Stroke is a medical emergency. The onset or last-known-well time defines thrombolysis and thrombectomy eligibility, so record it exactly. Always check glucose: hypoglycaemia mimics stroke.
Immediate assessment
- FAST and NIHSS; record exact onset or last-known-well time
- Capillary glucose, observations, 12-lead ECG for AF
- Urgent non-contrast CT head to exclude haemorrhage
- Do not lower BP acutely unless for thrombolysis or above 220/120 (local policy)
TIA
- Give aspirin 300 mg once haemorrhage excluded
- Specialist assessment within 24 h (NICE: do not use ABCD2 to delay)
- Carotid imaging if anterior circulation and a surgical candidate
- Admit if crescendo TIA or on anticoagulation
TIA (resolved)
- Aspirin 300 mg once haemorrhage excluded
- Specialist review within 24 h
- Do not use ABCD2 to delay
Ischaemic stroke in window
- Within 4.5 h: thrombolysis
- Large-vessel occlusion: thrombectomy
- Protect airway, glucose, swallow
Haemorrhage or unstable
- Reverse anticoagulation
- Neurosurgery and BP control
- Critical care if GCS falling
Hyperacute stroke
1
1. Activate
Stroke team and imaging within minutes. Record the onset time. Capillary glucose first.
Stroke team and imaging within minutes. Record the onset time. Capillary glucose first.
↓
2
2. Reperfusion
IV thrombolysis (alteplase or tenecteplase) if within 4.5 h and no contraindication. Refer large-vessel occlusion for thrombectomy.
IV thrombolysis (alteplase or tenecteplase) if within 4.5 h and no contraindication. Refer large-vessel occlusion for thrombectomy.
↓
3
3. Admit
Stroke unit. Swallow screen before any oral intake. Control glucose, temperature and hydration. VTE prophylaxis with intermittent pneumatic compression (not early heparin).
Stroke unit. Swallow screen before any oral intake. Control glucose, temperature and hydration. VTE prophylaxis with intermittent pneumatic compression (not early heparin).
↓
4
4. Prevent
Clopidogrel 75 mg long-term (or aspirin plus dipyridamole). Anticoagulate for AF after an interval. High-intensity statin, BP control. Minor stroke or high-risk TIA: short course aspirin plus clopidogrel per protocol.
Clopidogrel 75 mg long-term (or aspirin plus dipyridamole). Anticoagulate for AF after an interval. High-intensity statin, BP control. Minor stroke or high-risk TIA: short course aspirin plus clopidogrel per protocol.
| Treatment | Window and criteria |
|---|---|
| IV thrombolysis | Within 4.5 h of known onset, haemorrhage excluded, no contraindication |
| Thrombectomy | Large-vessel occlusion, up to 6 h (up to 24 h if favourable imaging) |
| Aspirin 300 mg | 24 h after thrombolysis, or immediately if not thrombolysed |
Swallow and nutrition
- Nil by mouth until swallow screen passed
- Aspiration pneumonia common if missed
Pitfalls
- Missing hypoglycaemia
- Delaying CT in suspected TIA with ongoing deficit
- No AF search on cardioembolic stroke
- Inappropriately lowering BP before reperfusion decision
MedPrep - www.medprep.uk - Educational revision aid only. Not clinical guidance. Doses are adult examples; check the BNF, current guidelines and local policy, and seek senior advice. Nov 2026