Back

Acute stroke and TIA

Emergencies

Time is brain: record the time the patient was last known to be well, and bleep the stroke team now.

Exclude hypoglycaemia in every sudden neurological deficit.

Act now

  1. 1

    Activate the hyperacute stroke or thrombolysis pathway; urgent non-contrast CT head.

  2. 2

    CT angiography if thrombectomy could be an option; CT perfusion if last known well 6–24 hours ago.

  3. 3

    Oxygen only if SpO₂ falls below 95%. Keep glucose 4–11 mmol/L.

  4. 4

    Nil by mouth, including tablets, until a swallow screen is done.

Assess

  • ABCDE, capillary glucose, GCS. Use ROSIER to recognise stroke; the stroke team will score NIHSS.
  • Anticoagulants (and time of last dose), recent surgery or bleeding, seizure at onset.
  • Mimics: hypoglycaemia, seizure or post-ictal (Todd's) paresis, migraine, sepsis, functional.

Investigations

  • Glucose, FBC, U&E, clotting, group and save, ECG (AF).

Manage

  • Ischaemic stroke, haemorrhage excluded, within 4.5 hours: thrombolysis with alteplase or tenecteplase. BP must be 185/110 mmHg or lower before treatment.
  • Thrombectomy as soon as possible for proximal anterior circulation occlusion within 6 hours, and up to 24 hours in selected patients with salvageable brain on imaging.
  • Aspirin 300 mg daily for 2 weeks: start 24 hours after thrombolysis, or as soon as possible once haemorrhage is excluded.
  • Intracerebral haemorrhage: reverse anticoagulation; consider rapid BP lowering if presenting within 6 hours with systolic 150–220 mmHg, aiming for 130–140 within 1 hour.

Escalate when

  • Every suspected stroke: stroke team immediately. Falling GCS or large haemorrhage: neurosurgery and critical care.

Doses and prescribing

Aspirin

300 mg oral, rectal or via NG tube daily for 2 weeks (once haemorrhage excluded).

Alteplase

0.9 mg/kg IV (max 90 mg): 10% as a bolus, the rest over 60 minutes — stroke team decision.

Tenecteplase

0.25 mg/kg IV single bolus (max 25 mg) — stroke team decision.

Check the BNF and your local formulary before prescribing.

Written to current guidance (NICE NG128, TA990) · sources checked 14 Nov 2026. We watch NICE for updates weekly.

Sources (3)

Reviewed by Aboodee Alhasso, MPharm MRCPharm IP on 14 Nov 2026

Calculators for this

For healthcare professionals, as an aid to clinical judgement — not a substitute for it. Follow your local policy and ask a senior when in doubt.