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Nursing Practice Keywords Stroke/Transient ischaemic

attack/FAST checklist/Brain/Imaging
Review
Stroke This article has been
double-blind peer reviewed

In this article...
● D
 efinitions of the different types of stroke
● The burden of stroke for individuals and healthcare systems
● Magnetic resonance imaging versus computed tomography in suspected stroke

Stroke 1: definition, burden, risk

factors and diagnosis
Key points
Author Alwin Puthenpurakal and Jane Crussell are university lecturers in adult nursing
Stroke is an acute, at London South Bank University.
focal injury of the
central nervous Abstract The field of stroke has benefitted from many advances in recent decades,
system of in particular improved imaging techniques. This, coupled with better knowledge of
a vascular origin brain function among professionals and greater awareness of stroke signs and
contributing to a symptoms among the general public, leads to earlier identification, diagnosis and
neurological insult treatment – which are key as stroke is a medical emergency. However, more needs to
be done to reduce the personal and societal burden of stroke. This article, the first of
Many risk factors a five-part series on stroke, discusses definitions, epidemiology, risk factors and
predispose a person diagnosis to help nurses gain in-depth understanding of this complex condition.
to stroke, some
of which are Citation Puthenpurakal A, Crussell J (2017) Stroke 1: definition, burden, risk factors
modifiable through and diagnosis. Nursing Times [online]; 113: 11, 43-47.
public health policies

S
If stroke is troke is the second-leading single Physiologically, stroke is an acute, focal
suspected outside cause of disease in the world, injury of the central nervous system (CNS)
the acute setting, closely behind ischaemic heart of a vascular origin, contributing to a local
reducing the time disease, and the fourth in the UK, or systemic neurological insult. Techno-
to diagnosis and with first-time stroke occurring world- logical advances (Adams et al, 2007) have
treatment is crucial wide every two seconds (World Health proved beneficial in terms of identifying
Organization, 2017). It is also one of the the origins of the injury and determining
Patients with largest causes of disability: half of all whether it is a cerebral infarct, subarach-
suspected stroke stroke survivors have a disability and over noid haemorrhage or intracerebral bleed.
should have a brain one-third are dependent on carers (Stroke However, despite these improvements, the
scan within one Association, 2016; Moorley et al, 2014). definition of stroke remains inconsistent
hour of arriving The media have played a crucial role in (Sacco et al, 2013).
at the hospital raising public awareness of the personal The WHO describes stroke as a clinical
and societal consequences of stroke. Our syndrome typified by “rapidly developing
Clinical examination society has become more cognisant of the clinical signs of focal or global disturbance
and imaging are function and complexity of the human of cerebral function, lasting more than 24
both key in brain, thanks to enhanced multidiscipli- hours or leading to death, with no apparent
diagnosing stroke nary and international communication, cause apart that of vascular origin”
expanding research, increasing media cov- (Hatano, 1976, WHO 1965).
erage, and high-profile cases such as those This definition is no longer accurate, as
of Andrew Marr and Sharon Stone. it does not take into account the advances
that have been and continue to be made in
Definition imaging techniques and diagnostics. The
The term ‘stroke’ was coined and intro- detrimental and permanent effects of
duced to medicine by William Cole in the stroke can occur much earlier, so the
late 17th century (Cole, 1689), and has 24-hour inclusion criteria is not accurate.
remained a generic definition since. Equally, the deterioration of global

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cerebral function can be the result of Fig 1. Areas of the brain and their functions
stroke, but also of other direct or indirect
Parietal lobe
cerebral pathologies. l Language and reading
Frontal lobe
Stroke is different from transient lL  ocomotion and mood l Coordination and
ischaemic attack (TIA) as its symptoms last l Intelligence and judgement sensation
longer than 24 hours and it carries an lL  ogic and decision making l Intelligence and reasoning
increased risk of mortality; diagnosis is lB  ehaviour and personality
lP  lanning and inhibition
supported by evidence of focal infarction or l Memory
haemorrhage on imaging. Conversely, a TIA
is a dysfunction of vascular origin lasting
less than 24 hours, with no evidence of Occipital lobe
infarction on imaging. l Vision
A group of experts convened by the Temporal lobe
American Heart Association and Amer- lS peech and
behaviour
ican Stroke Association (Sacco et al, 2013) lM emory and
has produced consensus definitions in an emotions
attempt to accurately describe the dif- lV ision and
ferent types of stroke (Table 1). hearing

Epidemiology and cost Pituitary gland

While the incidence of stroke is declining in l Hormones
many developed countries, it is likely that, l Growth Cerebellum
with a globally ageing population, the l Fertility l Balance and
Brain stem coordination
absolute numbers of stroke will increase l Blood pressure l Fine muscle control
worldwide. Stroke affects 15 million people l Breathing
worldwide every year; it is estimated that l Heartbeat
l Swallowing
five million of these will die and a further
five million will be left with a permanent

disability (WHO, 2002). This makes stroke

Table 1. Definitions of stroke the second-leading cause of death world-
Type of stroke Description wide behind ischaemic heart disease.
In the US, 795,000 strokes occur each
Ischaemic stroke Neurological dysfunction due to infarction at cerebral, spinal
year (Benjamin et al, 2017) while in the UK
or retinal sites
there are more than 100,000 (Royal College
Silent CNS CNS infarction supported by imaging/neuropathological of Physicians, 2017). Worldwide, someone
infarction evidence without prior acute neurodysfunction has a stroke every two seconds – in the UK
Intracerebral Localised collection of blood in the brain parenchyma/ it is every five minutes; in the US every 40
haemorrhage ventricular system that is not induced by trauma seconds – and worldwide, a stroke leading
to death occurs every four minutes.
Stroke from Non-trauma-induced, rapid development of neurological
In the UK, first-ever stroke affects about
intracerebral symptoms of dysfunction due to localised collection of blood in
230 people per 100,000 population each
haemorrhage the brain parenchyma/ventricular system
year and accounts for 11% of all deaths
Silent cerebral Long-term localised collection of blood in the brain (Rothwell et al, 2005). In England and
haemorrhage parenchyma/subarachnoid space/ventricular system that is not Wales alone, over 80,000 people are hospi-
induced by trauma, with no history of acute neurological talised with acute stroke each year (Inter-
dysfunction. Detected on neuroimaging and neuroexamination collegiate Stroke Working Party, 2016).
Subarachnoid Bleeding into the space between the arachnoid membrane Approximately 85% of strokes are due
haemorrhage and the pia mater of the brain or spinal cord to cerebral infarction, 10% to primary
haemorrhage and 5% to subarachnoid
Stroke from Changes to neurological function and incidence of headaches
haemorrhage. The risk of recurrence is
subarachnoid due to bleeding into subarachnoid space that are not induced
26% within five years and 39% within 10
haemorrhage by trauma
years of a first stroke (Mohan et al, 2011).
Stroke from Thrombosis in the cerebral venous structure that causes Most strokes occur in people over 40
cerebral venous infarction or haemorrhage years of age, but children are also affected.
thrombosis Approximately 400 childhood strokes
Unspecified stroke Acute neurological dysfunction due to ischaemia or occur in the UK each year (Stroke Associa-
haemorrhage lasting for more than 24 hours or until death, and tion, 2017). Children with sickle cell
lacking evidence allowing categorisation disease are 333 times more likely to be at
risk than a normal, healthy child (Ohene-
CNS = central nervous system
Frempong et al, 1998). In the UK, more
alamy

Source: Adapted from Sacco et al (2013)

people are surviving stroke than ever

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Fig 2. Potential impairments from stroke according to brain areas

Frontal lobe Parietal lobe
l Loss of simple movement of body parts l Anomia, agraphia, alexia, dyscalculia, apraxia
l Loss of sequencing l Inability to attend to more than one object at a time
l Loss of spontaneity in interaction l Difficulty drawing objects
l Loss of flexibility in thinking l Inability to focus visual attention
l Broca’s aphasia l Difficulty with hand and eye coordination
l Persistence of a single thought l Difficulty distinguishing left from right
l Inability to focus on a single task
l Mood changes and social behaviour changes
l Problem-solving difficulties Occipital lobe
l Changes in personality l Colour and movement agnosia
l Difficulty reading and writing
l Defects in field of vision
Temporal lobe
l Difficulty locating objects in
l Wernicke’s aphasia
the environment
l Disturbance of selective attendance
l Hallucinations
l Prosopagnosia
l Inaccurately seeing objects
l Difficulty identifying and naming objects
l Inability to recognise words
l Increased aggressive behaviour and
l Difficulty recognising drawn
persistent talking
objects
l Short- and long-term memory loss
l Hypersexuality
l Difficulty categorising objects

Brain stem Cerebellum

l Dysphagia l Tremors and vertigo
l Vertigo l Inability to coordinate fine
l Insomnia movements and to walk
l Sleep apnoea l Inability to reach out and grab
l Difficulty organising or understanding objects
the environment l Slurred speech
l Inability to balance and coordinate movement l Inability to make rapid movements

before; however, it is the largest single (Romero, 2008). Gender, ethnicity and trend has been reversed as risk factor pro-
cause of major disability. The conse- socioeconomic group are further dis- files have changed (WHO, 2011). This
quences of a stroke are wide-ranging and cussed below. reversal is largely due to higher levels of
often highly debilitating. Fig 1 shows the smoking, hypertension and diabetes in
different areas of the brain and their func- Sex lower socioeconomic groups.
tions, while Fig 2 shows the potential Men have a higher risk of a stroke than
impairments resulting from stroke women and often experience stroke at a Diagnosis
according to brain area. younger age (RCP, 2017). However, women Given the above statistics showing the per-
In England, the annual cost to the NHS are more likely to die from stroke, as they sonal and societal cost of stroke, it is
of caring for stroke patients is estimated to tend to live longer and have strokes at an imperative that stroke is efficiently and
be around £1.7bn, with each patient older age (Stroke Association, 2017). effectively diagnosed and treated globally.
costing £22,000 per year on average (RCP, It still carries a high morbidity and mor-
2016a). Previous research found that stroke Ethnicity tality and, despite lower incidence, much
as a whole costs the UK £9bn a year (Stroke White people are more likely than non- remains to be done to improve patient out-
Association, 2014) – this figure includes white people to have atrial fibrillation with comes and prevention.
£2.4bn in informal care costs, £1.3bn in a history of smoking or alcohol use, while Diagnosis is only possible through a
lost income due to disability, death and black people are more likely than white combination of thorough clinical exami-
caring duties, and £800m in benefit pay- people to have sickle cell disease, hyper- nation, critical review of the patient’s his-
ments (Saka et al, 2009). tension and diabetes – all of which are risk tory and careful investigations with multi-
factors for stroke. People of South Asian imaging techniques. Each step adds to the
Risk factors origins are more likely the rest of the popu- clarity of the eventual diagnosis, conse-
There are many risk factors that predispose lation, to have hypertension, high choles- quently improving the chances of patients
people to stroke, some of which are modifi- terol and diabetes (Banerjee et al, 2010). receiving the right treatment and experi-
able. Lack of exercise, poor diet, smoking encing better outcomes.
and excessive alcohol intake are common Socioeconomic group
risk factors that can be countered by cost- People from more deprived areas and back- ‘Time is brain’
effective patient education, and there is an grounds are more likely to have a stroke, Stroke is a medical emergency requiring
urgent need for government-led strategies and the strokes they experience are likely urgent diagnosis and treatment: the
aimed at improving public health. to be more severe (Marshall et al, 2015). phrase ‘time is brain’ stressing that human
Box 1 and Box 2 feature modifiable and Fifty years ago, stroke was associated with nervous tissue is rapidly lost as stroke pro-
alamy

non-modifiable risk factors, respectively higher socioeconomic groups, but this gresses (Saver, 2006).

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Imaging as a guide to treatment

Box 1. Modifiable risk factors Box 2. Non-modifiable risk
for stroke factors for stroke Computed tomography (CT) and magnetic
resonance imaging (MRI) are the two main
High blood pressure – Major risk Advancing age – Most powerful approaches used for brain imaging studies
factor for heart attack and the most independent risk factor for in the hospital setting. They can be further
important risk factor for stroke cardiovascular disease; risk of stroke divided into several types of CT and cate-
Abnormal blood lipids – High total doubles every decade after the age gories of MRI studies.
cholesterol levels, high levels of of 55 With the introduction of better tech-
low-density lipoprotein cholesterol Heredity or family history – Increased niques, the goals of brain imaging have
and triglycerides, and low levels of risk if a first-degree blood relative has shifted to include the detailed evaluation
high-density lipoprotein cholesterol had coronary heart disease or stroke of the intravascular thrombus, identifica-
increase risk of coronary heart disease before the age of 55 (if the relative is a tion of hypoperfused tissues and irrevers-
and ischaemic stroke man) or 65 years (if the relative is a ibly infarcted tissues, and evaluation of
Smoking – Increases risk of woman) thrombolytic and thrombectomical treat-
cardiovascular disease, especially in Sex – Higher rates of coronary ment approaches (Latchaw et al, 2009).
people who started young and heavy heart disease in men compared with Therapy is often guided by the use of
smokers; passive smoking is also a factor women of premenopausal age; risk of either CT or MRI. The primary goal of
Physical inactivity – Increases risk of stroke similar for men and women imaging in patients with suspected stroke
heart disease and stroke by 50% Ethnicity – Stroke occurs more often is to rule out haemorrhage. The current
Obesity – Major risk factor for coronary in black, some Hispanic-American, first-line treatment of acute ischaemic
heart disease and diabetes Chinese and Japanese populations; stroke, after ruling out haemorrhage, is
Unhealthy diet – Low fruit and increased number of deaths from recombinant tissue plasminogen activator
vegetable intake is estimated to cause cardiovascular disease in South Asian (rt-PA) (Hacke et al, 2008).
about 31% of coronary heart disease and black American people The aim of this intravenous, fast-acting
and 11% of stroke worldwide; high intake Source: Adapted from Romero et al, 2008
therapy is thrombolysis and restarting
of saturated fat increases the risk of blood flow around the affected tissues. It
heart disease and stroke through its should only be used after careful examina-
effect on blood lipids and thrombosis TIAs as a warning sign of stroke tion of imaging results, as administrating
Diabetes – Major risk factor for The UK Stroke Association recommends it without a clear diagnosis of the type of
coronary heart disease and stroke that TIAs – also called mini strokes stroke can have detrimental effects.
Source: Adapted from Romero et al, 2008
(Moorley et al, 2014) – are taken as seriously
as strokes. A TIA can be viewed as a Choosing the imaging technique
warning of a forthcoming stroke – approx- One key difference between imaging tech-
Most people experience stroke outside imately 15% of ischaemic strokes (the niques is that CT can provide static images
the acute hospital environment, so it is most common type) are preceded by a TIA, whereas MRI can deliver static or dynamic
crucial to improve the recognition and and there is a 5% risk of stroke in the 48 cerebral vascular images results rich in diag-
immediate management of acute stroke, hours following a TIA. It is estimated that nostic information. Another important dif-
both among the public and first- 10,000 strokes in the UK could be pre- ference is the risk of radiation. Longer expo-
responding health professionals. vented if TIAs were treated in time (Stroke sure to CT scanning carries an increased risk
The publicising of the FAST checklist Association, 2017). of radiation. With MRI, there is no exposure
(Harbison et al, 2003) and widespread to harmful ionising radiation, which means
media coverage of what to do in case of a Scan within one hour of hospital arrival its use is favoured over that of CT in clinical
TIA or stroke have had an informative and In 2016, the RCP published a revised ver- settings. Whether detailed CT images are
encouraging impact in stimulating public sion of its national clinical guideline for needed for diagnosis is a matter for collabo-
awareness about stroke and its symptoms. stroke (RCP, 2016b), which highlights how rative clinical judgement.
FAST provides a quick checklist of signs stroke care should be provided in the UK MRI also has a higher specificity for
and symptoms of stroke and prompts and the importance of reducing the time it detecting neurological and vascular mal-
people to urgent action. The acronym takes to diagnose and treat the condition formations, toxic and metabolic disorders,
stands for: to optimise patients’ outcomes. abnormal tissue growth and infection
Face – has the face fallen to one side? The guideline includes revised recom- (Hagmann et al, 2007). Thanks to new
Arms – can both arms be raised and held mendations for patients with suspected approaches in medical biophysics used in
raised? acute stroke. One of the main recommen- various MRI techniques, MRI helps differ-
Speech – is speech slurred or difficult to dations that differs from the earlier version entiate between stroke abnormalities with
understand? of the guideline is that all patients with sus- incredible accuracy and anatomical detail.
Time – call 999 if any of these signs of pected stroke should receive a brain scan Between CT and MRI, the latter prevails
stroke are present. within one hour of arriving at hospital. as the superior imaging technique due to
However, while the FAST checklist can The 2012 edition recommended scan- its high sensitivity, increased definition of
help identify the onset of TIA and stroke, it ning only certain patients (such as those results and multimodal functions. How-
does not take into account certain clinical who may be eligible for thrombolysis) ever, clinicians are often forced to use CT
presentations such as sudden-onset visual within one hour and all others within because of a lack of MRI equipment,
disturbance or unilateral and widespread 12 hours. Box 3 contains the key recom- patients’ fears of the MRI procedure, its
brain dysfunction. mendations from the new guideline. high cost, and contraindications linked to

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on neurology, go to
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the presence of ferromagnetic and other Mohan KM et al (2011) Risk and cumulative risk of
Box 3. Diagnosis and stroke recurrence. Stroke; 42: 5, 1489-1494.
metallic substances in patients’ bodies. treatment guidance Moorley C et al (2016) Stroke among African-
Ultimately, the choice of brain imaging Caribbean women: lay beliefs of risks and causes.
technique depends on the availability of l Patients with suspected acute Journal of Clinical Nursing; 25: 3-4, 403-411.
Moorley C et al (2014) Impact of stroke: a
instruments, speed of image acquisition, stroke should receive brain imaging functional, psychological report of an inner-city
patient stability, potential risks and clin- urgently and no later than one hour multiracial population: Traditions, norms and
values affect how stroke is perceived in
ical expertise available on site. after arrival at hospital different cultural populations. Primary Health
l Patients with suspected acute stroke Care; 24: 4, 26-34.
Stroke assessments should be admitted directly to a National Institute for Health and Care Excellence
(2017) Stroke and Transient Ischaemic Attack in
The brain and neurological system con- hyperacute stroke unit and assessed Over 16s: Diagnosis and Initial Management.
stantly produce signs and symptoms that for emergency treatment by a London: NICE. www.nice.org.uk/cg68
Ohene-Frempong et al (1998) Cerebrovascular
provide clues to diagnosis. There are many specialist physician without delay accidents in sickle cell disease: rates and risk
technological tools to aid diagnosis, but it l Interpreting acute stroke imaging to factors. Blood ; 91: 1, 288-94.
can also be achieved by thorough bedside decide whether to give thrombolytic Romero JR et al (2008) Stroke prevention:
modifying risk factors. Therapeutic Advances in
clinical assessment by clinicians with an treatment should only be made by Cardiovascular Disease; 2: 4, 287-303.
in-depth understanding of brain anatomy health professionals who have Rothwell et al (2005) Population-based study of
event-rate, incidence, case fatality, and mortality
and neurological function. received appropriate training for all acute vascular events in all arterial territories
Stroke requires a patient-centred, cul- l Patients with ischaemic stroke (Oxford Vascular Study). The Lancet; 366: 9499,
turally appropriate and evidence-based who are eligible for endovascular 1773-1783.
Royal College of Physicians (2017) Sentinel Stroke
approach to care and treatment (National therapy should immediately have National Audit Programme (SSNAP). National
Institute for Health and Care Excellence, a CT angiogram from aortic arch clinical audit annual results portfolio April
2015-March 2016. Bit.ly/RCP_SSNAP
2017). Stroke assessments should focus on to skull vertex – this should not
Royal College of Physicians (2016a) Sentinel
the disabilities and needs of patients and delay the administration of Stroke National Audit Programme (SSNAP) Stroke
be conducted with relatives and carers, to intravenous thrombolysis Health Economics: Cost and Cost-effectiveness
analysis 2016. London: RCP.
promote both holistic treatment and l MRI with stroke-specific sequences Royal College of Physicians (2016b) National
collaborative decision-making. It is impor- (diffusion-weighted imaging, T2) Clinical Guideline for Stroke. London: RCP.
tant to acknowledge spiritual beliefs and should be performed in patients with Bit.ly/RCPStrokeGuideline2016
Sacco RL et al (2013) An updated definition of
cultural specificities to ensure care is suspected acute stroke when there is stroke for the 21st century. Stroke; 44: 7, 2064-2089.
delivered sensitively (Moorley et al, 2016). diagnostic uncertainty Saka Ö et al (2009) Cost of stroke in the United
Kingdom. Age and Ageing; 38: 1, 27-32.
Source: Adapted from Royal College of Saver JL (2006) Time is brain – quantified. Stroke;
Conclusion Physicians (2016b) 37: 1, 263-266.
If left untreated, stroke is a debilitating Stroke Association (2017) State of the Nation
Stroke Statistics. London: Stroke Association.
disease that can lead to death. Current sta- Bit.ly/StrokeStatsJan2017
tistics reflect the negative impact of References Stroke Association (2016) State of the Nation
Adams HP Jr et al (2007) Guidelines for the early Stroke Statistics. London: Stroke Association.
unhealthy lifestyles and genetic and envi- Bit.ly/StrokeStatsJan2016
management of adults with ischemic stroke.
ronmental predispositions, and the conse- Circulation; 115: 20, e478-e534. Stroke Association (2014) Research Spend in the
quent burden on healthcare systems. Banerjee S et al (2010) South Asian strokes: UK: Comparing stroke, cancer, coronary heart
lessons from the St Mary’s stroke database. QJM: disease and dementia. Bit.ly/StrokeResearchSpend
Refining the definitions of the different Monthly Journal of the Association of Physicians; World Health Organization (2017) WHO Methods
types of stroke has helped us better under- 103: 1, 17-21. and Data Sources for Country-level Causes of
Benjamin EJ et al (2017) Heart disease and stroke Death 2000-2015. Bit.ly/WHODeathCauses10-15
stand the disease, improve its diagnosis World Health Organization (2011) The Atlas of
statistics—2017 update: a report from the
and tailor its treatment. For all the American Heart Association. Circulation. 2017; Heart Disease and Stroke. Bit.ly/WHOStrokeAtlas
advances in brain imaging techniques, 135:e229-e445. World Health Organization (2002) The World
Cole W (1689) A Physico-Medical Essay Health Report 2002: Reducing risks, promoting
thorough bedside clinical assessment is Concerning the Late Frequency of Apoplexies: healthy life. World Health Organization.
key in reaching an accurate diagnosis, Together with a General Method of their World Health Organization (1965) WHO:
Prevention, and Cure. Reprinted in 1995 by International Classification of Diseases. 1965
which then allows appropriate treatment. revision, 15. Geneva WHO.
Gryphon, Classics of Neurology and Neurosurgery
The importance of good clinical assess- Library, New York.
ments of patients with suspected stroke Hacke W et al (2008) Thrombolysis with alteplase
3 to 4.5 hours after acute ischemic stroke. New
cannot be overestimated. NT England Journal of Medicine; 359: 13, 1317-1329. Stroke series Date
Hagmann P et al (2007) Mapping human Part 1: Definition, risk factors and  Nov
Nursing Times whole-brain structural networks with diffusion MRI.
PloS One; 2: 7, e597.
diagnosis
Self-assessment Harbison J et al (2003) Diagnostic accuracy of
Part 2: Primary and secondary prevention Dec
stroke referrals from primary care, emergency Part 3: Assessment and rehabilitation Jan
room physicians, and ambulance staff using the Part 4: Acute stroke management Feb
Test your knowledge
face arm speech test. Stroke; 34: 1, 71-76. Part 5: Health promotion for stroke  Mar
with Nursing Times Hatano S (1976) Experience from a multicentre
prevention
Self-assessment after reading this article. stroke register: a preliminary report. Bulletin of the
World Health Organization; 54: 5, 541-553. Part 6: Intermittent catheterisation Apr
If you score 80% or more, you will receive Intercollegiate Stroke Working Party (2016)
a personalised certificate that you can National Clinical Guideline for Stroke, 5th edn.
download and store in your NT Portfolio London: Royal College of Physicians.
Latchaw RE et al (2009) Recommendations for For more on this topic go online...
as CPD or revalidation evidence. imaging of acute ischemic stroke. Stroke; 40: 11,
3646-3678. l Anatomy and physiology of ageing 1:
Visit nursingtimes.net/NTSAStroke
Marshall IJ et al (2015) The effects of the cardiovascular system
to take the test. socioeconomic status on stroke risk and outcomes. Bit.ly/NTAgeingCardiovascular2017
Lancet Neurology; 14: 12, 1206-1218.

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