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Transient ischaemic attack is an emergency medical condition that causes brief negative focal neurological symptoms such as unilateral weakness. The symptoms herald a high risk of stroke and hence require urgent assessment. The challenge lies in the brevity and compendium of associated symptoms that can ‘mimic’ a plethora of other conditions. The result is a high rate of referrals to transient ischaemic attack clinics for these stroke mimics. This article highlights the diagnostic challenges in transient ischaemic attack with relevance to unilateral weakness.

Many doctors take time out of clinical practice, and then have decreased confidence and poor performance ratings on their return. Simulation training provides a safe and effective learning platform for healthcare professionals to become immersed in realistic scenarios that provide an opportunity to develop technical and non-technical skills. A standardised, 1-day, multi-fidelity, interprofessional, simulation training course was developed and delivered at four sites, focusing on human factors, patient safety and acute clinical scenarios relevant for clinicians returning to practice in internal medicine. A total of 56 participants, with a median time out of training of 3.6 years, attended seven courses. Quantitative and qualitative analysis showed a significant pre/post-course increase in candidates' self-reported confidence in returning to practice along with learning in non-technical skills. The carefully designed standardised format may facilitate wider expansion of such training.

There have been considerable advances in stroke research leading to translation of drug therapy for stroke into the clinical arena. Thrombolysis has significantly reduced disability and revolutionised the manner in which acute ischaemic stroke is treated and anti- platelet agents and anticoagulants have a strong evidence base for the secondary prevention of ischaemic stroke. This article outlines the active approach towards treatment and prevention of ischaemic stroke utilising the antithrombotic medications currently available and highlights the role played by the stroke specialist nurse.

Background The best outcomes for acute stroke treatment occur through rapid recognition and transfer of patients to hospitals with a hyperacute stroke unit (HASU). Pre-hospital ambulance paramedics are crucial to this process as first responders, but they have limited feedback on subsequent patient care and progress to improve their learning. Methods A dedicated stroke training course for paramedics was developed on a HASU that involved a standardised introductory educational briefing and subsequent participation in clinical activities with multidisciplinary HASU staff. On completion of the course, attendees completed a standardised semi-structured questionnaire about their learning and experience. All text was thematically analysed and themes were developed by iteratively recoding and regrouping the data. Results 30 paramedics attended the training course over a three-month period. All candidates reported that the course was useful to their learning and training with ‘real-world’ transferability; 93% stated that they benefited from observing clinicians performing assessments on patients and 73% commented that they gained a better understanding of care pathways and treatment. These two themes encompassed 48% of 160 free-text responses with the other responses being grouped into four further themes (improved patient/family communication, increased awareness of subtle signs of stroke, localisation of intracranial pathology, and improved ‘handover’). Discussion This single centre experience of HASU training for paramedics demonstrated a number of key educational themes embedded within the stroke care pathway. This process may be a useful additional educational resource to develop further paramedic training in the hyperacute arena.

Dysphagia after stroke is common and has a significant impact on disability, institutionalisation and mortality. Patients who cannot achieve nutrition from food and fluids orally should be considered for a modified diet and/or tube feeding, taking into account their wishes and best interests. This article describes the issues in managing such patients, including feeding with acknowledged risk. The specialist stroke nurse plays a central role in the successful implementation of these strategies, particularly with regard to patient and carer education, monitoring and compliance.

National clinical guidelines have emphasized the need to identify acute stroke as a clinical priority for early assessment and treatment of patients on hyperacute stroke units. Nurses working on hyperacute stroke units require stroke specialist training and development of competencies in dealing with neurological emergencies and working in multidisciplinary teams. Educational theory suggests that experiential learning with colleagues in real-life settings may provide transferable results to the workplace with improved performance. Simulation training has been shown to deliver situational training without compromising patient safety and has been shown to improve both technical and non-technical skills ( McGaghie et al, 2010 ). This article describes the role that simulation training may play for nurses working on hyperacute stroke units explaining the modalities available and the educational potential. The article also outlines the development of a pilot course involving directly relevant clinical scenarios for hyperacute stroke unit patient care and assesses the benefits of simulation training for hyperacute stroke unit nurses, in terms of clinical performance and non-clinical abilities including leadership and communication.

Inequalities in stroke patient care have been demonstrated in different locations and at different times. To overcome the inequity of access to specialist stroke care, telemedicine systems have been developed to provide remote specialist assessment of patients with real-time clinical evaluation for hyperacute care and rehabilitation. An electronic database search was performed of MEDLINE, EMBASE and the Cochrane Library and extensive manual searching of articles was conducted to identify studies investigating the use of telemedicine in managing acute stroke and post-stroke rehabilitation. There were 20 observational and 2 randomized, controlled acute studies involving 15872 patients and 2 observational and 4 randomized controlled rehabilitation studies involving 112 patients that met the inclusion criteria. Telemedicine for stroke, in both acute and rehabilitation settings, was demonstrated to be safe, effective, feasible and acceptable and was shown to reduce geographical differences and increase diagnostic accuracy and uptake of thrombolytic treatment.

Although stroke units and thrombolysis are effective in acute stroke management, use of these treatment methods is limited because of a lack of expertise. Telemedicine allows a distant stroke clinician to provide remote specialist assessment of patients with real-time clinical evaluation and interpretation of brain imaging. This interaction can take place within minutes of arrival of a patient to hospital helping to meet the demands of ‘time is brain’ in acute stroke care. Telemedicine is feasible, acceptable, technically and diagnostically reliable and is associated with improved delivery of thrombolysis. Different models for providing audiovisual interaction between patient and stroke clinician have been developed to meet the local needs of a variety of populations. Telemedicine facilitates effective networking between different stroke providers, having potential for education and training in addition to ensuring that patients have a greater opportunity to receive the full range of therapeutic options now and in the future.

Spasticity is a common symptom of neurological diseases including cerebral palsy, multiple sclerosis, traumatic brain injury, stroke and spinal cord injury. Spasticity has many components including increased muscle tone, exaggerated reflexes, weakness and contractures. It is a symptom that is not isolated, and can cause pain, stiffness and spasm resulting in a massive impact on a person's physical and emotional lifestyle. The management of spasticity requires a multidisciplinary approach including nurses, physicians, physiotherapists and occupational therapists working together to provide a variety of treatments tailored to the needs of the individual.

Patients who have already suffered a stroke or transient ischaemic attack (TIA) are 10–15 times more likely than the general population to have another episode in the following year. The risk is greatest soon after the first event. This article describes approaches to secondary prevention of stroke, outlining specific lifestyle changes and treatment options that can lower a patient's risk. The specialist stroke nurse plays a central role in the successful implementation of these strategies, particularly with regard to patient education, monitoring and compliance.

This article describes thrombolysis for acute ischaemic stroke as an emerging treatment modality. National clinical guidelines emphasized the need to identify acute stroke as a clinical priority and to develop protocols for the early assessment and treatment of stroke patients. Fast-track services developed in other clinical scenarios have proven successful and this article outlines the potential benefits a fast-track service for acute stroke. The role of the clinical nurse specialist in stroke is central to this service; this role includes development and implementation of fast-track protocols in accident and emergency, rapid assessment for eligibility of thrombolysis and coordinating post-thrombolysis monitoring and acute stroke care.

This article outlines the case of a 62-year-old man who presented with a deep vein thrombosis, pulmonary embolus and right middle cerebral artery territory ischaemic stroke in association with a patent foramen ovale with right-to-left shunting. Despite anticoagulation, he was noted to have desaturation and tachypnoea when upright, without other symptoms or cardiovascular compromise, that resolved on lying down. The article describes the syndrome of platypnoea-orthodeoxia, characterized by breathlessness, hypoxia and/or cyanosis while in the upright position that improves on lying down, its relationship to this case, and its resolution by closure of the patent foramen ovale.