A stroke occurs when there is a blockage in the blood supply to the brain, or when a blood vessel in the brain ruptures and bleeds. When that happens, part of the brain cannot get the blood (and oxygen) it needs, and brain cells die. Symptoms of a stroke show up in the body parts that are controlled by the damaged areas of the brain. HOW RELEVANT IS THIS TO MY PRACTICE? Strokes are common, and the annual incidence in the general population is increasing despite a decline in mortality from stroke. Every year, 15 million people throughout the world suffer a stroke, and five million are left significantly disabled. In 2017, 7,741 stroke patients were admitted to Singapore public hospitals (about 21 per day). From 2008 to 2017, there was an overall increase in the crude incidence rate of stroke, from 187.9 to 229.6 per 100,000 population. In 2017, there were 759 deaths due to stroke, an increase from 698 in 2008. (1) It is the third commonest cause of death in developed nations and the leading cause of adult disability worldwide. A recent publication from the Global Burden of Diseases, Injuries and Risk Factors study forecasted that stroke will continue to be one of the top three causes of death worldwide in 2040. (2) WHAT CAN I DO IN MY PRACTICE? Management guidelines and recommendations for the patient with stroke remain largely focused on the acute in-hospital phase, emphasising medical diagnosis and treatment, including intensive rehabilitation. The focus is very much on improving survivorship. The immediate consequences of stroke during this acute phase are well recognised. But for many stroke survivors and their families, the acute stroke is the beginning of their ongoing struggle with physical impairment and subsequent disability. With time, the immediate clinical consequences of the stroke are complicated by a variety of lesser-known medical, musculoskeletal and psychosocial difficulties. (3) The primary care physician plays an important role in optimising chronic disease control and in managing and minimising any complications. Optimising clinical risk for stroke recurrence Prior stroke is a significant risk factor for the development of further strokes. (4,5) Patients who have had a stroke are four times more likely to have another stroke than matched controls. (6) Secondary preventative measures including antithrombotic therapy, (7) treatment of hypertension (8-11) and diabetes mellitus, (12) reduction of elevated low-density lipoprotein (LDL) cholesterol and triglyceride levels, (13) anticoagulation for atrial fibrillation (AF), and cessation of smoking (14) can reduce recurrence rates (Box 1). Late medical complications of stroke Scant attention has been paid to the long-term consequences and complications (i.e. medical, musculoskeletal and psychosocial complications) resulting from a stroke. These are summarised in Box 2. Late medical complications of stroke occur weeks to months after discharge from hospital. Some stroke survivors go on to develop these complications years after the acute stroke. The p...

Direct oral anticoagulants (DOACs) are increasingly being used in the elderly population in view of its ease of use, efficacy, and favorable side‐effect profile compared with the vitamin K antagonists. However, there is a need for increase awareness of well‐characterized cases, albeit a small number, of bullous pemphigoid‐like skin reactions associated with rivaroxaban.

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