Stroke: Management

Key points

• Maintain blood glucose, hydration, oxygen saturation and temperature within normal limits · do not lower blood pressure acutely unless there is a complication such as hypertensive encephalopathy (or to enable thrombolysis, where BP must be below 185/110).
• Urgent brain imaging to exclude haemorrhage — only blood glucose must precede thrombolysis; do not delay it for the rest of the blood results.
• Thrombolysis: alteplase OR tenecteplase within 4.5 hours of known onset in eligible patients (NG128 was amended in 2025 to include tenecteplase) · do not withhold thrombolysis from someone who is also a thrombectomy candidate.
• Thrombectomy: offer as soon as possible and within 6 hours of onset, together with IV thrombolysis if not contraindicated, for confirmed proximal anterior circulation occlusion · selected patients may benefit beyond 6 hours where imaging shows salvageable tissue.
• Aspirin 300 mg (orally, or rectally/by enteral tube if dysphagia) as soon as possible and within 24 hours once haemorrhage is excluded · continue 300 mg daily for 2 weeks, then start definitive long-term antithrombotic treatment · after thrombolysis, wait 24 hours before starting an antiplatelet.
• Atrial fibrillation: anticoagulate only after imaging excludes haemorrhage, and usually not until 14 days after an ischaemic stroke · start a statin, though many delay it 48 hours because of haemorrhagic transformation risk.

Decision points in this pathway

• Haemorrhage excluded?
• Ischaemic stroke within 4.5 h of known onset and eligible for thrombolysis?
• Proximal anterior circulation occlusion confirmed on angiography?

The full step-by-step algorithm, including what to do at each branch, opens in the app for approved members.