Guidelines for Prevention and Management of Stroke

Objectives

Implement stroke prevention and care through the National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke under the National Health Mission, addressing stroke as a major cause of mortality and disability through integrated prevention, early detection, treatment, rehabilitation and secondary prevention.[1][2]Improve the quality of care across primary, secondary and tertiary services, with district hospitals as a principal platform for acute stroke capability and rehabilitation.[3]

• Reduce first and recurrent strokes by preventing and controlling hypertension, diabetes, dyslipidaemia, obesity, tobacco use, harmful alcohol consumption, unhealthy diet, physical inactivity, cardiac disease and atrial fibrillation.[4][5]
• Strengthen population-wide and high-risk prevention through health promotion, risk assessment, screening and treatment for cardiovascular risk factors.[4][6]
• Ensure rapid recognition, stabilisation and referral of suspected stroke and transient ischaemic attack, followed by urgent diagnostic assessment and appropriate treatment.[7][8][9]
• Provide acute care that distinguishes ischaemic from haemorrhagic stroke, supports timely thrombolysis and thrombectomy for eligible patients, manages complications and enables specialist referral when required.[9][10]
• Deliver secondary prevention through antiplatelet therapy, anticoagulation where indicated, blood-pressure control, diabetes management, lipid-lowering treatment, carotid intervention for eligible patients and management of other modifiable risks.[11][12][13]
• Improve functional recovery, independence, social participation and quality of life through early, multidisciplinary and sustained rehabilitation, including post-discharge and community reintegration support.[14][15][16]

Implementation

Deliver an integrated, tiered stroke-care pathway through Health and Wellness Centres, primary healthcare teams, district-level non-communicable disease clinics, district hospitals, stroke-ready hospitals, Cardiac and Stroke Care Units and higher-level specialist centres.[1][2][17][18]Primary care focuses on prevention, risk assessment, recognition, stabilisation, referral and rehabilitation, while secondary and tertiary services provide acute management, complex investigations, specialist treatment and advanced rehabilitation.[7]

• Use community enumeration, risk assessment, weekly fixed-day screening and follow-up to identify hypertension and diabetes among adults aged over 30 years, refer abnormal findings for confirmation and treatment, and provide medicines and lifestyle support.[17][8]
• Mobilise Accredited Social Health Activists, auxiliary nurse midwives and primary healthcare teams to promote healthy behaviours, identify warning signs, communicate urgent referrals and support adherence, follow-up and home-based rehabilitation.[8][19]
• Refer suspected acute stroke directly to the nearest stroke-ready hospital, particularly within three hours of symptom onset, where computed tomography, thrombolysis and trained staff should be available around the clock.[20]
• Establish geographically defined stroke units with written protocols, multidisciplinary staffing, urgent imaging, continuous assessment, complication management, rehabilitation planning and caregiver education.[21][22]A minimum unit model includes four beds, at least two doctors trained in stroke care, four nurses and a physiotherapist.[21]
• Upgrade existing district hospital cardiac facilities into Cardiac and Stroke Care Units or establish stand-alone four-bedded Stroke Care Units, prioritising locations with readily available computed tomography and undertaking manpower gap analysis before staffing decisions.[23][24]
• Equip district services with monitoring, ventilation, infusion, rehabilitation and deep-vein thrombosis prevention equipment; provide essential laboratory, cardiac and imaging investigations, alongside thrombolytics, antiplatelets, anticoagulants and emergency medicines.[18][25][24]
• Apply time-sensitive acute ischaemic stroke pathways, including assessment for thrombolysis within 4.5 hours and selected thrombectomy within 24 hours of the last known well, with transfer to appropriately equipped higher centres for thrombectomy, neurosurgery or unavailable investigations.[10][26]
• Require informed consent and shared decision-making before thrombolysis, calculate and verify weight-based dosing, maintain safe blood pressure, avoid unnecessary invasive procedures and transfer patients for monitored post-treatment care.[27][28]
• Monitor thrombolysis through frequent vital-sign and neurological observations, repeat brain imaging at 24 hours or sooner if deterioration occurs, and withhold antiplatelet and anticoagulant therapy during the first 24 hours.[28][29]
• Maintain clinical monitoring for oxygenation, temperature, blood pressure, glucose, renal function, consciousness, swallowing, nutrition, venous thrombosis, infections and raised intracranial pressure, using specified treatment thresholds and escalation where necessary.[30][31][32][33]
• Deliver secondary prevention through physician-led risk assessment within one week, relevant brain, vascular, cardiac and laboratory investigations, and individually indicated antithrombotic, antihypertensive, lipid-lowering and diabetes treatment.[11][12][13]
• Provide rehabilitation through multidisciplinary teams spanning medical, nursing, physiotherapy, occupational therapy, speech and language therapy, psychology, orthotics, dietetics and social work; assess patients early, set goals with patients and caregivers, and continue therapy through outpatient or home-care services.[14][15]
• Use tiered rehabilitation provision, from basic district-hospital interventions to intermediate low-cost equipment and advanced specialist-centre technologies, with referral to higher centres for services unavailable locally.[34][35]
• Maintain screening records, submit them to districts, use supportive supervision and routine case review, and monitor patient-specific clinical measures such as blood pressure, blood glucose, international normalised ratio, functional goals and rehabilitation progress.[8][19][14]

Monitoring & Evaluation

Monitoring combines programme-service records, clinical assessment, treatment-safety surveillance and rehabilitation follow-up, but the guidance does not establish a comprehensive national indicator set, reporting schedule, audit system, surveillance framework or formal accountability structure.[17][8][22]

• Maintain, analyse and submit non-communicable disease screening records to district level; use supportive supervision and routine case review to oversee community screening.[8]
• Track hypertension and diabetes screening through enumeration, community risk assessment, referral for diagnostic confirmation, monthly follow-up and medicine provision.[17]
• Monitor blood pressure, blood glucose and complications among patients receiving chronic disease management; conduct monthly international normalised ratio testing for atrial fibrillation patients receiving anticoagulation at district level.[8][19]
• Evaluate stroke-risk prediction tools across age, sex and regional groups, assess additional risk factors, and determine whether risk-score use improves primary prevention.[5]
• Use annual transcranial Doppler screening from age two for children with sickle cell disease at elevated stroke risk.[6]
• Record consciousness using the Glasgow Coma Scale and assess neurological deficit with the National Institutes of Health Stroke Scale where appropriate; use urgent imaging to differentiate ischaemic and haemorrhagic stroke and identify stroke mimics.[22]
• Monitor acute stroke physiology, including temperature, blood pressure, blood glucose, renal function, oxygenation and neurological status. After thrombolysis, measure blood pressure every 15 minutes for two hours, every 30 minutes for six hours and hourly for 16 hours, maintaining it below 180/105 mmHg.[30][31]
• Document neurological observations hourly after thrombolysis, repeat National Institutes of Health Stroke Scale assessment following significant change, perform brain imaging at 24 hours or earlier after deterioration, and monitor for bleeding and coagulation abnormalities.[28][29]
• Assess swallowing, mobility and handling needs early in admission; maintain intake-output charts during raised intracranial-pressure management and conduct indicated coagulation testing before anticoagulation.[32][33]
• Assess recurrent vascular risk after stroke or transient ischaemic attack through blood pressure, diabetes, lipid, lifestyle, cardiac-rhythm and vascular investigations, including Holter monitoring in selected cases.[11]
• Monitor anticoagulation using international normalised ratio targets, generally 2.0–3.0, and assess carotid-intervention eligibility with concordant imaging and an operator perioperative morbidity and mortality threshold below 6%.[12][13]
• Review rehabilitation progress against functional goals, participation, self-care, fatigue and affected-limb use; reassess physiotherapy biweekly until discharge, weekly during the first month, monthly to six months and twice yearly thereafter until maximal recovery.[14]
• Use the Modified Barthel Index and Fugl-Meyer assessment system to establish and reassess functional status during rehabilitation, while monitoring physiological responses to early mobilisation.[36][37]

Costing & Financing

Financing information is limited primarily to indicative district-level Stroke Care Unit and Cardiac and Stroke Care Unit investments. Costs are to be incorporated in State Programme Implementation Plans under Health System Strengthening, procured through competitive market-price discovery and adjusted to patient load, state norms and manpower-gap analysis.[23][24]

• Provide one-time assistance of 150 lakh Indian rupees to establish a four-bedded Cardiac Care Unit and a recurring grant of 26 lakh Indian rupees annually.[18]
• Allocate indicative non-recurring expenditure of 890,500 Indian rupees to expand a Coronary Care Unit into a Comprehensive Stroke Care Unit, with annual recurring expenditure of 4,667,540 Indian rupees for investigations, drugs, manpower and training.[23]
• Base Comprehensive Stroke Care Unit medicine and investigation provisions on an assumed annual caseload of 200 patients, while allowing states to revise amounts for local caseload and norms.[25][23]
• Allocate 27,01,000 Indian rupees for non-recurring establishment of a stand-alone Stroke Care Unit and 10,245,275 Indian rupees annually for recurring investigations, drugs, other provisions, manpower and training.[38][39]
• Base stand-alone Stroke Care Unit drug provision on up to 150 patients annually, and provide up to eight nurses and one physiotherapist subject to gap analysis.[38]
• Recognise that intermediate, Level 2 rehabilitation equipment is characterised as low cost and readily procurable, although no monetary value is supplied.[34]

No wider national budget, external financing source, resource-mobilisation strategy, quantified funding gap or economic evaluation is specified. Cost is nevertheless identified as a barrier to primary stroke and cardiovascular disease prevention.[5][18][39]