Dr Kola Tytler MBBS CertHE MBA MRCGPClinical Lead • iatroX
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 NICE NG128.
- 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 NICE NG128. If thrombectomy might be indicated, a CT contrast angiography should follow the initial non-enhanced CT NICE NG128.
- 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 NICE NG128.
- Intracranial haemorrhage must be excluded by appropriate imaging techniques before administration NICE NG128.
- 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 NICE NG128. Protocols for delivery and managing complications must be in place NICE NG128.
- 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) NICE NG128.
- 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) NICE NG128.
- 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 NICE NG128.
- 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 NICE NG128.
- Maintain a blood glucose concentration between 4 and 11 mmol/litre NICE NG128.
- 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 NICE NG128.