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Immediate Management of Ischaemic Stroke
2
Key
Stroke- Clinical Presentation
Backing Information
History and examination
Primary Care
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information, hold down
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icon
3
Secondary Care
Referral Template
Perform standardised assessment
1
4
Consider time since symptom
onset
5
Background
Information
Consider urgent thrombolysis
within 3 hours of symptoms
6
Investigations
7
Consider differential
diagnosis
8
Blood tests
Brain imaging
9
10
Review investigation findings
11
12
Imaging reveals ischaemic
stroke or transient ischaemic
attack (TIA)
Imaging reveals
haemorrhagic stroke
Do the following in parallel
18
15
Refer to Stroke unit
16
Administer
thrombolysis if
appropriate
Imaging reveals
abnormalities other
than stroke or TIA
14
13
Complete the venous
thromboembolism
(VTE) risk assessment
17
Administer aspirin if
thrombolysis is
inappropriate
Assess
swallowing and
nutrition
19
20
Regular
physiological
monitoring
21
Assess and
manage
complications
22
Start aspirin 24 hours
after thrombolysis
23
Admit to stroke unit
24
Approval Date: June 2011/ Review Date: June 2013
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1 Information resources for patients and carers
• 'Diet and Hypertension' (PDF) from British Dietetic Association
• 'Stroke' (PDF) from Brain & Spine Foundation at http://www.brainandspine.org.uk
• 'Stroke' (URL) from Datapharm at http://www.medguides.medicines.org.uk
• 'Stroke' (URL) from Patient UK at http://www.patient.co.uk
• 'Stroke and high blood pressure' (URL) from Blood Pressure Association at
http://www.bpassoc.org.uk
• Sue Ryder Care at http://www.suerydercare.org
• The Carers Resource at http://www.carersresource.org
• The Disabled Living Foundation at http://www.dlf.org.uk
• The Stroke Association at http://www.stroke.org.uk
• 'Understanding NICE guidance: Early assessment and treatment of people who have had a stroke
or transient ischaemic attack (TIA)' (PDF) from National Institute for Health and Clinical Excellence
Information for carers and people with disabilities is available at:
• 'Caring for someone' (URL) from Directgov at http://www.direct.gov.uk
• 'Disabled people' (URL) from Directgov at http://www.direct.gov.uk
Explanations of clinical laboratory tests used in diagnosis and treatment are available at
‘Understanding Your Tests’ (URL) from Lab Tests Online-UK at http://www.labtestsonline.org.uk
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2 Stroke- clinical presentation
The following symptoms and signs of stroke or transient ischemic attack (TIA) should be promptly
recognised:
 weakness or numbness of the face, arm, and/or leg (especially if only on one side of the body)
 problems with speech and comprehension
 problems with swallowing
 problems with walking, balance, or coordination
 loss of vision
 confusion
 headache with or without nausea or vomiting
 decreased conscious state or coma
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3 History and examination
Assess any history of:
 weakness or numbness of the face, arm, and/or leg (especially if only on one side of the body)
 problems with speech and comprehension
 problems with swallowing
 problems with walking, balance, or coordination
 loss of vision
 confusion
 headache
 nausea and/or vomiting
 decreased conscious state or coma
Perform full neurological examination, especially examination of:
 speech
 power
 visual fields
 cranial nerves
 sensation
Approval Date: June 2011/ Review Date: June 2013
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Perform cardiovascular examination:
 pulse and rhythm
 blood pressure (BP)
 heart sounds and murmurs
 arterial bruits
 palpation for aortic aneurysm
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4 Perform standardised assessment
For all patients admitted to hospital, rapid recognition of symptoms and diagnosis must be made
within 3 hours using Recognition of Stroke in the Emergency Room (ROSIER) assessment. ROSIER
is most commonly used to:
 increase the accuracy of the initial stroke diagnosis
 assist with more rapid diagnosis
 assess factors, including:
o blood pressure (BP) and blood glucose concentration
o items on loss of consciousness and seizure activity
o physical assessment, including:
 facial weakness
 arm weakness
 leg weakness
 speech disturbance
 visual field defects
For every patient admitted to hospital the clinical team should obtain and confirm information
about the patients pre-existing medicine schedule and continue all necessary medications unless
contraindicated
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5 Consider time since symptom onset
Treatment of ischaemic stroke should be delayed as little as possible:
 all patients with suspected stroke should have brain imaging and in the majority of cases this
needs to be conducted rapidly – i.e. within 24 hours after admission
 thrombolysis can only be performed if transfer, imaging, and initial treatment is carried out
within 4.5 hours of onset of symptoms
 thrombolysis up to 3 hours is currently licensed but expert opinion suggests there is further
limited benefit if thrombolysis is given within 3 and 4.5 hours of onset of stroke:
o every effort should be made to shorten the delay in initiation of thrombolytic treatment
o prompt treatment can restore blood flow before major brain damage has occurred
 barriers to timely assessment include:
o patient or family not recognising symptoms of stroke or delay seeking help
o patient or family calling GP first
o failure to suspect stroke
o incorrect triage
o delays in neuro imaging
o delays in following in-hospital pathways
o delay in obtaining consent
o physician unfamiliarity with recombinant tissue plasminogen activator (rt-PA) use
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6 Consider urgent thrombolysis within 3 hours of symptoms
Indications for thrombolysis:
Approval Date: June 2011/ Review Date: June 2013
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
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
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consider intravenous (IV) recombinant tissue plasminogen activator (rt-PA) if:
o onset of symptoms is definitely within 4.5 hours of thrombolysis
o thrombolysis up to 3 hours is currently licensed but expert opinion suggests there is
further limited benefit if thrombolysis is given within 3 and 4.5 hours of onset of stroke
o benefits of thrombolysis are greater the earlier it is given- studies indicate
administration after 4.5 hours is associated with an increased mortality risk
o imaging has excluded an intracranial haemorrhage
o the hospital has high-quality protocols and policies in place regarding administration of
thrombolysis for stroke patients, as well as managing post-thrombolysis complications
Alteplase should only be administered within a well-organised stroke service with:
o staff trained in delivering thrombolysis and monitoring for any associated complications
o care up to level 1 and level 2 nursing staff trained in acute stroke and thrombolysis
o immediate access to imaging and re-imaging, and staff appropriately trained to interpret
the images
thrombolysis is not recommended where the patient has:
o symptoms that are mild or rapidly improving
o severely impaired conscious state
o persistent hypertension
o any evidence of bleeding or increased risk of bleeding, such as:
 intracranial pathology, e.g. untreated congenital aneurysm
 gastrointestinal or genito-urinary bleeding
 coagulopathy
o recent trauma, surgery, lumbar puncture or arterial puncture
o pregnancy
consider intra-arterial thrombolysis if service is available, particularly for basilar artery
thrombosis
if thrombolysis is given:
o closely monitor blood pressure (BP) and neurological status
o monitor for development of bleeding complications
o do not give anticoagulant or antiplatelet agents within 24 hours of thrombolysis
NB: Before prescribing any medication, consult product information and drug reference guides to
check indications, contraindications, cautions, and interactions
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7 Investigations
Patients who have had a suspected stroke should be transferred to an acute stroke unit and have
specialist assessment and investigation within 24 hours of onset of symptoms and be transferred to
the acute stroke unit.
Hyper-acute stroke services provide, as a minimum:
 24-hour access to brain imaging
 expert interpretation and the opinion of a consultant stroke specialist
 thrombolysis for those who can benefit:
o thrombolysis up to 3 hours is currently licensed but expert opinion suggests there is
further limited benefit if thrombolysis is given within 3 and 4.5 hours of onset of stroke
All patients should be reviewed immediately by an expert in stroke to determine and record:
 identification of possible underlying cardiovascular causes
 localisation of the cerebral area likely to have been affected, and identification of treatable risk
factors
 any clinical course that is unusual or inconsistent with the initial diagnosis of stroke:
o patient should be fully reassessed and investigated as appropriate for possible
alternative diagnoses
 ECG reading - ECG is urgently required in all strokes
Approval Date: June 2011/ Review Date: June 2013
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
continuous cardiac telemetry - this is important for those with suspected paroxysmal
arrhythmia
echocardiography may be required
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8 Consider differential diagnoses
There are several conditions with symptoms that mimic stroke, which need to be excluded consider differential diagnoses, e.g.:
 subdural haematoma
 cerebral vein thrombosis
 intracranial mass, e.g. tumour
 metabolic disorders, e.g. hypoglycaemia
 seizures
 encephalitis
 global ischaemia
 labyrinthine disorders
 temporal arteritis
 migraine
 psychological disorders, e.g. anxiety or panic disorder
 multiple sclerosis (MS)
 disorders of the peripheral nerves
 transient global amnesia
 trauma
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9 Blood tests
Assess the following:
 blood glucose level - exclude hypoglycaemia as the cause of sudden-onset neurological
symptoms
 full blood count (FBC)
 urea, electrolytes, and creatinine
 other tests to consider include:
o coagulation profile, especially if considering thrombolysis or if haemorrhagic stroke is
suspected
o erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP)
o lipid profile
o troponin, if ECG is abnormal or history of chest pain
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10 Brain imaging
Brain imaging (computed tomography [CT]) should be performed immediately (within the hour) for
those with acute stroke if any of the following apply:
 indications for thrombolysis or early anticoagulation treatment
 the patient is on anticoagulation therapy
 the patient has:
o a known bleeding tendency
o depressed level of consciousness (Glasgow Coma Scale below 13) Glasgow Coma
Scale.doc
o unexplained progressive or fluctuating symptoms
o papilloedema, neck stiffness, or fever
o severe headache at onset of stroke symptoms
If immediate imaging is not indicated, image as soon as possible and within 24 hours.
Approval Date: June 2011/ Review Date: June 2013
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Consider magnetic resonance imaging (MRI) if:
 CT is delayed
 diagnostic uncertainty after CT e.g. suspected non-stroke pathology but unsure
 atypical clinical presentation including:
o “young” stroke (under age 50 years)
o strong clinical suspicion of vessel dissection
o delayed clinical presentation (more than 7 days after symptom onset)
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12 Complete the venous thromboembolism (VTE) risk assessment
All patients should undergo venous thromboembolism (VTE) risk assessment as per National
Institute for Health and Clinical Excellence (NICE) guidance:
 upon admission
 for a second time, within 24 hours of initial assessment
 regularly thereafter for the duration of the inpatient stay, and, in some cases, following
discharge
 whenever the clinical situation changes
DoH Risk Assessment
for VTE.pdf
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13 Imaging reveals ischaemic stroke or transient ischaemic attack (TIA)
Image diagnosis of acute stroke or transient ischemic attack (TIA):
 a normal CT scan appearance in the presence of clinical features of acute stroke suggests an
acute ischaemic stroke
 acute infarction appears hypodense (or dark) compared with normal brain parenchyma on CT
scan
 the higher spatial resolution of magnetic resonance imaging (MRI) is better for determining
whether the diagnosis for TIA is correct and how large any infarction may be
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14 Imaging reveals haemorrhagic stroke
Excluding intracranial haemorrhage influences management, particularly in patients already on
antiplatelet or anticoagulant therapy:
 acute haemorrhage on CT appears hyperdense (or white)
Complications of intracerebral haemorrhage include:
 expansion of haematoma
 hydrocephalus
 intraventricular haemorrhage
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15 Imaging reveals abnormalities other than stroke or TIA
If CT scan suggests a diagnosis other than ischaemic or haemorrhagic stroke, consider further
investigation and manage appropriately:
 differential diagnoses that might be suggested by CT scan include:
o extracerebral intracranial haemorrhage
o cerebral vein thrombosis (may be difficult to detect by CT scan - requires CT
venography)
Approval Date: June 2011/ Review Date: June 2013
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o
o
subarachnoid haemorrhage
intracranial mass, e.g. tumour
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18 Administer thrombolysis if appropriate
Consider administering intravenous (IV) recombinant tissue plasminogen activator (rt-PA) if:
 onset of symptoms is definitely within 4.5 hours of thrombolysis
 thrombolysis up to 3 hours is currently licensed but expert opinion suggests there is further
limited benefit if thrombolysis is given within 3 and 4.5 hours of onset of stroke
 imaging has excluded an intracranial haemorrhage
 the hospital has protocols and policies in place regarding administration of thrombolysis for
stroke patients, including postthrombolysis complications
Studies indicate administration after 4.5 hours is associated with an increased mortality risk.
Alteplase is recommended for the treatment of acute ischaemic stroke and should only be
administered within a well-organised stroke service with:
 physicians trained and experienced in the management of acute stroke
 centres with facilities that enable it to be used in full accordance with its marketing
authorisation
 care up to level 1 and level 2 nursing staff trained in acute stroke and thrombolysis
 immediate access to imaging and re-imaging, and staff appropriately trained to interpret the
images
Thrombolysis is not recommended where the patient has:
 symptoms that are mild or rapidly improving
 severely impaired conscious state
 persistent hypertension
 any evidence of bleeding or increased risk of bleeding, such as:
o intracranial pathology, e.g. untreated congenital aneurysm
o gastrointestinal or genito-urinary bleeding
o coagulopathy, e.g. hereditary, anticoagulation, platelet count less than 100,000 or from
some other cause
 recent trauma, surgery, lumbar puncture, or arterial puncture
 pregnancy
Consider intra-arterial thrombolysis if service available, particularly for basilar artery thrombosis.
If thrombolysis is given:
 closely monitor blood pressure (BP) and neurological status
 monitor for development of bleeding complications
 do not give anticoagulant or antiplatelet agents within 24 hours of thrombolysis
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19 Administer aspirin if thrombolysis is inappropriate
Administer aspirin to all patients presenting with acute stroke who have had a diagnosis of primary
intracerebral haemorrhage excluded by brain imaging:
 give aspirin as soon as possible but certainly within 24 hours
 administer aspirin 300mg orally
 administer aspirin per rectum if patient is unable to swallow
 aspirin should be continued until two weeks after the onset of stroke symptoms, at which time
definitive long-term antithrombotic treatment should be initiated
 patients being discharged before two weeks can be started on long-term treatments earlier
Approval Date: June 2011/ Review Date: June 2013
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any patient with acute ischaemic stroke for whom previous dyspepsia associated with aspirin is
reported should be given a proton pump inhibitor (PPI) in addition to aspirin
consider alternative antiplatelet therapy if patient is aspirin sensitive:
o clopidogrel alone is recommended (within licensed indications)
anticoagulation treatment should not be routinely used in the treatment of acute stroke, unless
clinically indicated
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20 Assess swallowing and nutrition
Swallow and nutritional screening should commence within 24 hours of stroke
Screen patient's swallowing before giving any oral food, fluid, or medication - dehydration is a
particular problem among people with stroke because of complicating dysphagia.
Dysphagia can lead to:
 food, fluid, or saliva entering the lungs and causing aspiration pneumonia
 reduced intake of food which may lead to malnutrition or dehydration
 reduced intake of fluid which may lead to dehydration
 embarrassment when eating in social settings
Consider the following:
 use a water swallow test to identify aspiration risk
 exclude medications for pre-existing conditions where dysphagia could be a potential side effect
 if swallow disorder is suspected following initial screen, refer for specialist assessment within
24-72 hours
 monitor fluid loss and fluid intake
 intravenous (IV) fluids may be required
 check electrolytes periodically, especially if hydrated parenterally
 assess nutritional status using a validated screening tool such as the WAASP tool or the
Malnutrition Universal Screening Tool (MUST), and consider additional interventions where
nutritional status is indicated as poor or at high risk
 screening for malnutrition and the risk of malnutrition should be carried out by healthcare
professionals with appropriate skills and training
 patients who are unable to take adequate nutrition and fluids orally should receive feeding with
a nasogastric tube within 24hrs of admission
 healthcare professionals should be aware nutrition will be affected by poor oral health and
reduced ability to self-feed
 monitor weight and body mass index (BMI) at regular intervals
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21 Regular physiological monitoring
The patient should have regular neurological observations to detect any deterioration, along with
observations of:
 blood pressure (BP) - reduction to 185/110mmHg or lower should be considered in people who
are candidates for thrombolysis
 pulse rate
 respiratory rate
 oxygen saturation:
o patients should receive supplemental oxygen only if their oxygen saturation drops below
95%
o the routine use of supplemental oxygen is not recommended in people with acute stroke
who are not hypoxic
 blood glucose level:
Approval Date: June 2011/ Review Date: June 2013
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patients with acute stroke should maintain a blood glucose concentration between 4 and
11mmol/L
temperature
o

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22 Assess and manage complications
Observe patients for the development of common early complications:
 early neurological deterioration
 hypo- or hyperglycaemia
 electrolyte disturbances
 aspiration pneumonia or other sepsis
 deep vein thrombosis (DVT) or pulmonary embolism (PE)
 hypothermia or hyperthermia
 dehydration and malnutrition
 hypertension
 pressure ulcers
Assess for and treat as appropriate:
 intracranial hypertension (furosemide or mannitol and hyperventilation may be used)
 hydrocephalu
 large middle cerebral artery (MCA) or cerebellar infarcts:
o consider decompressive hemicraniectomy within a maximum of 48 hours of symptom
onset:
 in patients age 60 years or under
 when clinical deficits suggestive of infarction in the territory of the MCA with a
score on the National Institute of Health Stroke Scale (NIHSS) of above 15
 when patient shows a decrease in the level of consciousness to give a score of 1
or more on item 1a of the NIHSS
 signs on CT of an infarct of at least 50% of the MCA territory
 infarct volume greater than 145cm3 as shown on diffusion-weighted magnetic
resonance imaging (MRI)
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23 Start aspirin 24 hours after thrombolysis
Administer aspirin 24 hours after thrombolysis:
 administer aspirin orally
 administer aspirin per rectum if patient unable to swallow
 aspirin should be continued until two weeks after the onset of stroke symptoms, at which time
definitive long-term antithrombotic treatment should be initiated
 patients being discharged before two weeks can be started on long-term treatments earlier
 any patient with acute ischaemic stroke for whom previous dyspepsia associated with aspirin is
reported should be given a proton pump inhibitor (PPI) in addition to aspirin
 consider alternative antiplatelet therapy if patient is aspirin sensitive:
o clopidogrel alone is recommended (within licensed indications)

aspirin should only be administered following a repeat CT head scan to exclude any bleeding
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References
References for
Stroke Pathway.doc
Approval Date: June 2011/ Review Date: June 2013
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