Stroke

Acute Management (Ischaemic)

• Aspirin 300mg stat if non-haemorrhagic stroke confirmed on imaging, continue 100mg daily thereafter

• Blood pressure control

  • Pre-thrombolysis: <185/110mmHg

  • Post-thrombolysis: <140/90mmHg (use IV antihypertensives such as GTN or labetalol)

• Thrombolysis

  • Give IV alteplase within 4.5 hours of symptom onset

  • Ensure CT/MRI excludes haemorrhage and no contraindications

  • Aim for door-to-needle time <60 minutes

• Endovascular Thrombectomy

  • Recommended for large vessel occlusion (MCA, basilar)

  • Ideally within 6 hours of onset

  • Extended window (up to 24 hours) for selected patients with salvageable tissue on advanced imaging

Thrombectomy: Indications and Timing

• Large vessel occlusion in anterior circulation, confirmed on CTA/MRA

• Perfusion imaging (CTP/MR perfusion) demonstrates salvageable penumbra

• Key time frames

  • Standard up to 6 hours

  • Extended up to 24 hours if perfusion imaging shows ongoing viability

Haemorrhagic Stroke

• Reverse anticoagulation if present (vitamin K, prothrombin complex concentrate or FFP)

• Target systolic BP <140mmHg

• Avoid chemical DVT prophylaxis for first 48 hours, use mechanical prophylaxis (intermittent pneumatic compression)

• Urgent neurosurgical referral for possible surgical intervention if large haematoma or elevated intracranial pressure

Contraindications to Thrombolysis/Thrombectomy

• Intracranial haemorrhage, active bleeding, coagulopathy

• Recent ischaemic stroke or significant trauma in the past 3 months

• Persistent severe hypertension >185/110mmHg

• Uncertain time of onset beyond approved windows

Rehabilitation (Multidisciplinary)

• Early stroke unit involvement improves outcomes

• Physiotherapy: Mobility, balance, and strength training

• Occupational therapy: Activities of daily living, adaptive techniques

• Speech therapy: Swallowing, speech and language recovery

• Dietitian: Nutrition optimisation, dysphagia management

• Social work: Support services, carer planning, discharge coordination

• Aim to maximise functional recovery and prevent complications such as aspiration pneumonia, contractures, and DVT

Secondary Prevention

• Blood pressure control

  • Target <140/90mmHg in most patients

  • ACEI/ARB or CCB often first-line, especially if accompanied by diabetes or LVH

• Diabetes management

  • Aim for HbA1c ≤7% in type 2 diabetes

  • Emphasise dietary measures, exercise, and optimal medication adjustments

• Smoking cessation

  • Strongly recommended (NRT, varenicline, or bupropion plus behavioural support)

• Lipid management

  • High-potency statins (e.g. atorvastatin 40–80mg)

  • Consider ezetimibe if statin intolerance

• Antiplatelet therapy

  • Aspirin 100mg daily plus dipyridamole SR 200mg twice daily

    • Alternatively, clopidogrel monotherapy 75mg daily

  • Some guidelines recommend short-term dual antiplatelet therapy (e.g. aspirin + clopidogrel for 21–90 days) in minor stroke/TIA

• SNAP risk factor optimisation (Smoking, Nutrition, Alcohol, Physical activity)

Post-Hospital Discharge

• Assess ongoing rehabilitation needs and develop tailored care plan

• Ensure adequate carer support and consider respite care if required

• Ongoing therapy (physiotherapy, occupational therapy) for at least 6–12 weeks

• Long-term secondary prevention medications (antiplatelet/antihypertensive/statin)

• Driving restrictions

  • TIA: No driving for 2 weeks

  • Stroke: Minimum 4 weeks, then conditional on medical clearance

• Ensure safe swallow (monitor for aspiration risk)

• Advise on lifestyle measures and regular follow-up with GP or stroke clinic

Longer-Term Goals

• Review for residual impairments and address complications such as spasticity or neuropathic pain

• Monitor mood and cognition, as post-stroke depression and fatigue are common

• Encourage ongoing exercise or community programs for fitness and social support

• Optimise comorbidities such as hypertension, hyperlipidaemia, and diabetes to reduce recurrent stroke risk

• Assess for persistent dysphagia and malnutrition if patient has recurrent chest infections or weight loss

Notes:

• Early recognition of stroke is crucial (FAST: Face, Arms, Speech, Time), and immediate ED referral can reduce morbidity

• Telestroke services can expedite thrombolysis decisions for rural areas

• Uncomplicated haemorrhagic strokes with stable imaging may require conservative management, but close observation for expansion is essential

• Stroke Foundation resources can support patients and families with education and self-management strategies