surviving stroke to experience its long-term consequences, but outcomes in people living more >10 years after stroke have not been described in detail....

I1 Introduction Mona Kanaan, Noreen Dadirai Mdege, Ada Keding O1 The HiSTORIC trial: a hybrid before-and-after and stepped wedge design RA Parker, N Mills, A Shah, F Strachan, C Keerie, CJ Weir O2 Stepped wedge trials with non-uniform correlation structure Andrew Forbes, Karla Hemming O3 Challenges and solutions for the operationalisation of the EN...

Background There is no robust evidence that screening patients with acute stroke for dysphagia reduces the risk of stroke-associated pneumonia (SAP), or of how quickly it should be done after admission. We aimed to identify if delays in bedside dysphagia screening and comprehensive dysphagia assessments by a speech and language therapist (SALT) wer...

Background Implementing major system change in healthcare is not well understood. This gap may be addressed by analysing change in terms of interrelated components identified in the implementation literature, including decision to change, intervention selection, implementation approaches, implementation outcomes, and intervention outcomes. Methods...

Purpose: Several risk stratification scores for predicting stroke-associated pneumonia have been derived. We aimed to evaluate the performance and clinical usefulness of such scores for predicting stroke-associated pneumonia. Method: A systematic literature review was undertaken in accordance with the Preferred Reporting Items for Systematic Rev...

Stroke incidence is increased in Black individuals but the reasons for this are poorly understood. Exploring the differences in aetiological stroke subtypes, and the extent to which they are explained by conventional and novel risk factors is an important step in elucidating the underlying mechanisms for this increased stroke risk. Methods: Betw...

Background: Studies in many health systems have shown evidence of poorer quality health care for patients admitted on weekends or overnight than for those admitted during the week (the so-called weekend effect). We postulated that variation in quality was dependent on not only day, but also time, of admission, and aimed to describe the pattern and...

Introduction: Previous studies have identified that social deprivation is associated with the onset of stroke, with people from areas of higher deprivation being more likely to have a stroke at a younger age. Methods: Data were extracted from the national stroke register (Sentinel Stroke National Audit Programme (SSNAP)) of adults with acute ischem...

Introduction: National clinical guidelines in England and Wales recommend that intravenous thrombolysis is provided without restriction based on age. However, thrombolysis trials have included very few patients aged 90 and over. We therefore analysed data from the national stroke register of England and Wales to describe the safety and outcomes of...

Introduction: National clinical guidelines in England and Wales recommend that intravenous thrombolysis is provided regardless of pre-stroke disability, but thrombolysis trials have included very few patients with a modified Rankin scale (mRS) score of more than 2. We therefore analysed data from the national stroke register of England and Wales of...

Objectives: Our aim was to identify the factors influencing the selection of a model of acute stroke service centralization to create fewer high-volume specialist units in two metropolitan areas of England (London and Greater Manchester). It considers the reasons why services were more fully centralized in London than in Greater Manchester. Metho...

Background: The natural history of depression in stroke patients is complex and the mechanism of change in symptoms over time is not fully understood. We hypothesise that there are different trajectories of symptoms after stroke. Methods: The primary analysis comprised 761 patients who completed 5 years follow up, obtained from the prospective S...