When should I consider referring a patient with ischaemic stroke for specialist assessment or rehabilitation services?

Consider referring a patient with ischaemic stroke for specialist assessment immediately by arranging emergency admission to an acute stroke facility or hyperacute stroke unit for urgent assessment and treatment by a specialist physician without delay. This includes urgent brain imaging within 1 hour of hospital arrival to exclude intracerebral haemorrhage before starting antithrombotic treatment.

After initial acute management, refer patients who require rehabilitation to specialist stroke services, which may include inpatient stroke units, specialist stroke teams in the community, or specialist inpatient neurorehabilitation units. Referral should be considered especially if the patient has ongoing neurological deficits, swallowing difficulties, cognitive impairment, mood disorders, continence problems, or fatigue affecting daily life.

Specific indications for referral to specialist rehabilitation or support services include:

• Swallowing difficulties or deterioration in swallowing function requiring speech and language therapy and dietetic input.
• Incontinence issues needing continence team involvement.
• Cognitive impairment warranting neuropsychological assessment.
• Severe or persistent mood disorders requiring psychological or psychiatric referral.
• Post-stroke fatigue significantly impacting daily activities after excluding other causes.
• Need for social care assessment before discharge to community.

Follow-up in primary care should include screening for complications and unmet needs, with referral back to specialist services as appropriate.

These recommendations align with NICE guidelines on stroke and TIA diagnosis and management, and stroke rehabilitation in adults ¹,²,³.