19th July 2023

Management

Ischaemic stroke

Thrombolysis with alteplase is recommended if treatment can be started as soon as possible within 4.5 hours of onset of stroke symptoms and intracerebral haemorrhage has been excluded. It is important to be aware that there are contra-indications to thrombolysis.

Thrombectomy should be offered in addition to thrombolysis (unless contra-indicated) as soon as possible and within 6 hours of onset of stroke symptoms to those with:

• acute ischaemic stroke and
• confirmed occlusion of the proximal anterior circulation demonstrated on imaging

Thrombectomy can be offered to patients known to be well in the previous 6-24 hours, including ‘wake-up’ strokes, with:

• an acute ischaemic stroke and confirmed occlusion of the proximal anterior circulation demonstrated on imaging and
• potential to salvage brain tissue as shown by imaging, e.g. CT-perfusion or diffusion weighting MRI.

Thrombectomy (and thrombolysis, unless contraindicated) can be considered for those known to be well up to 24 hours previously, including ‘wake-up’ strokes, with

• an acute ischaemic stroke and confirmed occlusion of the proximal posterior circulation demonstrated on imaging and
• potential to salvage brain tissue as shown by imaging, e.g. CT-perfusion or diffusion weighting MRI

If a patient is not suitable for thrombolysis or they are outside the 4.5-hour window, they should be offered 300mg aspirin as soon as possible. This should be continued for 2 weeks, after which clopidogrel 75mg is recommended for secondary prevention.

Haemorrhagic stroke

Patients with intracerebral haemorrhage in association with anticoagulant treatment should be offered urgent reversal, if available.

Blood pressure should be controlled in accordance with local protocols. NICE recommends a target systolic blood pressure between 130-140mmHg within 1 hour of starting treatment and to be maintained for at least 7 days. Rapid blood pressure lowering should not be offered to people with any of the following: underlying structural cause for intracerebral bleed, GCS <6, are going to have early neurosurgery or have a massive haematoma with a poor prognosis.

Neurosurgical review will be needed to assess if the patient is likely to benefit from neurosurgery.

Secondary prevention

In addition to acute management, it is also important to identify and address risk factors for secondary prevention.

Diet and lifestyle factors should be addressed, as these can contribute to cardiovascular risk.

Further issues to target, if relevant, include hypertension, hyperlipidaemia, blood glucose control in diabetes, atrial fibrillation and carotid artery stenosis.