Acute Ischaemic Stroke

Time is brain — 1.9 million neurons die every minute in acute ischaemic stroke. FAST recognition, immediate imaging, and rapid thrombolysis/thrombectomy are the key interventions. Call the stroke team directly on recognition.

Hyperacute Stroke Pathway

The pathway

1 · FAST recognition

Face drooping, Arm weakness, Speech disturbance, Time to call
BE-FAST (Balance, Eyes)
Document exact time of symptom onset.

2 · Stroke team immediately

Activate the hyperacute stroke team directly — most centres have a dedicated bleep
Do NOT wait for MED reg.

3 · Non-contrast CT head

Within 25 minutes of arrival to exclude haemorrhagic stroke before thrombolysis
CT angiography (CTA) to identify large vessel occlusion for thrombectomy.

4 · Thrombolysis eligibility

Alteplase within 4.5 hours of onset if: ischaemic stroke confirmed, no contraindications, NIHSS scored
Dose: 0.9mg/kg (max 90mg), 10% as IV bolus, rest over 60 minutes.

5 · Thrombectomy

For large vessel occlusion (MCA/ICA/basilar): up to 24 hours from onset in selected patients.

6 · Blood pressure

Do NOT lower BP acutely unless >220/120 or for thrombolysis (target <185/110)

7 · Glucose

Maintain BM 5–10 mmol/L.

8 · Secondary prevention

Aspirin 300mg OD once CT has excluded haemorrhage — PR or NG if dysphagia. After thrombolysis, wait 24h AND repeat imaging showing no significant haemorrhage
2 weeks, then long-term antithrombotic
Statin
Antihypertensives
Anticoagulation for AF after 2 weeks.

Drugs

Drug	Dose	Route	Notes
Alteplase	0.9mg/kg (max 90mg)	IV	10% as bolus, rest over 60 minutes. Within 4.5h of onset.
Aspirin	300mg	PO/PR/NG	Start once CT has excluded haemorrhage — PR or NG if dysphagia. After thrombolysis, wait 24h and repeat imaging first. 2 weeks, then long-term antithrombotic.
Atorvastatin	40–80mg	PO	Start as soon as possible.

When to escalate

Haemorrhagic transformation on CT — stop thrombolysis immediately,Posterior circulation stroke (vertigo, ataxia, diplopia, reduced consciousness) — may need MRI,Malignant MCA syndrome (large infarct, deteriorating) — neurosurgical decompressive craniectomy,Stroke in pregnancy — obstetrics and stroke physician jointly

Reference: NICE NG128 Stroke / RCP Stroke Guidelines 2023

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