Acute ischaemic stroke

Red Flags

Door-to-needle target ≤60 minutes (preferably ≤45) for thrombolysis-eligible patients — every 15 minutes of delay reduces benefit^[1]
Large vessel occlusion (NIHSS ≥6, ICA or M1 MCA) within 24 hours — rapid transfer to thrombectomy-capable centre via established hub-and-spoke pathway^[1]
BP >185/110 mm Hg in thrombolysis candidate — IV labetalol or nicardipine to <185/110 before alteplase/tenecteplase; do not exclude solely for BP^[1]
Suspected intracerebral haemorrhage on CT — STOP thrombolytic; reverse anticoagulation; neurosurgery consult; manage BP <140 systolic if SBP 150–220^[1]

First-line treatment

Interventions

IV thrombolysis ≤4.5 hours of onset^[1]
Alteplase 0.9 mg/kg IV (max 90 mg; 10% bolus then 90% infusion over 60 min). Tenecteplase 0.25 mg/kg single bolus (max 25 mg) where available — easier administration, equivalent efficacy. BP <185/110 before drug; permissive <180/105 first 24 h
Endovascular thrombectomy for large vessel occlusion^[1]
Anterior circulation LVO with NIHSS ≥6 within 24 h; posterior circulation per local protocol. Hub-and-spoke transfer from primary stroke centre to comprehensive centre; achieve TICI 2b–3
Stroke unit admission for all confirmed stroke^[1]
Multidisciplinary care (medical, nursing, PT, OT, SLT, dietitian, social work, neurorehabilitation); reduces death and dependency more than any drug
Bedside dysphagia screen before any oral intake^[1]
Trained nurse-led screen within hours of admission; formal SLT assessment if abnormal; prevents aspiration pneumonia
Permissive hypertension in non-thrombolysis candidates^[1]
Allow up to 220/120 mm Hg first 24 h unless other indication (ACS, dissection, encephalopathy); reduce gradually 15% in first 24 h

First-line drug therapy

Drug	Class	Adult	Paediatric	Notes
Aspirin^[1]	Antiplatelet (COX-1 irreversible inhibitor)	300–325 mg PO loading within 24–48 h of stroke or 24 h after thrombolysis; 75–150 mg daily thereafter	—	Within 24–48 h of stroke if no thrombolysis; not concurrent with thrombolytic
Aspirin + clopidogrel (DAPT for minor stroke / high-risk TIA)^[1]	Dual antiplatelet therapy	Aspirin 325 mg + clopidogrel 300 mg loading, then aspirin 75 mg + clopidogrel 75 mg daily × 21 days, then aspirin alone	—	NIHSS ≤3 minor non-cardioembolic stroke or ABCD2 ≥4 high-risk TIA — initiate within 24 h
Atorvastatin (high-intensity)^[1]	HMG-CoA reductase inhibitor	80 mg PO daily	—	All atherosclerotic stroke; start during admission; LDL-C target <70 mg/dL long-term
Anticoagulation for cardioembolic stroke^[1]	DOAC or warfarin	Apixaban 5 mg BD; rivaroxaban 20 mg daily; 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 against re-embolic risk; CT-confirmed before starting

Aspirin^[1]

Antiplatelet (COX-1 irreversible inhibitor)

Adult: 300–325 mg PO loading within 24–48 h of stroke or 24 h after thrombolysis; 75–150 mg daily thereafter
Paediatric: —

Within 24–48 h of stroke if no thrombolysis; not concurrent with thrombolytic

Aspirin + clopidogrel (DAPT for minor stroke / high-risk TIA)^[1]

Dual antiplatelet therapy

Adult: Aspirin 325 mg + clopidogrel 300 mg loading, then aspirin 75 mg + clopidogrel 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

Atorvastatin (high-intensity)^[1]

HMG-CoA reductase inhibitor

Adult: 80 mg PO daily
Paediatric: —

All atherosclerotic stroke; start during admission; LDL-C target <70 mg/dL long-term

Anticoagulation for cardioembolic stroke^[1]

DOAC or warfarin

Adult: Apixaban 5 mg BD; rivaroxaban 20 mg daily; 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 against re-embolic risk; CT-confirmed before starting

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, attend rehabilitation and risk-factor follow-up consistently — most disability gain happens in the first 3 months^[1]
New weakness, speech change, or worsening symptoms — return to A&E immediately (recurrence risk highest in first 90 days)^[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 with acute ischaemic stroke; delivered in resource-tiered stroke pathway.

References

1.Indian Stroke Association Guidelines for the Management of Acute Ischaemic Stroke (2022); ESO Guidelines on Acute Ischaemic Stroke (2022)