Management of Acute Stroke 2

The First 24 hours

Assessment / Monitoring

  • Potential thrombolysis case:
    • If the patient presents within 4.5 hours of onset of focal symptoms, thrombolysis referral may be appropriate – see Acute Stroke 1 Guideline.
    • If patient presents >4.5 hours, follow local protocol for stroke admissions.
  • Request ECG, U&Es, glucose (non-fasting), LFTs, cholesterol, FBC and ESR.
  • Swallow test must be done within 4 hours of admission. Check swallow before prescribing and administering oral medication, oral fluids or diet.
  • Check BP, document but do not intervene unless:
    • <100/60mmHg seek cause and consider commencing IV fluids (see General management and drug therapy section below for details).
    • >200/120mmHg seek evidence of malignant hypertension and consider treatment only after discussion with consultant.
  • Temperature: if >37.5ºC look for evidence of infection and send blood / urine / sputum culture as appropriate.
  • Check oxygen saturation and treat hypoxaemia if necessary (see General Management and drug therapy below).
  • Withhold antiplatelet / antithrombotic medication until CT scan excludes haemorrhage.
  • Rhythm check - atrial fibrillation may be present.

CT scans

CT brain scans should be requested as soon as possible after admission, and immediate scanning should be carried out in the following instances:

  • Deteriorating consciousness level or coma.
  • On anticoagulants (ensure INR / coagulation is checked and discussed with consultant whether reversal of anticoagulation is appropriate for patient).
  • Brain stem symptoms plus bilateral signs or progression of signs of 'locked in'.
  • Cerebellar stroke with headache or features of raised intracranial pressure.
  • Severe headache.
  • 'Stuttering' onset.
  • Immunocompromised patients.
  • Unexplained fever.
  • Clinical signs of raised intracranial pressure.

General management and drug therapy

  • Do not prescribe antihypertensive drugs, warfarin or other anticoagulant, heparin or steroids except after discussion with a consultant. There is no evidence of harm from temporarily withholding antihypertensive drugs in patients early after stroke. Early blood pressure lowering may be of benefit in patients with intracranial haemorrhage or who receive thrombolytic therapy. This should only be commended after discussion with a stroke specialist.
  • Blood glucose:
    • If high – may require insulin but important to avoid hypoglycaemia. See the "Diabetes, Inpatient Prescribing FAQs for Junior Doctors" on NHSGGC StaffNet / Clinical Info / Clinical Guideline Directory (link only active if connected to GGC network) for more information.
  • All patients should receive fluids. Prescribe intravenous fluids as clinically indicated and adjust infusion volume of fluids as clinically necessary.
  • Oxygen saturation: Target O2 saturation is 95% – if <95%, change posture, clear upper airway, start oxygen supplements as clinically appropriate.
  • After CT brain - see below for information
  • Temperature >37.5ºC and evidence of infection:

    If aspiration probable, commence appropriate antibiotic therapy while awaiting culture results and give paracetamol (oral or per rectum) 1g every four to six hours as required (maximum dose 4g/day). N.B. Consider dose reduction in patients with low body weight (<50kg), renal impairment, glutathione deficiency (chronic malnourishment, chronic alcoholism) to 15mg/kg/dose up to four times daily (max 60mg/kg/day). An example is: paracetamol oral 500mg four times daily. Patients with chronic liver failure may require a further dose adjustment (7.5mg/kg/dose, max 30mg/kg/day).

  • Atrial fibrillation: for management see here.
  • DVT prophylaxis: for management see here and also protocols in stroke units regarding intermittent pneumatic compression (IPC) stocking use.

After CT brain

If CT scan shows no haemorrhage, prescribe a 'one-off' dose of aspirin oral 300mg (or PR if swallow impaired). Ensure aspirin is given immediately i.e. do not leave for administration at next morning's drug round. Dual antiplatelet therapy (DAPT) with aspirin and clopidogrel can be used in people with non-cardioembolic minor ischaemic stroke (NIHSS score of 3 or less) or high-risk TIA (ABCD score of 4 or more) in the past 24 hours, if diagnosis is confirmed by a stroke specialist and brain imaging has excluded intracranial haemorrhage (ICH). DAPT is usually used for 21 days then the patient is continued on clopidogrel oral 75mg daily for long-term treatment.

If patient has had thrombolysis, delay aspirin initiation for 24 hours and ensure follow up CT brain scan is done before aspirin is administered. After the initial stat dose of aspirin, further antiplatelet therapy should be prescribed as per guidance in Secondary Prevention of Stroke and TIA.

If CT scan shows haemorrhage:

  • Consider Neurosurgical referral.
  • Check urgent coagulation screen and discuss treatment of coagulopathies with consultant.
  • Stop all antithrombotics or anticoagulants patient may have been on previously, and consider anticoagulant reversal – should be discussed with consultant.

If CT scan shows an alternative pathology (e.g. tumour, subdural haematoma), discuss with consultant.

Patient deterioration after admission

In the event of deterioration after admission, re-examine and specifically:

  • Check oxygenation and correct hypoxaemia with oxygen supplementation and postural change.
  • Check blood pressure: treat as outlined at the start of this guideline.
  • Check temperature: if pyrexial, check for signs of infection and treat. Also administer antipyretic (paracetamol dose as above).
  • Check blood sugar and correct hypoglycaemia, consider insulin for hyperglycaemia (blood glucose >9mmol/L). See above for links to GGC guidelines. 
  • Consider repeat ECG and treat as appropriate.
  • Reconsider potential indications for urgent CT or discuss repeat CT with stroke consultant.
  • Proximal occlusion of the middle cerebral artery can lead to a large cerebral infarct which may go on to develop cerebral oedema, causing raised intracranial pressure, deteriorating conscious level, loss of consciousness and eventual death. This syndrome is more common in younger stroke patients. If any clinical suspicion of Malignant Middle Artery Syndrome, request immediate CT brain scanning and refer to Neurosurgery for possible hemi-craniectomy to relieve the intracranial pressure.


Guideline reviewed September 2021
Page updated November 2021