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.