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Ischaemic Stroke

National Clinical Guideline for Stroke 2023 Edition. NICE Guideline [NG128] Stroke and transient ischaemic attack in over 16s: diagnosis and initial management. Last updated: Apr 2022

Guidelines

In order of priority:
  1. Refer to hyperacute stroke service
  2. Non-contrast head CT to exclude intracerebral haemorrhage
  3. Once intracerebral haemorrhage excluded → aspirin 300mg ASAP
  4. Consider thrombolysis and/or thrombectomy depending on eligibility criteria
  5. Consider decompressive hemicraniectomy in MCA stroke

Admit all suspected stroke patients directly to hyperacute stroke service

1st line and most important investigation: non-contrast head CT within 1 hour to exclude any haemorrhage 

Further imaging:
  • Diagnostic uncertainty → MRI brain with stroke-specific sequences
 
  • Potentially eligible for thrombectomy → CT angiogram from aortic arch to skull vertex 
 
  • Delayed presentation (e.g. wake up stroke) → CT / MR perfusion (alternative: MRI measuring DWI-FLAIRDiffusion-weighted imaging (DWI)–fluid-attenuated inversion recovery (FLAIR) mismatch)

Admit all suspected stroke patients directly to hyperacute stroke service

The follow management options should only be considered and carried out once intracerebral haemorrhage has been excluded and confirms ischaemic stroke.
 

Aspirin 300mg should be offered ASAP once intracerebral haemorrhage as been excluded

If the patient is dysphagia → enteral / rectal tube

  • Onset of symptoms <4.5 hours 
  • Last known to be well >4.5 hours earlier if
    • Thrombolysis can be started between 4.5-9 hours or known onset OR within 9 hours of midpoint of sleep for wake-up stroke, AND
    • NeuroimagingCT / MR perfusion, or MRI DWI-FLAIR mismatch shows potential to salvage brain tissue

Ensure BP <185/110 mmHg before initiating thrombolysis. 

Agent of choice: IV alteplase / tenecteplase 
  • Drug class: tPA (tissue plasminogen activator) 
  • MoA: tPA attaches to the fibrin on the clot surface → activate fibrin-bound plasminogen into plasmin → plasmin breaks down molecules to dissolve the clot 

Contraindications outlined by the National Clinical Guideline for Stoke:
  • BP >185/110 mmHg (control BP prior thrombolysis)
  • Intracranial haemorrhage
  • Known ↑ risk of bleeding
    • Recent major surgery
    • Significant head trauma
    • Known bleeding disorders, including those receiving anticoagulant therapy beyond safe therapeutic parameters

This section is based on NICE guidelines, as the National Clinical Guideline for Stroke includes specialist-level details.

Offer thrombectomy in proximal anterior circulation occlusion (confirmed on CTA / MRA) if:
  • <6 hours of symptom onset, OR
  • Last known to be well 6-24 hours (including wake-up strokes) + there is potential to salvage brain tissue

Consider thrombectomy in proximal posterior circulation occlusion ​Basilar / posterior cerebral artery(confirmed on CTA / MRA) if:
  • Last known to be well up to 24 hours (including wake-up strokes), AND
  • There is potential to salvage brain tissue

NICE recommends that thrombectomy is favoured in:
  • Pre-stroke modified Rankin scale <3 (i.e. good pre-stroke functional status)
  • NIHSS >5 (i.e. stroke causing disabling neurological deficits)
 

Decisions regarding thrombectomy is complicate and is made by specialist. The general concepts that favour thrombectomy are:

  • Proximal occlusion (i.e. large vessel occlusion) 
  • If there is potential to salvage brain tissue (indicated by imaging)
  • Good pre-stroke functional status (measured by modified Rankin scale)
  • Disabling / severe neurological deficits (measured by NIHSS)

NICE recommends to consider decompressive hemicraniectomy within 48 hours if ALL of the following:
  • Clinical features that suggest MCA infarct + NIHSS score >15
  • ↓ Level of consciousness + ≥1 on NIHSS item 1a
  • MCA territory infarct >50% on CT
 

Rationale: in malignant MCA infarction, extensive cerebral oedema develops rapidly. Decompressive hemicraniectomy prophylactically prevents cerebral oedema from raising ICP and reduce risk of ICP. 

Offer:
  • High-intensity statin (e.g. atorvastatin 80mg) 
  • Antithrombotic treatment (antiplatelet or anticoagulation)

Choice of antiplatelet vs anticoagulation as long-term antithrombotic treatment depends on the cause of stroke

  • Aspirin 300mg OD continued for 2 weeks after stroke onset
 
  • After 2 weeks → clopidogrel 75mg OD lifelong
    • Alternative: aspirin 75mg OD
 

If the patient is treated with thrombolysis, antiplatelet should be started 24 hours after once repeat imaging excludes haemorrhage.

  • Aspirin 300mg OD before initiating anticoagulation
 
  • Start anticoagulation  within 2 weeks of stroke onset
    • 1st line for non-valvular AF: DOAC
    • 1st line for valvular AF / with mechanical heart valve: warfarin

References


Author: Adams Lau
Reviewer:
Last Edited: 28/02/25