How should I manage a patient with an ischaemic stroke who presents within the thrombolysis time window?

For a patient presenting with suspected ischaemic stroke within the thrombolysis time window, the management involves rapid assessment, immediate brain imaging, and consideration of pharmacological and mechanical interventions within a specialist stroke service ¹.

• Immediate Brain Imaging: A non-enhanced CT scan should be performed immediately for people with suspected acute stroke if there are indications for thrombolysis or thrombectomy, or if they are on anticoagulant treatment, have a known bleeding tendency, or other specific risk factors ¹. If thrombectomy might be indicated, a CT contrast angiography should follow the initial non-enhanced CT ¹.
• Thrombolysis with Alteplase:
  • Alteplase is recommended for treating acute ischaemic stroke if treatment can be started as soon as possible within 4.5 hours of symptom onset ¹.
  • Intracranial haemorrhage must be excluded by appropriate imaging techniques before administration ¹.
  • Alteplase should only be administered within a well-organised stroke service with staff trained in thrombolysis, immediate access to imaging, and staff trained to interpret images ¹. Protocols for delivery and managing complications must be in place ¹.
• Thrombectomy:
  • Thrombectomy should be offered as soon as possible and within 6 hours of symptom onset, together with intravenous thrombolysis (if not contraindicated and within the licensed time window) ¹.
  • This is for people with acute ischaemic stroke and confirmed occlusion of the proximal anterior circulation, demonstrated by computed tomographic angiography (CTA) or magnetic resonance angiography (MRA) ¹.
  • Decisions about thrombectomy should consider the person's overall clinical status, the extent of established infarction, a pre-stroke modified Rankin scale score of less than 3, and a National Institutes of Health Stroke Scale (NIHSS) score of more than 5 ¹.
• General Acute Management:
  • Offer aspirin 300 mg orally (or rectally/enteral tube if dysphagia) as soon as possible, but certainly within 24 hours, after intracerebral haemorrhage has been excluded by brain imaging ¹.
  • Maintain a blood glucose concentration between 4 and 11 mmol/litre ¹.
  • Give supplemental oxygen only if the oxygen saturation drops below 95%; routine use is not recommended for people with acute stroke who are not hypoxic ¹.