Neurology · AHA

Acute ischaemic stroke

AHA

Source:AHA/ASA Guidelines for the Early Management of Patients With Acute Ischemic Stroke (2019, with 2024 thrombectomy and tenecteplase updates)

Verified Apr 2026

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Red Flags

Door-to-needle target ≤45 minutes for thrombolysis-eligible patients — every 15 minutes of delay reduces benefit; treat in CT scanner room where possible^[1]
Large vessel occlusion (NIHSS ≥6, ICA or M1 MCA occlusion) presenting within 24 hours — emergent transfer to thrombectomy-capable centre; do not delay for transfer if at primary stroke centre^[1]
BP >185/110 mm Hg in thrombolysis candidate — treat to <185/110 with IV labetalol or nicardipine before alteplase/tenecteplase; do not exclude solely for BP^[1]
Suspected intracerebral haemorrhage on CT — STOP thrombolysis; reverse anticoagulation; neurosurgery; admit to ICU; manage BP <140 systolic if SBP 150–220^[1]

First-line treatment

Interventions

IV thrombolysis with tenecteplase or alteplase ≤4.5 hours^[1]
Tenecteplase 0.25 mg/kg IV bolus (max 25 mg) — preferred per 2024 update over alteplase 0.9 mg/kg (10% bolus then 90% infusion over 60 min, max 90 mg). BP <185/110 before drug; monitor for ICH; permissive BP <180/105 first 24 h
Endovascular thrombectomy for large vessel occlusion^[1]
Anterior circulation LVO with NIHSS ≥6 within 24 hours; posterior circulation per local protocol; do not exclude solely on age, mild deficit, or pre-stroke disability — individualise. Achieve TICI 2b–3 reperfusion
Stroke unit care^[1]
Admit all confirmed stroke to a dedicated stroke unit; multidisciplinary team (medical, nursing, PT, OT, SLT, dietitian, social worker); reduces death and dependency more than any drug
Dysphagia screen before any oral intake^[1]
All stroke patients within hours of admission; bedside swallow screen by trained nurse, formal SLT assessment if abnormal; prevents aspiration pneumonia
Permissive hypertension in non-thrombolysis candidates^[1]
Allow BP up to 220/120 mm Hg in first 24 h unless other indication (ACS, dissection, encephalopathy, pre-eclampsia); reduce gradually 15% in first 24 h

First-line drug therapy

Drug	Class	Adult	Paediatric	Notes
Aspirin^[1]	Antiplatelet (COX-1 irreversible inhibitor)	300 mg PO loading within 24–48 h; 75 mg PO daily thereafter	—	Within 24–48 h of stroke or 24 h after thrombolysis; not concurrent with thrombolytic
Dual antiplatelet therapy (DAPT) — minor stroke or high-risk TIA^[1]	Antiplatelet combination	Aspirin 300 mg PO loading then 75 mg daily + clopidogrel 300 mg loading then 75 mg daily × 21 days, then aspirin alone	—	NIHSS ≤3 minor non-cardioembolic stroke or ABCD2 ≥4 high-risk TIA — initiate within 24 h. POINT and CHANCE trials
Atorvastatin (high-intensity)^[1]	HMG-CoA reductase inhibitor	80 mg PO once daily	—	All atherosclerotic stroke; start during admission; continue indefinitely
Anticoagulation for cardioembolic stroke^[1]	DOAC or warfarin	Apixaban 5 mg BD; rivaroxaban 20 mg OD; dabigatran 150 mg BD; or warfarin INR 2–3. Timing: minor stroke 1–3 days, moderate 6 days, severe 12–14 days post-event	—	AF-related stroke; balance haemorrhagic transformation risk against re-embolic risk; CT-confirmed before starting; bridge with aspirin if anticoagulation deferred

Aspirin^[1]

Antiplatelet (COX-1 irreversible inhibitor)

Adult: 300 mg PO loading within 24–48 h; 75 mg PO daily thereafter
Paediatric: —

Within 24–48 h of stroke or 24 h after thrombolysis; not concurrent with thrombolytic

Dual antiplatelet therapy (DAPT) — minor stroke or high-risk TIA^[1]

Antiplatelet combination

Adult: Aspirin 300 mg PO loading then 75 mg daily + clopidogrel 300 mg loading then 75 mg daily × 21 days, then aspirin alone
Paediatric: —

NIHSS ≤3 minor non-cardioembolic stroke or ABCD2 ≥4 high-risk TIA — initiate within 24 h. POINT and CHANCE trials

Atorvastatin (high-intensity)^[1]

HMG-CoA reductase inhibitor

Adult: 80 mg PO once daily
Paediatric: —

All atherosclerotic stroke; start during admission; continue indefinitely

Anticoagulation for cardioembolic stroke^[1]

DOAC or warfarin

Adult: Apixaban 5 mg BD; rivaroxaban 20 mg OD; dabigatran 150 mg BD; or warfarin INR 2–3. Timing: minor stroke 1–3 days, moderate 6 days, severe 12–14 days post-event
Paediatric: —

AF-related stroke; balance haemorrhagic transformation risk against re-embolic risk; CT-confirmed before starting; bridge with aspirin if anticoagulation deferred

Safety-net

Time is brain — call emergency services on first symptoms (face droop, arm weakness, slurred speech, sudden vision change); thrombolysis benefit halves every 30 minutes^[1]
After discharge, manage cardiovascular risk factors aggressively; secondary stroke risk is highest in first 90 days^[1]
Look out for new neurological symptoms in the first 90 days — recurrence symptoms include new weakness, speech change, or worsening — return to A&E^[1]

Referral criteria

All suspected acute stroke or TIAEmergency department / hyperacute stroke unit^[1]
Large vessel occlusion at primary stroke centreComprehensive stroke centre for thrombectomy — direct transfer^[1]
Carotid stenosis 50–99% on the symptomatic sideVascular surgery for revascularisation within 2 weeks^[1]
Cryptogenic stroke in young adult (<60 years)Stroke specialist for hypercoagulability work-up, prolonged cardiac monitoring, PFO assessment^[1]

Clinical summary

Hyperacute imaging, thrombolysis, endovascular thrombectomy, and supportive care for adults presenting with acute ischaemic stroke within 24 hours.

References

1.AHA/ASA Guidelines for the Early Management of Patients With Acute Ischemic Stroke (2019, with 2024 thrombectomy and tenecteplase updates) (2019)

Drug

Class

Adult

Paediatric

Notes