Stroke Management: The Outpatient Perspective

Continuation of post-stroke care following hospital discharge is paramount for optimal recovery from stroke and for prevention of recurrent stroke. While dramatic gains in effective treatment of acute stroke have garnered excitement in recent years, the greatest impacts on long-term disability and death from stroke accrue from long-term interventions made in the ambulatory setting. Outpatient neurological care must address multiple factors to achieve goals of care, aiding stroke patients in transitioning to postacute care settings, coping with stroke deficits, accessing rehabilitative therapies, and implementing individualized strategies for stroke prevention. Effective patient-centered stroke care in the ambulatory setting is the focus of this special issue of Practical Neurology.

For the stroke patient, a new life begins with the transition from the inpatient setting in the acute care hospital—to either an inpatient rehabilitation hospital or, with ambulatory therapies, to a residence. This transition to life outside of a healthcare facility is fraught with risks of discontinuation of treatments and missed opportunities for care. Drs. Jakita Baldwin and Amy K. Guzik provide an insightful overview of some of the barriers to implementation of effective post-stroke outpatient care and present strategies for overcoming those barriers.

Recovery from the deficits inflicted by stroke continues long after leaving the acute rehabilitation setting. Dr. Richard L. Harvey reviews current approaches to rehabilitative and restorative therapies for stroke in the outpatient setting—summarizing available therapeutic interventions to treat spasticity and to manage joint and muscle contractures and examining the roles for novel interventions for post-stroke recovery, including robotic technologies and data supporting implantable vagal nerve stimulation for upper limb motor recovery.

Secondary prevention of stroke can sometimes overlook the importance of nonpharmacological aspects of treatment, including diet and lifestyle choices. Dr. Laurel Cherian provides an elegant review of the available data supporting interventions in nutrition, exercise, and sleep to improve post-stroke outcomes and prevent recurrent strokes. Evidence to assist the challenging discussions with patients and caregivers regarding dietary and nutritional interventions and lifestyle modifications to prevent stroke are cogently summarized and supported by a useful table.

Completion of diagnostic evaluation of stroke mechanism often extends to the outpatient realm, with need for completion of additional cardiac imaging and extended cardiac monitoring to fully investigate possible cardiac sources of embolism. Drs. Elisheva Coleman and Elham Azizi provide a balanced overview of the relative strengths and benefits of different diagnostic strategies for evaluation of cardioembolic sources. Useful tables summarize cardioembolic sources and the specific strengths and insensitivities of the different methods for advanced cardiac imaging.

Medical secondary prevention of stroke often requires implementation of guidelines-supported antithrombotic therapies in the face of the threat of hemorrhagic conversion of recent ischemic infarction, or of recurrence of intracranial hemorrhage. Dr. Liqi Shu and colleagues review the evidence available for guiding decisions that must balance the risks of ischemic stroke recurrence and of hemorrhagic complications when applying antiplatelet or anticoagulant therapies, and the vexing questions regarding the timing of initiation of such therapies.

Finally, real-word stroke practice frequently confronts decisions that fall outside the bounds of clinical trial evidence. Dr. Michael J. Schneck and colleagues provide a cogent overview of the evidence that guides these difficult antithrombotic management decisions—summarizing available evidence regarding indications for dual antiplatelet therapy (DAPT) and for combining antithrombotics. Selected scenarios are addressed, including patients with reduced CYP2C19 function, intracranial stenosis, and cryptogenic stroke.

By addressing these topics, this issue aims to provide an update and overview of the current status of evidence guiding clinicians managing stroke patients in the real-world environment of the outpatient setting, where lasting impacts on the health and function of stroke survivors can be achieved.