The National Clinical Guideline for Stroke was published in 2023 and is a partial update of the 2016 Royal College of Physicians (RCP) guidelines.

Selected points relating to the management of acute stroke include:

• blood glucose, hydration, oxygen saturation and temperature should be maintained within normal limits
• blood pressure
  • blood pressure should not be lowered in the acute phase of ischaemic stroke unless there are complications e.g. Hypertensive encephalopathy or they are being considered for thrombolysis (see below)
  • blood pressure control should be considered for patients who present with an acute ischaemic stroke, if they present within 6 hours and have a systolic blood pressure > 150 mmHg
• aspirin 300mg orally or rectally should be given as soon as possible if a haemorrhagic stroke has been excluded
• with regards to atrial fibrillation, the RCP state: 'anticoagulants should not be started until brain imaging has excluded haemorrhage, and usually not until 14 days have passed from the onset of an ischaemic stroke'
• if the cholesterol is > 3.5 mmol/l patients should be commenced on a statin. Many physicians will delay treatment until after at least 48 hours due to the risk of haemorrhagic transformation

Thrombolysis for acute ischaemic stroke

Thrombolysis is now given to around 10% of patients who present with an acute ischaemic stroke in the UK. It requires a dedicated team to determine eligibility, ensure timely delivery and provide hyperacute stroke services to patients afterwards.

The standard criteria for thrombolysis with alteplase or tenecteplase are as follows:

• it is administered within 4.5 hours of onset of stroke symptoms
• haemorrhage has been definitively excluded (i.e. Imaging has been performed)

The 2023 National Clinical Guideline for Stroke broadened the potential inclusion criteria.

• it recommends that patients with an 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:
  • 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
  • they have evidence from CT/MR perfusion (core-perfusion mismatch) or MRI (DWI-FLAIR mismatch) of the potential to salvage brain tissue
• this should be irrespective of whether they have a large artery occlusion and require mechanical thrombectomy.
• there are specific criteria in the guidelines that determine the imagine criteria that determine whether thrombolysis should be performed

Blood pressure should be lowered to 185/110 mmHg before thrombolysis.

Contraindications to thrombolysis

• Seizure at onset of stroke
• Intracranial neoplasm
• Suspected subarachnoid haemorrhage
• Stroke or traumatic brain injury in preceding 3 months
• Lumbar puncture in preceding 7 days
• Gastrointestinal haemorrhage in preceding 3 weeks
• Active bleeding
• Oesophageal varices
• Uncontrolled hypertension >200/120mmHg | - Pregnancy
• Concurrent anticoagulation (INR >1.7)
• Haemorrhagic diathesis
• Active diabetic haemorrhagic retinopathy
• Suspected intracardiac thrombus
• Major surgery / trauma in the preceding 2 weeks |

Thrombectomy for acute ischaemic stroke