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Quality and safety/delivery.


'The national clinical guideline for stroke for the UK and Ireland'.

Date of expiry / review:

N/A. The 2023 edition of the national clinical guideline for stroke is a partial update of the 2016 fifth edition.

Action by: 

All NHS trusts, health boards.

Required by:

Immediate effect.


  • Sir Frank Atherton, Chief Medical Officer / Medical Director NHS Wales
  • Sue Tranka, Chief Nursing Officer
  • Ruth Crowder, Chief Allied Health Professions Adviser

Welsh Government contacts:

Quality and Nursing Directorate
Health and Social Services Group
Welsh Government,
Cathays Park,
CF10 3NQ. 


The national clinical guideline for stroke for the United Kingdom and Ireland.

The national clinical guideline for stroke for the United Kingdom and Ireland

Dear colleagues,

Stroke is the fourth leading cause of death in Wales and has a significant and life changing impact on those who survive. It is devastating for individuals, their families, and loved ones.

This Welsh health circular provides a national clinical guideline for stroke for the UK and Ireland. London: Intercollegiate Stroke Working Party; 2023 May 4. The full guideline is available at 'National clinical guideline for stroke for the United Kingdom and Ireland'.

Published on 4 May 2023, this guideline is an initiative of the Intercollegiate Stroke Working Party. The 2023 edition is a partial update of the 2016 edition and was developed in collaboration with the Scottish Intercollegiate Guidelines Network (SIGN) and the National Clinical Programme for Stroke, Ireland and is endorsed for use in clinical practice by the Royal College of Physicians of London, SIGN and the Royal College of Physicians of Ireland.

In addition to the National Clinical Guideline for Stroke, the NICE guideline [NG236] published in October 2023 provides updated recommendations for stroke rehabilitation in adults.

Facing the challenges

Implementing the guideline's ambitious recommendations poses a challenge, especially given the current financial climate. The guideline sets high standards for stroke care, emphasising the importance of organisational structure, staffing levels, and timely access to care. While the difficulty in meeting these recommendations is acknowledged, the potential long-term benefits for stroke survivors, their families, and our healthcare system far outweigh the initial challenges.

Stroke is estimated to cost NHS Wales £220 million annually, and for all sectors of the Welsh economy this is a combined £1.63 billion (£45,409 per patient in the first year). The latter cost is forecast to rise to £2.8bn by 2035 if no action is taken to mitigate against this. Utilising thrombectomy for eligible patients represents a saving of £47,000 per patient, over a 5-year period. If Welsh targets are met this would equate to a saving of £350 million over a 10-year period.

Technological innovation

Adoption of cutting-edge technological innovation including advancements in AI and neuro interventional solutions will have significant benefits for streamlining the clinical pathway, increase patient survival rates and assist rapid recovery. As these technologies advance more patients will become eligible for suitable treatment therefore it is important to invest in the pathway to achieve the best outcome for patients.

Guideline overview

'The national clinical guideline for stroke' provides authoritative, evidence-based practice guidance to improve the quality of care delivered to every adult who has a stroke in the United Kingdom and Ireland, regardless of age, gender, type of stroke, location, or any other feature.

Of the 538 recommendations within the guideline, almost 300 have been updated, added, or endorsed since the 2016 edition, together with the change to the geographic remit of the guideline, which now covers the four nations of the United Kingdom, and the Republic of Ireland.

The guideline covers the entire stroke pathway, emphasising prevention, treatment, rehabilitation and recovery, and long-term management.

Key recommendations

  • Organisation of stroke services: training in early stroke recognition, direct admission to hyperacute stroke units, continuous access to brain imaging, assessment of suspected Transient Ischaemic Attack (TIA) patients within 24 hours, and increased specialist staffing levels.
  • Acute care: extended reperfusion treatment windows, thrombectomy window extended to over 12 hours, thrombolysis extended to 9 hours with advanced imaging techniques, and timely provision of hyperacute stroke care.
  • Rehabilitation and recovery: a needs-led, multi-professional approach with a focus on increased physiotherapy, occupational therapy, speech and language therapy, psychological therapy and self-directed therapy practices.
  • Long-term management and secondary prevention: identification and modification of risk factors, personalised advice on lifestyle factors, and regular blood pressure checks. Updated guidance on use of Direct Oral Anticoagulants (DOACs) for the management of atrial fibrillation for stroke prevention.
  • Life after stroke: holistic reviews, support for psychological and emotional needs, self-management plans, and promotion of social and leisure activities.

To implement the recommendations set out in the guideline will pose significant challenges. However this is an opportunity for transformative change. By investing wisely, we can elevate stroke care, improve outcomes for the people of Wales and contribute to the long-term sustainability of our healthcare system.

We would like to thank you for your continued support in delivering stroke services to the people of Wales.

Yours sincerely,
Sir Frank Atherton
Prif Swyddog Meddygol | Chief Medical Officer
Cyfarwyddwr Meddygol GIG Cymru | Medical Director NHS Wales

Sue Tranka
Prif Swyddog Nyrsio | Chief Nursing Officer
Cyfarwyddwr Nyrs GIG Cymru | Nurse Director NHS Wales

Ruth Crowder
Prif Gynghorydd Proffesiynau Perthynol i Iechyd | Chief Allied Health Professions Adviser