Ischaemic stroke

Overview 
Theory 
Diagnosis 
Management 
Follow up 
Resources 

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

INITIAL

suspected ischaemic stroke

1st line – stabilisation and referral to hyperacute or acute stroke unit

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1st line –

stabilisation and referral to hyperacute or acute stroke unit

Manage any airway, breathing, and circulatory insufficiencies requiring urgent treatment. In particular:

Consider endotracheal intubation for patients who are unable to protect their airway or for those presenting with a depressed level of consciousness (Glasgow Coma Scale score ≤8). This should be done by an anaesthetist or trained emergency department staff.[101]
Give supplemental oxygen only if oxygen saturation drops below 93%.[102]
- Monitor controlled oxygen therapy. An upper SpO ₂ limit of 96% is reasonable when administering supplemental oxygen to most patients with acute illness who are not at risk of hypercapnia. Evidence suggests that liberal use of supplemental oxygen (target SpO ₂ >96%) in acutely ill adults is associated with higher mortality than more conservative oxygen therapy.[103] A lower target SpO ₂ of 88% to 92% is appropriate if the patient is at risk of hypercapnic respiratory failure.[104]
- Do not routinely give oxygen to people who are not hypoxic.[67]

Evidence: Target oxygen saturation in acutely ill adults

Too much supplemental oxygen increases mortality.

Evidence from a large systematic review and meta-analysis supports conservative/controlled oxygen therapy versus liberal oxygen therapy in non-hypercapnic acutely ill adults.

Guidelines differ in their recommendations on target oxygen saturation in acutely unwell adults who are receiving supplemental oxygen.
- The 2017 British Thoracic Society (BTS) guideline recommends a target SpO ₂ range of 94% to 98% for patients not at risk of hypercapnia, whereas the 2022 Thoracic Society of Australia and New Zealand (TSANZ) guideline recommends 92% to 96%.[104][107]
- The Global Initiative For Asthma (GINA) guidelines recommend a target SpO ₂ range of 93% to 96% in the context of severe exacerbations of asthma.[108]
A systematic review including a meta-analysis of data from 25 randomised controlled trials published in 2018 found that in adults with acute illness, liberal oxygen therapy (broadly equivalent to a target saturation >96%) is associated with higher mortality than conservative oxygen therapy (broadly equivalent to a target saturation ≤96%).[103] In-hospital mortality was 11 per 1000 higher for the liberal oxygen therapy group versus the conservative therapy group (95% CI 2 to 22 per 1000 more). Mortality at 30 days was also higher in the group who had received liberal oxygen (RR 1.14, 95% CI 1.01 to 1.29). The trials included adults with sepsis, critical illness, stroke, trauma, myocardial infarction, and cardiac arrest, and patients who had emergency surgery. Studies that were limited to people with chronic respiratory illness or psychiatric illness, and patients on extracorporeal life support, receiving hyperbaric oxygen therapy, or having elective surgery, were all excluded from the review.
An upper SpO₂ limit of 96% is therefore reasonable when administering supplemental oxygen to patients with acute illness who are not at risk of hypercapnia. However, a higher target may be appropriate for some specific conditions (e.g., pneumothorax, carbon monoxide poisoning, cluster headache, and sickle cell crisis).[102]
In 2019 the BTS reviewed its guidance in response to this systematic review and meta-analysis and decided an interim update was not required.[109]
- The committee noted that the systematic review supported the use of controlled oxygen therapy to a target.
- While the systematic review showed an association between higher oxygen saturations and higher mortality, the BTS committee felt the review was not definitive on what the optimal target range should be. The suggested range of 94 to 96% in the review was based on the lower 95% confidence interval and the median baseline SpO ₂ from the liberal oxygen groups, along with the earlier 2015 TSANZ guideline recommendation.
Subsequently, experience during the COVID-19 pandemic has also made clinicians more aware of the feasibility of permissive hypoxaemia.[110]
Management of oxygen therapy in patients in intensive care is specialised and informed by further evidence (not covered in this summary) that is more specific to this setting.[111][112][113]

Admit everyone with suspected stroke directly to a hyperacute (or acute, depending on availability) stroke unit as soon as possible; UK guidelines recommend doing this within 4 hours of presentation to hospital.[67]

On admission, ensure the patient has their swallowing function assessed by appropriately trained staff before being given any oral food, fluid, or medication.[67][68]
Start nutrition support for people who are at risk of malnutrition. Routine nutritional supplementation is not recommended for people who are adequately nourished on admission.[67]

ACUTE

confirmed ischaemic stroke

thrombolysis not contraindicated

1st line – supportive care plus monitoring

Back

1st line –

supportive care plus monitoring

Level of consciousness

Assess and monitor the patient’s level of consciousness using the Glasgow Coma Scale. [ Glasgow Coma Scale Opens in new window ]

In patients with decreased level of consciousness or coma, urgently exclude haemorrhage and stroke mimics such as seizures. See Differentials.

Practical tip

Haemorrhagic stroke is more often associated with seizures, decreased level of consciousness, and signs of increased intracranial pressure than ischaemic stroke.

Blood glucose

Monitor blood glucose regularly. Maintain a blood glucose concentration between 4 and 11 mmol/L.[67]

Give insulin and glucose to all adults with type 1 diabetes with threatened or actual stroke. Follow your local protocol.[67]

Blood pressure

Monitor blood pressure regularly and give antihypertensive treatment only if there is a hypertensive emergency with one or more of the following serious concomitant conditions:[67]

Hypertensive encephalopathy
Hypertensive nephropathy
Hypertensive cardiac failure/myocardial infarction
Aortic dissection
Pre-eclampsia/eclampsia.

Oxygen saturations

Monitor oxygen saturations and give supplemental oxygen only if oxygen saturation drops below 93%.[102]

Monitor controlled oxygen therapy. An upper SpO ₂ limit of 96% is reasonable when administering supplemental oxygen to most patients with acute illness who are not at risk of hypercapnia. Evidence suggests that liberal use of supplemental oxygen (target SpO ₂ >96%) in acutely ill adults is associated with higher mortality than more conservative oxygen therapy.[103] A lower target SpO ₂ of 88% to 92% is appropriate if the patient is at risk of hypercapnic respiratory failure.[104]
Do not routinely give oxygen to people who are not hypoxic.[67]

Evidence: Target oxygen saturation in acutely ill adults

Too much supplemental oxygen increases mortality.

Evidence from a large systematic review and meta-analysis supports conservative/controlled oxygen therapy versus liberal oxygen therapy in non-hypercapnic acutely ill adults.

Guidelines differ in their recommendations on target oxygen saturation in acutely unwell adults who are receiving supplemental oxygen.
- The 2017 British Thoracic Society (BTS) guideline recommends a target SpO ₂ range of 94% to 98% for patients not at risk of hypercapnia, whereas the 2022 Thoracic Society of Australia and New Zealand (TSANZ) guideline recommends 92% to 96%.[104][107]
- The Global Initiative For Asthma (GINA) guidelines recommend a target SpO ₂ range of 93% to 96% in the context of severe exacerbations of asthma.[108]
A systematic review including a meta-analysis of data from 25 randomised controlled trials published in 2018 found that in adults with acute illness, liberal oxygen therapy (broadly equivalent to a target saturation >96%) is associated with higher mortality than conservative oxygen therapy (broadly equivalent to a target saturation ≤96%).[103] In-hospital mortality was 11 per 1000 higher for the liberal oxygen therapy group versus the conservative therapy group (95% CI 2 to 22 per 1000 more). Mortality at 30 days was also higher in the group who had received liberal oxygen (RR 1.14, 95% CI 1.01 to 1.29). The trials included adults with sepsis, critical illness, stroke, trauma, myocardial infarction, and cardiac arrest, and patients who had emergency surgery. Studies that were limited to people with chronic respiratory illness or psychiatric illness, and patients on extracorporeal life support, receiving hyperbaric oxygen therapy, or having elective surgery, were all excluded from the review.
An upper SpO₂ limit of 96% is therefore reasonable when administering supplemental oxygen to patients with acute illness who are not at risk of hypercapnia. However, a higher target may be appropriate for some specific conditions (e.g., pneumothorax, carbon monoxide poisoning, cluster headache, and sickle cell crisis).[102]
In 2019 the BTS reviewed its guidance in response to this systematic review and meta-analysis and decided an interim update was not required.[109]
- The committee noted that the systematic review supported the use of controlled oxygen therapy to a target.
- While the systematic review showed an association between higher oxygen saturations and higher mortality, the BTS committee felt the review was not definitive on what the optimal target range should be. The suggested range of 94 to 96% in the review was based on the lower 95% confidence interval and the median baseline SpO ₂ from the liberal oxygen groups, along with the earlier 2015 TSANZ guideline recommendation.
Subsequently, experience during the COVID-19 pandemic has also made clinicians more aware of the feasibility of permissive hypoxaemia.[110]
Management of oxygen therapy in patients in intensive care is specialised and informed by further evidence (not covered in this summary) that is more specific to this setting.[111][112][113]

Hydration

Assess the patient’s hydration within 4 hours of their arrival at hospital.[67] Review regularly; manage as needed to maintain normal hydration.[67][68]

Cardiac rhythm and rate

In people who would be eligible for secondary prevention treatment for atrial fibrillation:[68]

Perform prolonged ECG monitoring (at least 24 hours)
Consider prolonged ECG monitoring with an external patch, wearable recorder, or implantable loop recorder in those in whom no other cause of stroke has been found, particularly if they have a pattern of cerebral ischaemia on brain imaging suggestive of cardioembolism.

Atrial fibrillation is an independent risk factor for ischaemic stroke and indicates a poor prognosis.[29] See New-onset atrial fibrillation.

Intracranial pressure

Monitor the patient for signs of elevated intracranial pressure (ICP). For information on other complications, see Complications.

Repeat the CT head immediately if you suspect elevated ICP, which may present as:

A reducing level of consciousness
Severe headache
Nausea/vomiting
A sudden increase in blood pressure.

Refer immediately to a neurosurgeon any patients with large middle cerebral artery territory infarcts and those with large infarctions affecting the cerebellum. These types of stroke have a very high mortality if urgent neurosurgical intervention is delayed.[69]

Patients with large middle cerebral artery territory infarcts (at risk of malignant middle cerebral artery syndrome) may need decompressive hemicraniectomy (neurosurgical removal of part of the skull to reduce intracerebral pressure).[69]
Patients with large infarctions affecting the cerebellum may need ventriculostomy (placement of an external ventricular drain) or posterior fossa craniectomy.[69]

Practical tip

Patients with large infarctions affecting the cerebellum or middle cerebral artery are at risk of developing oedema and elevated intracranial pressure. If left unchecked, the oedema compromises blood flow and causes brain herniation, which is frequently fatal.

In line with recommendations from the National Institute for Health and Care Excellence (NICE) in the UK, decompressive hemicraniectomy should be considered (performed within 48 hours of symptom onset) in any patient who meets all of the following criteria:[67]

Clinical deficits that suggest infarction in the territory of the middle cerebral artery, with a score >15 on the National Institutes of Health Stroke Scale (NIHSS) [ NIH Stroke Score Opens in new window ]
Decreased level of consciousness, with a score of 1 or more on item 1a of the NIHSS
Signs on CT of an infarct of at least 50% of the middle cerebral artery territory:
- With or without additional infarction in the territory of the anterior or posterior cerebral artery on the same side
  or
- With infarct volume greater than 145 cm ³, as shown on diffusion-weighted MRI scan.

Evidence: Decompressive hemicraniectomy

Decompressive hemicraniectomy reduces mortality, with some evidence of improved functional outcomes (although overall functional outcomes are poor in this population) and a variable impact on quality of life (which is generally low with or without surgery). There is no evidence that there should be an age cut-off for surgery, with the patient’s pre-stroke functional status being a more useful indicator of the potential outcomes of surgery.

There has been much debate about the net benefits of hemicraniectomy, especially in patients aged over 60 years due to the possibility of an increased risk of surviving with a serious disability, compared with people under 60 years.

The 2008 NICE guideline recommended hemicraniectomy only in people aged under 60 years. This was updated in 2019 to recommend that patients or their family members or carers should be given specific information on the risks and benefits in terms of functional outcomes and risk of mortality, so that personal values and preferences, especially regarding disability, are considered in shared decision-making.[158] This updated recommendation followed new evidence focusing on patient age, in particular the 2014 DESTINY II trial.[158]

The review by NICE found 5 randomised controlled trials (RCTs) of patients with an average age <60 years (HeMMi, HeADDFIRST, HAMLET, DESTINY and DECIMAL).[158]
- In these studies, decompressive hemicraniectomy reduced mortality at 30 days (1 study; n=32; risk difference 416 fewer per 1000 [95% CI 64 fewer to 501 fewer]; moderate-quality evidence assessed using GRADE), 6 months (3 studies; n=86; risk difference 262 fewer per 1000 [95% CI 76 fewer to 371 fewer]; GRADE moderate) and 1 year (3 studies; n=134; risk difference 392 fewer per 1000 [95% CI 261 fewer to 469 fewer]; GRADE high).
- There was a clinically important difference in functional outcomes (score 0 to 3 on modified Rankin Scale) at 6 months (risk difference 110 more per 1000 [95% CI 68 fewer to 441 more]; GRADE very low) or 1 year (risk difference 130 more per 1000 [95% CI 25 fewer to 392 more]; GRADE low).
- There was no clinically important difference for quality of life at 1 year as measured by the SF-36 mental summary score (1 study; n=35; GRADE very low) or as measured using visual analog scales (1 study; n=32; GRADE low), but a clinically important harm of surgery for the SF-36 physical summary scale (1 study; n=35; GRADE low). Overall, quality of life scores were low in both groups.
NICE found 3 RCTs in patients with an average age over 60 years (including DESTINY II).[158]
- In these studies, decompressive hemicraniectomy reduced mortality at 6 months (1 study; n=29; risk difference 487 fewer per 1000 [95% CI 122 fewer to 579 fewer]; GRADE moderate) and 1 year (3 studies; n=162; risk difference 364 fewer per 1000 [95% CI 227 fewer to 462 fewer]; GRADE moderate).
- There was no difference in functional outcomes between groups at 6 months (2 studies; n=141; risk difference 23 more per 1000 [95% CI 7 fewer to 159 more]; GRADE very low) but a significant benefit for surgery at 12 months (3 studies; n=165; risk difference 100 more per 1000 [95% CI 10 more to 180 more]; GRADE very low).
- Quality of life was higher at 1 year after surgery (1 study; n=100; GRADE low). Overall quality of life scores were low in both groups.
In all of the trials in people aged over 60 years, surgery had to be within 48 hours of symptom onset. Two of the trials in those aged under 60 years included people who had surgery longer than 48 hours after symptom onset (HeMMi 72 hours and HAMLET 96 hours). The NICE guideline group felt the beneficial results were largely driven by studies which only allowed surgery up to a maximum of 48 hours after onset, hence the time limit for surgery in their recommendation.
The NICE guideline committee notes that there was a clear mortality benefit of surgery at any age and that the patient’s pre-morbid state is more important than their age when making a decision about the risks of surgery. However, survivors have a high likelihood of moderate or severe disability with or without surgery.

Discuss the risks and benefits of the procedure with the patient or their family members or carers. Take into account the patient’s functional status before the stroke, and their wishes and preferences.[67] A shared decision-making process should include a careful discussion with the patient or their representatives about the risk of survival with substantial disability.[159]

Seizures

Consult immediately with a neurologist or neurosurgeon if the patient has uncontrolled or recurrent seizures, or status epilepticus. The choice of anticonvulsant will depend on individual patient characteristics.[69] See Status epilepticus.

Follow your hospital protocol. In practice, levetiracetam and sodium valproate are commonly used.

Temperature

Monitor temperature and maintain normal body physiology.[68][105]

Give an antipyretic (e.g., paracetamol) in patients with high temperature.

Do not use therapeutic hypothermia (i.e., active cooling) to reduce the risk of secondary brain damage.[67]

Primary options

paracetamol: oral: 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day; intravenous (<51 kg body weight): 15 mg/kg intravenously every 4-6 hours when required, maximum 60 mg/kg/day; intravenous (≥51 kg body weight): 1000 mg intravenously every 4-6 hours when required, maximum 4000 mg/day (3000 mg/day if risk factors for hepatotoxicity)

Plus – alteplase or tenecteplase

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Plus –

alteplase or tenecteplase

Treatment recommended for ALL patients in selected patient group

Follow your local protocols for recommendations on intravenous thrombolysis.

Guidelines in the UK and from the European Stroke Organisation (ESO) recommend to give intravenous alteplase (recombinant tissue plasminogen activator) to eligible patients if not contraindicated and:[65][67][68][116]

Treatment is started as soon as possible within 4.5 hours of onset of stroke symptoms
AND
Intracranial haemorrhage has been excluded using appropriate imaging techniques.

The National Clinical Guideline for Stroke for the UK and Ireland recommends patients with acute ischaemic stroke, regardless of age or stroke severity, who were last known to be well more than 4.5 hours earlier should be considered for thrombolysis with alteplase if intracranial haemorrhage has been excluded and:[68]

Treatment can be started between 4.5 and 9 hours of known onset, or within 9 hours of the midpoint of sleep when they have woken with symptoms
AND
There is evidence of the potential to salvage brain tissue on CT perfusion or MRI (DWI-FLAIR mismatch [diffusion-weighted MRI and fluid-attenuated inversion recovery MRI mismatch]).

This should be irrespective of whether patients have a large artery occlusion and require mechanical thrombectomy.[68]

The ESO further recommends intravenous thrombolysis for:[65]

Patients who were last seen well 4.5 to 9 hours earlier (known onset time), with CT or MRI core/perfusion mismatch, and for whom mechanical thrombectomy is either not indicated or not planned
Patients with acute ischaemic stroke on awakening from sleep, who were last seen well more than 4.5 hours earlier, who have MRI DWI-FLAIR mismatch, and for whom mechanical thrombectomy is either not indicated or not planned.

Refer to the prescribing information for contraindications to thrombolysis with alteplase. Examples include recent surgery and current anticoagulation use.

Do not delay treatment with alteplase while waiting for results or waiting to perform tests, unless you suspect contraindications that must be ruled out first (eg., hypoglycaemia, coagulopathy), or while monitoring for further improvement.[70][71]

Exclude hypoglycaemia and hyperglycaemia before giving thrombolysis hypoglycaemia is a stroke mimic and hyperglycaemia is associated with intracerebral bleeding and worse clinical outcomes.[67][69]

In the UK, alteplase should only be administered within a well-organised stroke service by staff trained in delivering thrombolysis and in monitoring for complications.[67][68] Trained staff in emergency departments can also administer alteplase provided that the patient can be managed in an acute stroke service.[67] Patients who are over 80 years old with mild or severe stroke also benefit from treatment with thrombolysis.[68] Intravenous thrombolysis should not delay mechanical thrombectomy.[106]

Consider reducing blood pressure to 185/110 mmHg or lower in people who are candidates for intravenous thrombolysis.[67][117]

The use of intravenous tenecteplase is off-label for this indication in the UK. However, the 2023 National Clinical Guideline for Stroke for the UK and Ireland recommends to consider thrombolysis with either alteplase or tenecteplase in all patients with acute ischaemic stroke within 4.5 hours of known onset.[68]

Tenecteplase may be considered as a safe and effective alternative to alteplase in this group of patients.[68][106] Tenecteplase is not recommended for patients with ischaemic stroke on awakening from sleep or of unknown onset who undergo no brain imaging other than CT.[68][106]

Primary options

alteplase: 0.9 mg/kg intravenously (maximum 90 mg/dose); give 10% of the total dose by intravenous bolus initially, then give the remainder of the dose by intravenous infusion over 60 minutes

Secondary options

tenecteplase: consult specialist for guidance on dose

Consider – mechanical thrombectomy

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Consider –

mechanical thrombectomy

Additional treatment recommended for SOME patients in selected patient group

The decision to offer mechanical thrombectomy (endovascular intervention) should be made by clinicians experienced in the use of thrombolysis for stroke and in interpretation of relevant imaging.[67] The procedure should only be carried out by appropriately trained specialists with regular experience in intracranial endovascular interventions, with appropriate facilities and neuroscience support.[85] Patients eligible for mechanical thrombectomy should receive prior intravenous thrombolysis as rapidly as possible (unless contraindicated), irrespective of whether they have presented to an acute stroke centre or a thrombectomy centre.[68]

Guidelines in the UK recommend to offer mechanical thrombectomy:[68]

As soon as possible and within 6 hours of symptom onset (together with intravenous thrombolysis, if not contraindicated and within the licensed time window) to patients with no previous disability (modified Rankin Scale [mRS] 0 or 1) with confirmed occlusion of the proximal anterior circulation and proximal intracranial large artery occlusion causing a disabling neurological deficit (National Institutes of Health Stroke Scale [NIHSS] score of 6 or more) [ NIH Stroke Score Opens in new window ]
As soon as possible in patients last known to be well between 6-24 hours previously (including wake-up strokes) and with no previous disability (mRS 0 or 1) combined with thrombolysis, if eligible:
- Who have confirmed proximal intracranial large artery occlusion (ICA and/or M1) causing a disabling neurological deficit (NIHSS score of 6 or more) [ NIH Stroke Score Opens in new window ]
- If there is potential to salvage brain tissue, as shown by perfusion imaging:
  - Between 6 and 12 hours: an Alberta Stroke Program Early Computed Tomography Score (ASPECTS) score of 3 or more, irrespective of the core infarct size
  - Between 12 and 24 hours: an ASPECTS score of 3 or more and CT or MRI perfusion mismatch of greater than 15 mL, irrespective of the core infarct size.

Guidelines in the UK recommend to consider mechanical thrombectomy (together with intravenous thrombolysis, if not contraindicated and within the licensed time window) in patients with confirmed occlusion of the proximal anterior circulation (by CT angiography or MR angiography [CTA/MRA]):[68]

If there is potential to salvage brain tissue, as shown by perfusion imaging.

Caution should be exercised when considering mechanical thrombectomy for patients presenting between 12 and 24 hours of onset and/or over the age of 80 owing to the paucity of data in these groups.[68]

Plus – antiplatelet agent

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Plus –

antiplatelet agent

Treatment recommended for ALL patients in selected patient group

Offer an antiplatelet agent as soon as possible but certainly within 24 hours (unless contraindicated) to any patient presenting with acute stroke who has had intracerebral haemorrhage excluded by imaging.[67] In practice, administration of aspirin (or alternative) is usually delayed 24 hours after alteplase or tenecteplase, once a further CT scan has excluded significant bleeding.

The National Clinical Guideline for Stroke for the UK and Ireland recommends to offer:[68]

Aspirin (only) to patients with disabling ischaemic stroke. Continue aspirin daily until 2 weeks after the onset of stroke, then start definitive long-term antithrombotic treatment. Patients being transferred to care at home before 2 weeks should be started on long-term treatment earlier.[68]
Dual antiplatelet therapy with either aspirin and clopidogrel for 21 days, or aspirin and ticagrelor for 30 days in patients presenting within 24 hours of minor stroke and with a low risk of bleeding. For patients with minor ischaemic stroke who are not appropriate for dual antiplatelet therapy, give clopidogrel monotherapy.[68] After 21 days, for long-term prevention of vascular events in people with ischaemic stroke without paroxysmal or permanent atrial fibrillation, single antiplatelet treatment should be used. See Secondary prevention.

However, the National Institute for Health and Care Excellence (NICE) in the UK recommends to offer:[67][161][162]

Aspirin orally (for those with no dysphagia), or
Aspirin rectally or by enteral tube (for those with dysphagia).

NICE recommends to offer an alternative antiplatelet agent to anyone who is allergic to or genuinely intolerant of aspirin.[67] In practice, clopidogrel is often used.

Antiplatelet treatment may be contraindicated or delayed in patients with active bleeding (e.g., from the gastrointestinal tract).

Offer a proton-pump inhibitor, in addition to aspirin, to any patient who reports previous dyspepsia associated with aspirin.[67] A proton-pump inhibitor should be considered for concurrent use with dual antiplatelet therapy to reduce the risk of gastrointestinal haemorrhage.[68]

Primary options

aspirin: 300 mg orally/rectally once daily

aspirin: 300 mg orally as a loading dose, followed by 75 mg once daily for 21 days

and

clopidogrel: 300 mg orally as a loading dose, followed by 75 mg once daily for 21 days

aspirin: 300 mg orally as a loading dose, followed by 75 mg once daily for 30 days

and

ticagrelor: 180 mg orally as a loading dose, followed by 90 mg twice daily for 30 days

Secondary options

clopidogrel: 300 mg orally as a loading dose, followed by 75 mg once daily

Consider – venous thromboembolism prophylaxis plus early mobilisation

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Consider –

venous thromboembolism prophylaxis plus early mobilisation

Additional treatment recommended for SOME patients in selected patient group

Give intermittent pneumatic compression within 3 days of admission for the prevention of deep vein thrombosis and pulmonary embolism. Do not routinely give low molecular weight heparin or graduated compression stockings.[68] However in practice, prophylactic low molecular weight heparin may be considered if intermittent pneumatic compression is contraindicated or not possible.

Arrange assessment of patients with mobilisation difficulties by an appropriately trained healthcare professional as soon as possible. Ensure this assessment is conducted within the first 24 hours of onset to determine the most appropriate and safe methods of transfer and mobilisation.[68] Help the patient to sit out of bed, stand, or walk as soon as their clinical condition permits, as part of an active management programme in a specialist stroke unit.[67] Mobilisation typically begins between 24 and 48 hours of stroke onset.[68]

If the patient needs help to sit out of bed, stand, or walk, do not provide high-intensity mobilisation in the first 24 hours after symptom onset.[67][68]

High-intensity mobilisation refers to the very early mobilisation intervention from the AVERT trial.[68][179] It includes mobilisation that: begins within the first 24 hours of stroke onset; includes at least three additional out-of-bed sessions compared with usual care; focuses on sitting, standing and walking (that is, out of bed) activity.

Plus – high-intensity statin

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Plus –

high-intensity statin

Treatment recommended for ALL patients in selected patient group

Do not start statin treatment immediately. Usually it would be appropriate to start statin treatment once a patient can swallow medication safely, and there is consensus that it is safe to start statins after 48 hours.[67][68]

Offer high-intensity statin therapy (unless contraindicated) to all patients.[68]

Give moderate- or low-intensity statin therapy at the maximum tolerated dose if a high-intensity statin is unsuitable or not tolerated.[68]

Continue statin treatment in people who are already receiving statins.[67] Consider increasing the statin intensity or dose if the patient is not currently taking a high-intensity statin at the maximum tolerated dose.[61]

Primary options

atorvastatin: 20-80 mg orally once daily

thrombolysis contraindicated

1st line – supportive care plus monitoring

Back

1st line –

supportive care plus monitoring

Level of consciousness

Assess and monitor the patient’s level of consciousness using the Glasgow Coma Scale. [ Glasgow Coma Scale Opens in new window ]

In patients with decreased level of consciousness or coma, urgently exclude haemorrhage and stroke mimics such as seizures. See Differentials.

Practical tip

Haemorrhagic stroke is more often associated with seizures, decreased level of consciousness, and signs of increased intracranial pressure than ischaemic stroke.

Blood glucose

Monitor blood glucose regularly. Maintain a blood glucose concentration between 4 and 11 mmol/L.[67]

Give insulin and glucose to all adults with type 1 diabetes with threatened or actual stroke. Follow your local protocol.[67]

Blood pressure

Monitor blood pressure regularly and give antihypertensive treatment only if there is a hypertensive emergency with one or more of the following serious concomitant conditions:[67]

Hypertensive encephalopathy
Hypertensive nephropathy
Hypertensive cardiac failure/myocardial infarction
Aortic dissection
Pre-eclampsia/eclampsia.

The National Institute for Health and Care Excellence (NICE) in the UK recommends to consider reducing blood pressure to 185/110 mmHg or lower in people who are candidates for intravenous thrombolysis.[67][117] In patients with acute ischaemic stroke not treated with intravenous thrombolysis or mechanical thrombectomy and blood pressure >220/120 mmHg, the European Stroke Organisation states that careful blood pressure reduction (<15% systolic blood pressure reduction in 24 hours) is reasonable and likely to be safe.[117] In patients on antihypertensive medication, resume oral treatment once the patient is medically stable and as soon as they can swallow medication safely.[68]

Oxygen saturations

Monitor oxygen saturations and give supplemental oxygen only if oxygen saturation drops below 93%.[102]

Monitor controlled oxygen therapy. An upper SpO ₂ limit of 96% is reasonable when administering supplemental oxygen to most patients with acute illness who are not at risk of hypercapnia. Evidence suggests that liberal use of supplemental oxygen (target SpO ₂ >96%) in acutely ill adults is associated with higher mortality than more conservative oxygen therapy.[103] A lower target SpO ₂ of 88% to 92% is appropriate if the patient is at risk of hypercapnic respiratory failure.[104]
Do not routinely give oxygen to people who are not hypoxic.[67]

Evidence: Target oxygen saturation in acutely ill adults

Too much supplemental oxygen increases mortality.

Evidence from a large systematic review and meta-analysis supports conservative/controlled oxygen therapy versus liberal oxygen therapy in non-hypercapnic acutely ill adults.

Guidelines differ in their recommendations on target oxygen saturation in acutely unwell adults who are receiving supplemental oxygen.
- The 2017 British Thoracic Society (BTS) guideline recommends a target SpO ₂ range of 94% to 98% for patients not at risk of hypercapnia, whereas the 2022 Thoracic Society of Australia and New Zealand (TSANZ) guideline recommends 92% to 96%.[104][107]
- The Global Initiative For Asthma (GINA) guidelines recommend a target SpO ₂ range of 93% to 96% in the context of severe exacerbations of asthma.[108]
A systematic review including a meta-analysis of data from 25 randomised controlled trials published in 2018 found that in adults with acute illness, liberal oxygen therapy (broadly equivalent to a target saturation >96%) is associated with higher mortality than conservative oxygen therapy (broadly equivalent to a target saturation ≤96%).[103] In-hospital mortality was 11 per 1000 higher for the liberal oxygen therapy group versus the conservative therapy group (95% CI 2 to 22 per 1000 more). Mortality at 30 days was also higher in the group who had received liberal oxygen (RR 1.14, 95% CI 1.01 to 1.29). The trials included adults with sepsis, critical illness, stroke, trauma, myocardial infarction, and cardiac arrest, and patients who had emergency surgery. Studies that were limited to people with chronic respiratory illness or psychiatric illness, and patients on extracorporeal life support, receiving hyperbaric oxygen therapy, or having elective surgery, were all excluded from the review.
An upper SpO₂ limit of 96% is therefore reasonable when administering supplemental oxygen to patients with acute illness who are not at risk of hypercapnia. However, a higher target may be appropriate for some specific conditions (e.g., pneumothorax, carbon monoxide poisoning, cluster headache, and sickle cell crisis).[102]
In 2019 the BTS reviewed its guidance in response to this systematic review and meta-analysis and decided an interim update was not required.[109]
- The committee noted that the systematic review supported the use of controlled oxygen therapy to a target.
- While the systematic review showed an association between higher oxygen saturations and higher mortality, the BTS committee felt the review was not definitive on what the optimal target range should be. The suggested range of 94 to 96% in the review was based on the lower 95% confidence interval and the median baseline SpO ₂ from the liberal oxygen groups, along with the earlier 2015 TSANZ guideline recommendation.
Subsequently, experience during the COVID-19 pandemic has also made clinicians more aware of the feasibility of permissive hypoxaemia.[110]
Management of oxygen therapy in patients in intensive care is specialised and informed by further evidence (not covered in this summary) that is more specific to this setting.[111][112][113]

Hydration

Assess the patient’s hydration within 4 hours of their arrival at hospital.[67] Review regularly; manage as needed to maintain normal hydration.[67][68]

Cardiac rhythm and rate

In people who would be eligible for secondary prevention treatment for atrial fibrillation or flutter:[68]

Perform prolonged ECG monitoring (at least 24 hours)
Consider prolonged sequential or continuous ECG monitoring with an external patch, wearable recorder, or implantable loop recorder in those in whom no other cause of stroke has been found, particularly if they have a pattern of cerebral ischaemia on brain imaging suggestive of cardioembolism.

Atrial fibrillation is an independent risk factor for ischaemic stroke and indicates a poor prognosis.[29] See New-onset atrial fibrillation.

Intracranial pressure

Monitor the patient for signs of elevated intracranial pressure (ICP). For information on other complications, see Complications.

Repeat the CT head immediately if you suspect elevated ICP, which may present as:

A reducing level of consciousness
Severe headache
Nausea/vomiting
A sudden increase in blood pressure.

Patients with large middle cerebral artery territory infarcts (at risk of malignant middle cerebral artery syndrome) may need decompressive hemicraniectomy (neurosurgical removal of part of the skull to reduce intracerebral pressure).[69]
Patients with large infarctions affecting the cerebellum may need ventriculostomy (placement of an external ventricular drain) or posterior fossa craniectomy.[69]

Practical tip

Clinical deficits that suggest infarction in the territory of the middle cerebral artery, with a score >15 on the National Institutes of Health Stroke Scale (NIHSS) [ NIH Stroke Score Opens in new window ]
Decreased level of consciousness, with a score of 1 or more on item 1a of the NIHSS
Signs on CT of an infarct of at least 50% of the middle cerebral artery territory:
- With or without additional infarction in the territory of the anterior or posterior cerebral artery on the same side
  or
- With infarct volume greater than 145 cm ³, as shown on diffusion-weighted MRI scan.

Evidence: Decompressive hemicraniectomy

The review by NICE found 5 randomised controlled trials (RCTs) of patients with an average age <60 years (HeMMi, HeADDFIRST, HAMLET, DESTINY and DECIMAL).[158]
- In these studies, decompressive hemicraniectomy reduced mortality at 30 days (1 study; n=32; risk difference 416 fewer per 1000 [95% CI 64 fewer to 501 fewer]; moderate-quality evidence assessed using GRADE), 6 months (3 studies; n=86; risk difference 262 fewer per 1000 [95% CI 76 fewer to 371 fewer]; GRADE moderate) and 1 year (3 studies; n=134; risk difference 392 fewer per 1000 [95% CI 261 fewer to 469 fewer]; GRADE high).
- There was a clinically important difference in functional outcomes (score 0 to 3 on modified Rankin Scale) at 6 months (risk difference 110 more per 1000 [95% CI 68 fewer to 441 more]; GRADE very low) or 1 year (risk difference 130 more per 1000 [95% CI 25 fewer to 392 more]; GRADE low).
- There was no clinically important difference for quality of life at 1 year as measured by the SF-36 mental summary score (1 study; n=35; GRADE very low) or as measured using visual analog scales (1 study; n=32; GRADE low), but a clinically important harm of surgery for the SF-36 physical summary scale (1 study; n=35; GRADE low). Overall, quality of life scores were low in both groups.
NICE found 3 RCTs in patients with an average age over 60 years (including DESTINY II).[158]
- In these studies, decompressive hemicraniectomy reduced mortality at 6 months (1 study; n=29; risk difference 487 fewer per 1000 [95% CI 122 fewer to 579 fewer]; GRADE moderate) and 1 year (3 studies; n=162; risk difference 364 fewer per 1000 [95% CI 227 fewer to 462 fewer]; GRADE moderate).
- There was no difference in functional outcomes between groups at 6 months (2 studies; n=141; risk difference 23 more per 1000 [95% CI 7 fewer to 159 more]; GRADE very low) but a significant benefit for surgery at 12 months (3 studies; n=165; risk difference 100 more per 1000 [95% CI 10 more to 180 more]; GRADE very low).
- Quality of life was higher at 1 year after surgery (1 study; n=100; GRADE low). Overall quality of life scores were low in both groups.
In all of the trials in people aged over 60 years, surgery had to be within 48 hours of symptom onset. Two of the trials in those aged under 60 years included people who had surgery longer than 48 hours after symptom onset (HeMMi 72 hours and HAMLET 96 hours). The NICE guideline group felt the beneficial results were largely driven by studies which only allowed surgery up to a maximum of 48 hours after onset, hence the time limit for surgery in their recommendation.
The NICE guideline committee notes that there was a clear mortality benefit of surgery at any age and that the patient’s pre-morbid state is more important than their age when making a decision about the risks of surgery. However, survivors have a high likelihood of moderate or severe disability with or without surgery.

Seizures

Follow your hospital protocol. Levetiracetam and sodium valproate are commonly used.

Temperature

Monitor temperature and maintain normal body physiology.[68][105]

Give an antipyretic (e.g., paracetamol) in patients with high temperature.

Do not use therapeutic hypothermia (i.e., active cooling) to reduce the risk of secondary brain damage.[67]

Primary options

Consider – mechanical thrombectomy

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Consider –

mechanical thrombectomy

Additional treatment recommended for SOME patients in selected patient group

Candidates for thrombectomy alone include patients who cannot receive thrombolysis (e.g., with contraindications including recent surgery, current anticoagulation use).[68]

Guidelines in the UK recommend to offer mechanical thrombectomy:[68]

As soon as possible and within 6 hours of symptom onset to patients with confirmed occlusion of the proximal anterior circulation
As soon as possible in patients last known to be well between 6-24 hours previously (including wake-up strokes) and with no previous disability (modified Rankin Scale [mRS] 0 or 1):
- Who have confirmed proximal intracranial large artery occlusion (ICA and/or M1) causing a disabling neurological deficit (National Institutes of Health Stroke Scale [NIHSS] score of 6 or more) [ NIH Stroke Score Opens in new window ]
- If there is potential to salvage brain tissue, as shown by perfusion imaging:
  - Between 6 and 12 hours: an Alberta Stroke Program Early Computed Tomography Score (ASPECTS) score of 3 or more, irrespective of the core infarct size
  - Between 12 and 24 hours: an ASPECTS score of 3 or more and CT or MRI perfusion mismatch of greater than 15 mL, irrespective of the core infarct size.

Guidelines in the UK recommend to consider mechanical thrombectomy in patients with confirmed occlusion of the proximal posterior circulation:[68]

If there is potential to salvage brain tissue, as shown by perfusion imaging.

Plus – antiplatelet agent

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Plus –

antiplatelet agent

Treatment recommended for ALL patients in selected patient group

Offer an antiplatelet agent as soon as possible but certainly within 24 hours (unless contraindicated) to any patient presenting with acute stroke who has had intracerebral haemorrhage excluded by imaging.[67] In practice, administration of aspirin (or alternative) is usually delayed 24 hours after alteplase or tenecteplase, once a further CT scan has excluded significant bleeding.

The National Clinical Guideline for Stroke for the UK and Ireland recommends to offer:[68]

Aspirin (only) to patients with disabling ischaemic stroke. Continue aspirin daily until 2 weeks after the onset of stroke, then start definitive long-term antithrombotic treatment. Patients being transferred to care at home before 2 weeks should be started on long-term treatment earlier.[68]
Dual antiplatelet therapy with either aspirin and clopidogrel for 21 days, or aspirin and ticagrelor for 30 days in patients presenting within 24 hours of minor stroke and with a low risk of bleeding. For patients with minor ischaemic stroke who are not appropriate for dual antiplatelet therapy, give clopidogrel monotherapy.[68] After the completion of dual antiplatelet therapy, for long-term prevention of vascular events in people with ischaemic stroke without paroxysmal or permanent atrial fibrillation, single antiplatelet treatment should be used. See Secondary prevention.

However, the National Institute for Health and Care Excellence (NICE) in the UK recommends to offer:[67]

Aspirin orally (for those with no dysphagia), or
Aspirin rectally or by enteral tube (for those with dysphagia).

NICE recommends to offer an alternative antiplatelet agent to anyone who is allergic to or genuinely intolerant of aspirin.[67] In practice, clopidogrel is often used.

Antiplatelet treatment may be contraindicated or delayed in patients with active bleeding (e.g., from the gastrointestinal tract).

Primary options

aspirin: 300 mg orally/rectally once daily

aspirin: 300 mg orally as a loading dose, followed by 75 mg once daily for 21 days

and

clopidogrel: 300 mg orally as a loading dose, followed by 75 mg once daily for 21 days

aspirin: 300 mg orally as a loading dose, followed by 75 mg once daily for 30 days

and

ticagrelor: 180 mg orally as a loading dose, followed by 90 mg twice daily for 30 days

Secondary options

clopidogrel: 300 mg orally as a loading dose, followed by 75 mg once daily

Consider – venous thromboembolism prophylaxis plus early mobilisation

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Consider –

venous thromboembolism prophylaxis plus early mobilisation

Additional treatment recommended for SOME patients in selected patient group

If the patient needs help to sit out of bed, stand, or walk, do not provide high-intensity mobilisation in the first 24 hours after symptom onset.[67]

High-intensity mobilisation refers to the very early mobilisation intervention from the AVERT trial.[68][179] It includes mobilisation that: begins within the first 24 hours of stroke onset; includes at least three additional out-of-bed sessions compared with usual care; focuses on sitting, standing, and walking (that is, out of bed) activity.

Plus – high-intensity statin

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Plus –

high-intensity statin

Treatment recommended for ALL patients in selected patient group

Offer high-intensity statin therapy (unless contraindicated) to all patients.[68] Give moderate- or low-intensity statin therapy at the maximum tolerated dose if a high-intensity statin is unsuitable or not tolerated.[68]

Primary options

atorvastatin: 20-80 mg orally once daily

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Ischaemic stroke

Treatment algorithm

suspected ischaemic stroke

stabilisation and referral to hyperacute or acute stroke unit

Evidence: Target oxygen saturation in acutely ill adults

confirmed ischaemic stroke

thrombolysis not contraindicated

supportive care plus monitoring

Level of consciousness

Practical tip

Blood glucose

Blood pressure

Oxygen saturations

Evidence: Target oxygen saturation in acutely ill adults

Hydration

Cardiac rhythm and rate

Intracranial pressure

Practical tip

Evidence: Decompressive hemicraniectomy

Seizures

Temperature

Primary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

alteplase or tenecteplase

Primary options

Secondary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Secondary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

Secondary options

mechanical thrombectomy

antiplatelet agent

Primary options

Secondary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Secondary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

Secondary options

venous thromboembolism prophylaxis plus early mobilisation

high-intensity statin

Primary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

thrombolysis contraindicated

supportive care plus monitoring

Level of consciousness

Practical tip

Blood glucose

Blood pressure

Oxygen saturations

Evidence: Target oxygen saturation in acutely ill adults

Hydration

Cardiac rhythm and rate

Intracranial pressure

Practical tip

Evidence: Decompressive hemicraniectomy

Seizures

Temperature

Primary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

mechanical thrombectomy

antiplatelet agent

Primary options

Secondary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Secondary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.