Stroke and transient ischaemic attack

Management— do this, in order

• Correct hypoglycaemia at once — adult: 50 mL of 50% glucose intravenously into a large vein, or 100 mL of 20%, or 200 mL of 10%, each delivering 25 g; or glucagon 1 mg intramuscularly if there is no access — then recheck the glucose on arrival and at least 6-hourly.Doctor / Nurse
• Airway: a nasopharyngeal airway is better tolerated where the gag is intact; position the vomiting patient with the paralysed side uppermost; intubate where the airway cannot be protected.
• Oxygen only if SpO2 is below 92%, targeting 94-98% — hyperoxia may harm, and hypoxaemia demands an explanation, usually aspiration.
• Nil by mouth, including oral tablets, until the swallow is screened; failure or drowsiness means a nasogastric tube for all fluids, feed and medication.
• Treat pyrexia, which worsens outcome: treat the cause and give paracetamol 1 g orally, by nasogastric tube or per rectum 6-hourly, maximum 4 g in 24 hours (child 15 mg/kg per dose, maximum 60 mg/kg in 24 hours).
• Position and skin: semi-erect at 30 degrees, head midline, regular turning, a pressure-relieving mattress; palpate the bladder for retention, a common silent cause of agitation and hypertension; use intermittent pneumatic compression for thromboprophylaxis, with prophylactic heparin only in high-risk patients and never in the first days after intracerebral haemorrhage.
• Use 0.9% sodium chloride for maintenance fluid, treat hyperglycaemia with variable-rate insulin while avoiding hypoglycaemia, which is more dangerous, and start rehabilitation alongside acute treatment — though very early mobilisation within the first 24 hours may be harmful.Doctor / Nurse
• Once CT excludes haemorrhage, give aspirin 300 mg immediately, continued at 300 mg daily for two weeks before conversion to a long-term antiplatelet, usually clopidogrel 75 mg daily; in the dysphagic or drowsy patient give it as a rectal suppository or dispersed down a nasogastric tube, never as a tablet in the mouth.Not available at your setup — CT scan.
• Where aspirin is contraindicated use clopidogrel 300 mg orally then 75 mg daily; add dual antiplatelet therapy for 21 days in minor ischaemic stroke (NIHSS ≤ 3) or high-risk TIA (ABCD2 ≥ 4) with low bleeding risk, but not for a large stroke.
• Thrombolyse the eligible patient: alteplase 0.9 mg/kg intravenously, maximum 90 mg, with 10% as a bolus over 1 minute and the remainder infused over 60 minutes; or tenecteplase 0.25 mg/kg as a single bolus, maximum 25 mg.Doctor / NurseNot available at your setup — CT scan, Infusion pump.
• Blood pressure must be below 185/110 mmHg before thrombolysis and below about 180/105 mmHg for 24 hours afterwards, and aspirin is withheld for at least 24 hours after thrombolysis, started only after follow-up CT excludes thrombolysis-related haemorrhage.Not available at your setup — CT scan.
• Refer for mechanical thrombectomy in large-vessel occlusion — about 20% of ischaemic strokes — performed within 6 hours, and in selected patients with salvageable tissue on perfusion imaging up to 24 hours; thrombolysis, where the patient is eligible, is given first and must not delay it.
• Do not lower the blood pressure in the first 72 hours of ischaemic stroke except for candidacy for thrombolysis (below 185/110 mmHg), acute heart failure or pulmonary oedema, hypertensive encephalopathy, aortic dissection, acute coronary syndrome, or a sustained pressure above 220/120 mmHg — and then by no more than 15% over 24 hours.
• Where reduction is required use labetalol 10-20 mg by slow intravenous injection over 2 minutes, repeated and doubled at 10-minute intervals to a maximum cumulative 300 mg with the pressure checked before each dose, or an infusion at 0.5-2 mg/min; where labetalol is contraindicated by asthma, bradycardia, heart block or decompensated heart failure, use a glyceryl trinitrate infusion 5-200 micrograms/min.Doctor / NurseNot available at your setup — Infusion pump.
• In intracerebral haemorrhage the pathway inverts — no antiplatelet, no anticoagulant, no thrombolysis — and coagulopathy is reversed as fast as physically possible: warfarin needs vitamin K (phytomenadione) 10 mg by slow intravenous injection plus immediate prothrombin complex concentrate (fresh frozen plasma 15 mL/kg where PCC is unavailable); direct oral anticoagulants need activated charcoal 50 g if taken within 2 hours, idarucizumab 5 g intravenously for dabigatran or andexanet alfa for apixaban and rivaroxaban, otherwise PCC; unfractionated heparin needs protamine sulfate 1 mg intravenously per 100 units of heparin given in the preceding hour, maximum 50 mg.Doctor / NurseNot available at your setup — Blood & blood products, Coagulation (PT/INR).
• In intracerebral haemorrhage lower the blood pressure promptly and smoothly to 130-140 mmHg systolic with a firm floor of 130 mmHg, maintained for at least 7 days, using labetalol or glyceryl trinitrate as above or hydralazine 5 mg intravenously over 5 minutes repeated every 20 minutes to a maximum of 20 mg.Doctor / Nurse
• For raised intracranial pressure nurse head up at 30 degrees with the head midline, treat pain, fever and seizures, and give mannitol 20%, 0.5-1 g/kg intravenously over 20 minutes provided the patient is not hypovolaemic; hypertonic saline is an alternative.Doctor / Nurse
• Begin secondary prevention during the admission: long-term antiplatelet therapy, oral anticoagulation for atrial fibrillation, a high-intensity statin such as atorvastatin 40-80 mg daily targeting LDL-C below 2 mmol/L, blood pressure reduction, smoking cessation, carotid endarterectomy where indicated, and attention to diabetes, weight, diet and activity.