Stroke and transient ischaemic attack

Manage now— do this, in order

• Correct hypoglycaemia at once — adult: 50 mL of 50% glucose IV into a large vein (or 100 mL of 20%, or 200 mL of 10%, each 25 g); glucagon 1 mg IM if no access. Child: 2 mL/kg of 10% glucose IV then a 10% infusion — never give 50% glucose to a child.Doctor / Nurse
• Airway, oxygen and nil by mouth: a nasopharyngeal airway is better tolerated where the gag is intact; position the vomiting patient with the paralysed side uppermost. Oxygen only if SpO2 is below 92%, targeting 94-98%. Nothing by mouth — including tablets — until the swallow is screened; failure or drowsiness means a nasogastric tube for all fluids, feed and medication.
• Once CT excludes haemorrhage: aspirin 300 mg immediately, continued 300 mg daily for two weeks, then usually clopidogrel 75 mg daily — in the dysphagic patient as a rectal suppository or dispersed down the NG tube, never a tablet in the mouth. Dual antiplatelet therapy 21 days for minor stroke (NIHSS ≤ 3) or high-risk TIA (ABCD2 ≥ 4), not for a large stroke.Doctor / Nurse
• Thrombolyse the eligible patient within 4.5 hours: alteplase 0.9 mg/kg IV, max 90 mg — 10% as a bolus over 1 minute, the remainder over 60 minutes; or tenecteplase 0.25 mg/kg single bolus, max 25 mg. Blood pressure must be below 185/110 mmHg before and below about 180/105 mmHg for 24 hours after; withhold aspirin for at least 24 hours until follow-up CT excludes haemorrhage.Doctor / NurseNot available at your setup — CT scan.
• Refer for mechanical thrombectomy in large-vessel occlusion (about 20% of ischaemic strokes) within 6 hours — up to 24 hours with salvageable tissue on perfusion imaging. Thrombolysis, where 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 thrombolysis candidacy (below 185/110), acute heart failure or pulmonary oedema, hypertensive encephalopathy, aortic dissection, acute coronary syndrome, or sustained pressure above 220/120 — and then by no more than 15% over 24 hours: labetalol 10-20 mg slow IV over 2 minutes, repeated and doubled every 10 minutes to max 300 mg, or GTN infusion 5-200 micrograms/min if labetalol is contraindicated. Hypotension is the greater enemy — a systolic below 120 mmHg demands a cause.Doctor / Nurse
• In intracerebral haemorrhage the pathway inverts — no antiplatelet, no anticoagulant, no thrombolysis — and coagulopathy is reversed as fast as physically possible: warfarin — vitamin K 10 mg slow IV plus immediate prothrombin complex concentrate (FFP 15 mL/kg if unavailable); dabigatran — idarucizumab 5 g IV; apixaban/rivaroxaban — andexanet alfa, otherwise PCC; heparin — protamine 1 mg per 100 units in the preceding hour, max 50 mg. Lower systolic BP promptly and smoothly to 130-140 mmHg with a firm floor of 130.Doctor / NurseNot available at your setup — Blood & blood products.
• For raised intracranial pressure: nurse head up at 30 degrees, head midline; treat pain, fever (paracetamol 1 g 6-hourly, max 4 g/24 h) and seizures; mannitol 20%, 0.5-1 g/kg IV over 20 minutes if not hypovolaemic. Corticosteroids are contraindicated in stroke; intravenous heparin has no place in acute ischaemic stroke; never treat the Cushing response (rising BP, slowing pulse, irregular respiration) as hypertension.Doctor / Nurse
• Begin secondary prevention during the admission: long-term antiplatelet, oral anticoagulation for atrial fibrillation, atorvastatin 40-80 mg daily (LDL-C below 2 mmol/L), blood pressure reduction, smoking cessation, and carotid endarterectomy within 2 weeks for 70-99% ipsilateral stenosis. Treat every TIA as unstable angina of the brain — assess and treat within 24 hours.