Stroke
Check the sugar, pin down the time last known well, get a CT head immediately, and decide with your senior who needs thrombolysis, thrombectomy, aspirin only, or supportive care.
A 62-year-old woman has sudden right-sided weakness and cannot get her words out. Her son says she was normal at breakfast at 07:30. It is now 09:20. Blood sugar 6.1 mmol/L (110 mg/dL), BP 196/104.
What do you do in the next ten minutes?
- Check the blood sugarIf it is below 4 mmol/L (72 mg/dL), treat the low sugar first and reassess. Low sugar can look exactly like a stroke, and it is completely reversible.
- Airway, breathing, circulationCheck GCS, SpO₂, BP, pulse (an irregular pulse suggests AF) and temperature. Give oxygen only if SpO₂ is below 95%.
- Find the time last known wellAsk whoever last saw the patient normal. Write down the exact clock time, not "this morning".
- Call the stroke team or your seniorIf the time is within 4.5 hours (or within 24 hours with a large deficit), say "possible thrombolysis" in your first sentence.
- CT head nowA plain (non-contrast) CT. Add a CT angiogram if thrombectomy is possible. Go with the patient if you can.
- Two cannulas and bloodsFull blood count, clotting, urea and electrolytes, glucose, group and save. Get the weight (weigh them or ask a reliable estimate), because the alteplase dose depends on it.
- Nil by mouthNo food, water or tablets until a swallow screen is passed. Tell the family as well as the nurse.
- ECGLooks for AF. It must not delay the CT.
- Last known well within 4.5 hours (or within 24 hours with a large deficit)
- Gaze deviation, aphasia, neglect or dense weakness
- On warfarin or a DOAC
- Thunderclap headache or neck stiffness
- Vertigo, double vision, unsteadiness or drowsiness (posterior stroke)
- Falling GCS or vomiting
- Low blood sugar
- Brain haemorrhage
- Subarachnoid haemorrhage
- Basilar artery occlusion
- Post-ictal (Todd's) weakness
- Subdural haematoma
- Brain tumour or abscess
- Cerebral venous sinus thrombosis
| Time windows | Thrombolysis within 4.5 hours of last known well. Thrombectomy usually within 6 hours, selected patients up to 24 hours |
| Aspirin | 300 mg only after the CT shows no blood and thrombolysis is not going ahead. Never before the CT |
| Thrombolysis | A stroke team decision only, after the CT and the contraindication checklist. Doses are in the Thrombolysis section below |
| BP | Thrombolysis: below 185/110 before and below 180/105 for 24 hours after. Not thrombolysed: leave it unless above about 220/120. Haemorrhage within 6 hours with systolic 150–220: aim 130–140 within 1 hour |
| Blood sugar | Keep 4–11 mmol/L (72–200 mg/dL). Below 4 mmol/L (72 mg/dL): treat first, then reassess |
Check every dose against a current drug reference and your hospital protocol.
On this page
The first ten minutes
Stroke is an emergency in the same way a heart attack is. In a blocked-artery stroke, brain cells die every minute the blood flow is not restored, and the treatments that can reverse disability (thrombolysis and thrombectomy) only work inside a time window. Your job in the first minutes is to find the few facts that decide treatment and to get the patient to the CT scanner fast.
Do not give aspirin, heparin or any blood thinner before the CT. Until the scan shows no bleeding, you do not know whether this is a clot or a bleed.
Time last known well
This single time decides whether the patient can have thrombolysis. Get it right and write it down.
- Last known well is the last time someone saw the patient behaving normally. It is not the time the symptoms were noticed.
- Woke up with symptoms? The last known well time is when they went to sleep (or the last time they were seen normal before sleep), not the time they woke.
- Symptoms came and went, then came back? If they fully recovered in between, the clock restarts from the last time they were completely normal. If they did not fully recover, use the original time.
- Family unsure? Ask specific questions: what were they doing at the time, who spoke to them last, did they answer the phone, did they pray or eat normally. A phone call log can pin down the time.
- 22:30Went to bed, talking normally
- 06:30Woke with a weak right arm
- 07:15Arrives in the emergency department
Last known well here is 22:30, not 06:30. Almost nine hours have passed, so standard thrombolysis is not possible. Still call the stroke team: some centres use advanced imaging (CT perfusion or MRI) to treat selected wake-up and late patients, especially for thrombectomy.
What a stroke is
A stroke is sudden loss of brain function caused by a problem with its blood supply, lasting more than 24 hours or shown on imaging. There are two main types:
- The common type
- A clot from the heart (often AF) or from a narrowed artery (carotid), or disease of small vessels deep in the brain
- Treated with thrombolysis, thrombectomy and antiplatelets
- Bleeding into the brain tissue, most often from long-standing high BP
- Also from anticoagulants, malformations or amyloid
- Treated by stopping the bleeding from getting worse: BP control and reversing blood thinners
- The penumbra. Around the core of dead brain in an ischaemic stroke is a zone of brain that is not working but is still alive. Restoring the blood supply quickly saves the penumbra. This is why "time is brain".
- TIA (transient ischaemic attack) is the same process but the symptoms resolve completely, usually within an hour, with no infarct. It is a warning: the risk of a full stroke is highest in the next few days. See the separate TIA guide.
- You cannot tell a clot from a bleed at the bedside. Headache, vomiting, very high BP and drowsiness make a bleed more likely, but only a CT scan can tell them apart.
Recognising a stroke
- FFaceOne side of the face droops when they smile
- AArmOne arm drifts down or cannot be lifted
- SSpeechSlurred speech, wrong words, or no words
- TTimeNote the time and act immediately
FAST misses strokes at the back of the brain. Learn the posterior circulation signs:
- Sudden vertigo with vomiting, especially with any other sign below
- Double vision, or the eyes not moving together
- Unsteady walking, cannot sit up without support, clumsy limbs
- Slurred speech or difficulty swallowing
- Drowsiness or reduced consciousness
- Loss of vision in both eyes or half of both visual fields
A patient who "just has dizziness" but cannot walk unaided needs a senior review. Basilar artery occlusion can present with fluctuating drowsiness and is often fatal if missed. It can be treated up to 24 hours.
The ROSIER score
ROSIER helps you decide whether a suspected stroke in the emergency department is likely to be a stroke. Check the blood sugar first.
| Feature | Score |
|---|---|
| Loss of consciousness or fainting | −1 |
| Seizure activity | −1 |
| New, sudden facial weakness on one side | +1 |
| New, sudden arm weakness on one side | +1 |
| New, sudden leg weakness on one side | +1 |
| Speech disturbance | +1 |
| Visual field defect | +1 |
A total above 0 means a stroke is likely. A score of 0 or less makes stroke less likely but does not exclude it. If you still suspect a stroke, treat it as one and discuss it with your senior.
History
Take a focused history quickly. The time and the medicines matter most.
- Time last known well, and how the symptoms started: sudden, or gradual over hours or days (gradual suggests a tumour, subdural or abscess).
- Headache. Sudden severe headache suggests a bleed or subarachnoid haemorrhage.
- Seizure at the start (Todd's paresis after a fit can mimic stroke).
- Head injury or fall (subdural haematoma).
- Medicines: warfarin, apixaban, rivaroxaban, dabigatran, heparin injections, aspirin, clopidogrel, insulin or sulfonylureas. Ask the family to bring or photograph the medicines.
- Risk factors: hypertension, diabetes, AF, previous stroke or TIA, smoking, high cholesterol, rheumatic heart disease, recent heart attack.
- Things that may stop thrombolysis: recent bleeding (stomach, urine), recent surgery, recent stroke or head injury, known bleeding problem, pregnancy.
- Baseline function: were they walking and caring for themselves before? This affects decisions about thrombectomy.
Examination
You do not need to be a neurologist. You need a quick, repeatable examination so you can describe the deficit and notice if it changes.
- GCS and pupilsRecord the GCS fully (eyes, verbal, motor), not just the total.
- Speech and languageCan they name a pen and a watch, repeat a sentence, and follow "close your eyes, open your mouth"? Slurred speech is dysarthria. Wrong words or no words is aphasia.
- EyesAre the eyes looking to one side (gaze deviation)? Check eye movements and visual fields in all four quadrants.
- FaceAsk them to smile and raise their eyebrows. In a stroke, the forehead is usually spared. A whole-face weakness including the forehead suggests Bell's palsy.
- Arms and legsHold both arms out, palms up, eyes closed, for 10 seconds: watch for drift. Lift each leg. Grade power 0 to 5.
- Sensation and neglectTouch both sides at once. Ignoring one side when both are touched is neglect.
- Coordination and gaitFinger to nose, heel to shin. If safe, can they sit or stand unsupported?
- GeneralNeck stiffness, heart murmur, carotid bruit, signs of injury, irregular pulse.
The NIHSS
The National Institutes of Health Stroke Scale (NIHSS) scores stroke severity from 0 to 42. The stroke team uses it to decide on treatment and to track change. It covers: level of consciousness, gaze, visual fields, facial palsy, arm and leg strength, limb ataxia, sensation, language, dysarthria and neglect. Learn it from a training video in your first week. Even if you are not scoring it, repeat your own examination at regular times and record exactly what changed.
Where is the stroke?
Being able to name the likely artery helps you talk to your senior and is examined in FCPS and NRE.
| Artery or area | Typical signs |
|---|---|
| Middle cerebral artery (MCA) | Weakness and numbness of the opposite face and arm more than leg. Aphasia if the dominant (usually left) side is affected. Neglect if the non-dominant side. Homonymous hemianopia. Eyes deviate towards the side of the lesion. |
| Anterior cerebral artery | Weakness of the opposite leg more than the arm. Behaviour change, urinary incontinence. |
| Posterior cerebral artery | Homonymous hemianopia on the opposite side, often with macular sparing. |
| Lacunar (small deep vessels, internal capsule or pons) | Pure weakness or pure numbness of face, arm and leg equally, or ataxic hemiparesis. No aphasia, neglect or field loss. |
| Lateral medulla (vertebral or posterior inferior cerebellar artery) | Vertigo, vomiting, hoarse voice, difficulty swallowing, Horner's syndrome and loss of pain and temperature on the same side of the face, with loss on the opposite side of the body. |
| Cerebellum | Vertigo, vomiting, unsteadiness, nystagmus. A large cerebellar stroke can swell and block CSF flow, so a falling GCS needs urgent neurosurgery advice. |
| Basilar artery | Reduced consciousness, weakness in all four limbs, eye movement problems, pupils abnormal. Can cause "locked-in" syndrome. |
The Oxford (Bamford) classification groups these clinically:
- Total anterior circulation stroke (TACS): all three of: higher cortical problem (aphasia or neglect), homonymous hemianopia, and weakness or sensory loss in at least two of face, arm and leg.
- Partial anterior circulation stroke (PACS): two of the three, or a higher cortical problem alone.
- Lacunar stroke (LACS): pure motor, pure sensory, sensorimotor or ataxic hemiparesis.
- Posterior circulation stroke (POCS): cranial nerve palsy with weakness on the opposite side, weakness on both sides, eye movement problems, cerebellar signs, or isolated hemianopia.
Stroke mimics
Many patients sent in as "stroke" turn out to have something else. Some mimics are dangerous in their own right.
| Condition | Points towards it | Test that helps |
|---|---|---|
| Low blood sugar | On insulin or a sulfonylurea, sweaty, confused | Blood sugar |
| Post-ictal (Todd's) weakness | Witnessed fit before the weakness, improves over hours | History, EEG later |
| Migraine with aura | Symptoms spread over minutes, headache, previous similar episodes | History |
| Subdural haematoma | Older patient, fall, on blood thinners, fluctuating confusion | CT head |
| Brain tumour or abscess | Gradual onset over days, headache, fever with abscess | CT with contrast or MRI |
| Sepsis or encephalopathy | Fever, confusion more than focal weakness, previous stroke weakness unmasked | Bloods, cultures, urine |
| Bell's palsy | Whole half of the face including forehead, nothing else | Clinical |
| Hypertensive encephalopathy | Very high BP, headache, confusion, fits, visual problems | CT or MRI, fundoscopy |
| Cerebral venous sinus thrombosis | Young woman, after delivery or on the pill, headache, fits | CT or MR venogram |
| Functional weakness | Inconsistent signs, positive Hoover's sign | Diagnosis of exclusion |
Investigations
| Test | Why | What to look for |
|---|---|---|
| Blood sugar | First test, at the bedside | Below 4 or very high values can mimic stroke |
| CT head without contrast | Separates bleed from clot before any treatment | Blood is white on CT. Early ischaemia is often invisible: a normal CT does not exclude a stroke. A bright (hyperdense) artery can be a visible clot. |
| CT angiogram (arch to vertex) | If thrombectomy may be possible | Large artery blocked. Do not wait for the creatinine result if the stroke team wants it. |
| ECG | AF and heart attack | AF, ischaemic changes |
| Full blood count, clotting, U&E | Baseline, platelet count, INR before thrombolysis | Platelets, INR, kidney function |
| Group and save | In case of bleeding after thrombolysis | |
| Lipids, HbA1c | Risk factors | |
| MRI with diffusion imaging | If the diagnosis is unclear, or for TIA | Small fresh infarcts |
| Carotid Doppler | Anterior circulation stroke or TIA in someone fit for surgery | Narrowing of the internal carotid artery |
| Echo, prolonged heart monitoring | Suspected heart source | Clot, valve disease, intermittent AF |
"Suspected acute stroke. Last known well 07:30. Right arm and leg weakness and aphasia. Possible thrombolysis candidate. Glucose 6.1 mmol/L (110 mg/dL). Not on anticoagulants. Urgent CT head without contrast, plus CT angiogram if the stroke team requests."
Then phone the radiographer or radiologist so the scan is done straight away, and go with the patient if you can.
Who needs what
Once the CT is done, the treatment depends on two questions: is there blood, and how long ago was the patient last well?
- No thrombolysis, no aspirin, no heparin
- Reverse blood thinners
- BP target systolic 130–140
- Neurosurgery opinion if needed
Go to the next question
- IV thrombolysis (stroke team decision)
- Hold aspirin
- Thrombectomy, usually within 6 hours, selected patients up to 24 hours
- Can follow thrombolysis
- Aspirin 300 mg now
- Then 300 mg daily for 14 days
Thrombolysis
Thrombolysis dissolves the clot with a drug given into a vein. The stroke team or your senior makes the decision. Your job is to have everything ready and to know the safety checks.
Who can have it: ischaemic stroke with a disabling deficit, last known well within 4.5 hours, no blood on CT, BP that can be brought below 185/110, and no contraindication.
- Any blood on the CT
- Ischaemic stroke or serious head injury in the last 3 months
- Major surgery or serious trauma in the last 2 weeks
- Bleeding from the gut or urinary tract in the last 3 weeks, or active bleeding now
- Known bleeding disorder, or platelets below 100 × 10⁹/L (100,000/µL)
- Warfarin with INR above 1.7
- Treatment-dose heparin or enoxaparin in the last 24 hours
- A DOAC (apixaban, rivaroxaban, dabigatran, edoxaban) in the last 48 hours, unless your protocol allows otherwise
- BP that stays above 185/110 despite treatment
- Symptoms that are mild and not disabling, or improving fast
- A seizure at the onset
- Blood sugar below 2.7 or above 22 mmol/L (below 50 or above 400 mg/dL): correct it and reassess
- Pregnancy or recent delivery
- Very large stroke on CT, or very old age with poor baseline function
Exact cut-offs vary between protocols. Your hospital's thrombolysis checklist is the one to follow.
Streptokinase is not used for stroke. It is common in Pakistan for heart attacks, but in stroke trials it caused more bleeding and more deaths. Never substitute it for alteplase or tenecteplase.
Your jobs during and after thrombolysis
- Two working cannulas, weight recorded, bloods sent, BP below 185/110.
- Avoid catheters, NG tubes, arterial stabs and intramuscular injections just before and during the infusion unless essential. Bleeding from these sites is hard to stop.
- Neurological observations and BP every 15 minutes for 2 hours, then every 30 minutes for 6 hours, then every hour until 24 hours.
- No aspirin, clopidogrel or heparin for 24 hours. Repeat CT at 24 hours before starting an antiplatelet.
- New headache, vomiting, falling GCS, rising BP or new weakness may be bleeding into the brain.
- Stop the infusion. Call your senior immediately.
- Urgent CT head. Send full blood count, clotting, fibrinogen and group and save.
- Bleeding is treated according to protocol (often cryoprecipitate and tranexamic acid).
- Swelling of the tongue or lips (angioedema) can happen, especially in patients on ACE inhibitors. Stop the infusion, give an antihistamine and hydrocortisone, and treat as anaphylaxis with adrenaline if the airway is at risk.
Thrombectomy
Thrombectomy pulls the clot out through a catheter passed up from the groin or wrist. It is done in a few specialist centres.
- Who: a blocked large artery on the CT angiogram (internal carotid, the first part of the middle cerebral, or basilar), a significant deficit, and reasonable function before the stroke.
- When: ideally within 6 hours. Selected patients up to 24 hours if imaging shows brain that can still be saved. Basilar occlusion can be treated up to 24 hours.
- What you do: call the stroke team early, get the CT angiogram, and if transfer is needed, send the patient with the time last known well, the CT images or report, drug history and weight. Thrombolysis is not delayed for transfer: the patient can be thrombolysed and then transferred.
Aspirin: give or hold?
This is the question house officers get wrong most often. Aspirin helps in ischaemic stroke, but it is harmful in a bleed and it adds to bleeding risk if thrombolysis is still to come.
- Hold aspirin
- Phone the stroke team or receiving centre and ask
- Write down their answer and their name
- Give aspirin 300 mg now
- Then 300 mg daily for 14 days
- No aspirin or heparin for 24 hours
- Repeat CT at 24 hours
- Start antiplatelet if there is no bleed
- Do not give it
- Ask your senior about an alternative
- Never give aspirin before the CT.
- Hold aspirin if thrombolysis is planned or still possible, including while transfer for possible thrombolysis is being arranged.
- Give aspirin 300 mg when the CT shows no blood and thrombolysis will not happen: outside the window, contraindicated, the team says no, or transfer cannot arrive in time.
- If the swallow screen has not been passed, give it rectally (where available) or through an NG tube. Do not leave tablets at the bedside "for later".
- If you cannot reach the receiving team and arrival will clearly be outside any treatment window, give aspirin 300 mg and document why.
If thrombolysis is not available here
Many hospitals in Pakistan do not offer thrombolysis or have CT available around the clock. That is common, and these patients still need full, careful care.
- Confirm the time last known wellRemember: for a wake-up stroke, it is the time they went to sleep.
- Phone the nearest stroke centreAsk whether the patient can arrive inside a treatment window. Get the name of the doctor and a clear plan.
- Get a CT as soon as possibleIf there is blood, follow the haemorrhage section: reverse blood thinners, control BP, no aspirin.
- No blood and transfer is realisticHold aspirin. Stabilise, and send the patient with written notes, the time last known well, the CT and the drug list.
- No blood and transfer is not possible or too lateGive aspirin 300 mg now (unless allergic), then daily for 14 days.
- Either way, start good stroke careBlood sugar 4–11 mmol/L (72–200 mg/dL), treat fever, nil by mouth until swallow screen, ECG for AF, pressure care, early physiotherapy.
- Document everythingTime last known well, CT time, who you called, the advice given, and whether aspirin was given or held and why.
Blood pressure in acute stroke
BP is often high after a stroke. In ischaemic stroke, the brain around the infarct depends on that pressure, so lowering it too much can make the stroke bigger. In haemorrhage, lowering it early may limit growth of the bleed.
- Below 185/110 before
- Below 180/105 for 24 hours after
- Leave it alone unless above about 220/120
- Or another emergency: aortic dissection, heart attack, heart failure, eclampsia, hypertensive encephalopathy
- If you must lower it, go slowly (about 15% in the first day)
- Aim for 130–140 within 1 hour
- Keep it there for at least 7 days
- Do not drop it by more than 60 mmHg in an hour
Never give sublingual nifedipine for high BP in stroke. It causes sudden, unpredictable drops in BP that can extend the stroke. Use IV drugs with careful monitoring, as your protocol directs.
- Usual BP tablets: do not rush to restart them in the first day or two of an ischaemic stroke. Ask the stroke team when to restart, and only once the swallow is safe.
Haemorrhagic stroke
- No thrombolysis, no aspirin, no heparin or enoxaparin.
- Reverse blood thinners immediately. This is time-critical.
- BP: within 6 hours, with systolic 150–220, aim for 130–140 within 1 hour (see above).
- Neurosurgery opinion for a bleed in the cerebellum, hydrocephalus (enlarged ventricles), a falling GCS, or a large bleed near the surface in a younger patient.
- Platelet transfusion does not help patients on aspirin or clopidogrel who are not having surgery, and may cause harm.
- Clot prevention: use intermittent pneumatic compression (IPC) on the legs, not drugs.
Care for every stroke patient
These steps matter for every stroke, whatever the type and whether or not the patient had thrombolysis. They prevent the complications that kill and disable stroke patients in the first weeks.
- Swallow screen within 4 hours of arrival, before any food, drink or oral medicine. If they fail, keep nil by mouth and ask for a specialist swallow assessment. Start NG feeding within 24 hours if they cannot swallow safely.
- Blood sugar 4–11 mmol/L (about 72–200 mg/dL). Treat high sugar with insulin as per protocol.
- Fluids: if they cannot drink, give IV 0.9% sodium chloride. Avoid dextrose drips unless the sugar is low: high sugar and low-sodium fluids can worsen brain swelling.
- Oxygen only if SpO₂ is below 95%.
- Temperature: treat fever with paracetamol and look for the cause (aspiration pneumonia and urine infection are common).
- Clot prevention: IPC on the legs within 3 days for patients who cannot walk. Compression stockings are not used.
- Pressure areas, bladder and bowels: turn regularly, avoid a urinary catheter unless needed, prevent constipation.
- Getting up: sit out and mobilise when stable, guided by physiotherapy. Very intensive mobilisation within the first 24 hours is not recommended.
- Mood and family: low mood is common. Explain the plan to the family, and teach them positioning and safe feeding.
- Steroids (such as dexamethasone) do not reduce brain swelling from stroke and are not given for it.
- Drugs sold as "brain protectors" (such as citicoline) have not been shown to improve recovery in large trials. They are not part of guideline treatment.
- Heparin or enoxaparin as stroke treatment does not improve outcome in ischaemic stroke and increases bleeding.
TIA
That is a transient ischaemic attack (TIA), and it has its own guide: aspirin now, specialist review within 24 hours, carotid imaging, and how to keep the patient from having a stroke in the next few days.
Secondary prevention and discharge
- Antiplatelet: clopidogrel 75 mg daily long term after the first 2 weeks of aspirin (unless anticoagulated).
- AF: anticoagulation (usually a DOAC) prevents further strokes. The stroke team decides when to start; it depends on the size of the stroke and the bleeding risk. Do not start it in the first days on your own.
- Statin: atorvastatin 20–80 mg daily for ischaemic stroke and TIA.
- BP: long-term target usually below 130/80, once the acute phase is over.
- Diabetes, smoking, weight and exercise: treat and advise.
- Rehabilitation: physiotherapy, occupational therapy and speech therapy. Teach the family how to help with transfers, feeding and exercises.
- Driving: no driving for at least one month after a stroke or TIA, longer if there is a lasting deficit or a field defect.
- Follow-up: clinic review, BP and sugar control, adherence to medicines.
Calling your senior
Make the call short and structured. Lead with the time and the possibility of thrombolysis.
"I'm the house officer in the emergency department. I have a 62-year-old woman with a suspected acute stroke. Last known well was 07:30, so she is within the thrombolysis window. She has right arm and leg weakness and expressive aphasia. Sugar 6.1 mmol/L (110 mg/dL), BP 196/104, pulse irregular. She is not on blood thinners. CT head has been requested. Can you come to see her now, and do you want a CT angiogram?"
Documentation
Write it down as you go, with clock times.
- Time last known well, and who gave it.
- Time of arrival, time seen, time of CT, time of the CT result.
- Your examination findings (and repeat findings with times).
- Who you called, when, and what they advised.
- Whether thrombolysis was given (time started) or why not.
- Whether aspirin was given or held, and why.
- Swallow screen result and the feeding plan.
Common mistakes
- Not checking the blood sugar first.
- Using the time the patient woke up, instead of the time they went to sleep.
- Giving aspirin before the CT, or giving aspirin to a patient who is still a thrombolysis candidate.
- Dropping the BP in ischaemic stroke, especially with sublingual nifedipine.
- Letting the family give water or tablets before the swallow screen.
- Calling a posterior stroke "just vertigo".
- Assuming a normal early CT means no stroke.
- Running a 5% dextrose drip in a stroke patient who is not hypoglycaemic.
Frequently asked questions
What is the time window for thrombolysis in stroke?
Within 4.5 hours of the time the patient was last known to be well, after a CT has excluded bleeding and there is no contraindication. The stroke team or your senior makes the decision.
Should I give aspirin if the patient is being transferred for thrombolysis?
Usually not. Hold aspirin and ask the receiving stroke team. Give aspirin 300 mg once the CT shows no blood and thrombolysis is no longer an option.
What is the last known well time for a stroke on waking?
The time the patient went to sleep, or the last time they were seen normal before sleeping. It is not the time they woke up.
What BP target should be used in acute stroke?
Below 185/110 before thrombolysis and below 180/105 for 24 hours after. In haemorrhage within 6 hours with systolic 150–220, aim for 130–140 within an hour. Otherwise avoid lowering BP in ischaemic stroke unless it is above about 220/120 or there is another emergency.
When can aspirin start after thrombolysis?
After 24 hours, once a repeat CT shows no bleeding.
Is a normal CT scan enough to rule out stroke?
No. Early ischaemic stroke is often invisible on CT in the first hours. The CT is done mainly to exclude bleeding.
Test yourself
Exam-style questions on this guide, from our two question banks. Choose an answer to see why each option is right or wrong.
1. A 66-year-old woman went to bed talking normally at 23:00. Her husband found her at 06:30 unable to move her left arm. She arrives in the emergency department at 07:00. Which time should be recorded as "last known well"?
Answer: 23:00, when she was last seen normal. In wake-up stroke, last known well is the time the patient was last seen normal, usually going to sleep. Here that is 23:00, so she is outside the standard 4.5-hour thrombolysis window. The stroke team should still be called: some centres use advanced imaging to treat selected late patients.
- 06:30, when the weakness was found: Symptoms present on waking: onset is taken as the last time she was known to be normal.
- 07:00, arrival time: Arrival time has nothing to do with the treatment window.
- Unknown, so thrombolysis is decided on symptom severity alone: Last known well is known here: it is when she went to bed.
- Halfway between going to bed and waking: There is no "midpoint" rule.
2. A 62-year-old man has right-sided weakness for 90 minutes. CT head shows no bleed. He is within the thrombolysis window and you are arranging urgent transfer to a centre that can give alteplase. What is the best step regarding aspirin?
Answer: Hold aspirin and ask the receiving stroke team. If the patient may still receive thrombolysis, aspirin is held. Aspirin is given 300 mg once a bleed is excluded and thrombolysis is not going to happen (outside the window, contraindicated, or transfer impossible). After thrombolysis, antiplatelets wait 24 hours until a repeat CT.
- Give clopidogrel 300 mg instead: Same problem: antiplatelets are held if thrombolysis may follow.
- Give aspirin 300 mg now: Aspirin before thrombolysis increases bleeding risk; the receiving team decides.
- Start enoxaparin: Anticoagulation is not used in acute ischaemic stroke before thrombolysis.
- Give aspirin 75 mg now as a compromise: Any antiplatelet before thrombolysis adds bleeding risk.
3. A 70-year-old man with acute ischaemic stroke presented 9 hours after onset. He is not a thrombolysis candidate. BP is 190/100. He has no chest pain, no heart failure and no signs of dissection. What is the best management of his blood pressure now?
Answer: Do not lower it acutely; monitor. In ischaemic stroke not treated with thrombolysis, BP is left alone unless it is extreme (around 220/120 or more) or there is another emergency such as aortic dissection, acute heart failure or hypertensive encephalopathy. Before thrombolysis, BP must be below 185/110.
- Start ramipril and amlodipine today: Long-term BP treatment usually starts after the acute phase.
- IV GTN infusion to below 160/90: No indication to lower acutely below the treatment threshold.
- Sublingual nifedipine: Sudden uncontrolled drops in BP are harmful in acute stroke.
- IV labetalol to below 140/90: Rapid lowering can reduce blood flow to the threatened brain.
4. A 58-year-old woman on insulin has slurred speech and drift of the right arm. Capillary glucose is 2.4 mmol/L (43 mg/dL). What is the next step?
Answer: Correct the glucose first. Hypoglycaemia can cause focal neurological signs and is the first mimic to exclude. Check the sugar in every suspected stroke. If the signs resolve fully after correction, this was not a stroke.
- Aspirin 300 mg: Aspirin is never given before a CT, and this may not be a stroke at all.
- Call the stroke team for thrombolysis: Hypoglycaemia is a classic stroke mimic: correct it first.
- Urgent CT head before anything else: A low sugar is quick to treat and can cause the whole picture.
- Give IV thiamine only: Thiamine does not correct the low sugar.
5. A 65-year-old with an anterior STEMI arrives at a district hospital 3 hours from a PCI centre. Which history is an absolute contraindication to thrombolysis?
Answer: Ischaemic stroke 2 months ago. If primary PCI can’t be delivered within 120 minutes of diagnosis, give fibrinolysis (tenecteplase) within 12 hours of symptom onset, then transfer for angiography. Absolute contraindications: previous intracranial haemorrhage, ischaemic stroke within 6 months, CNS tumour/AVM, major trauma/surgery/head injury within 1 month, GI bleeding within 1 month, known bleeding disorder, aortic dissection, non-compressible punctures in 24 h. Relative: uncontrolled hypertension (> 180/110), oral anticoagulants, pregnancy, TIA within 6 months.
- Well-controlled hypertension: Controlled hypertension is not a contraindication.
- Age over 75 years: Age over 75 is not absolute.
- Background diabetic retinopathy: Diabetic retinopathy is not absolute.
6. Which artery supplies the medial surfaces of the frontal and parietal lobes, including the leg area of the motor cortex?
Answer: Anterior cerebral artery. The anterior cerebral artery supplies the medial frontal and parietal lobes, including the leg and foot areas of the motor and sensory cortex. ACA stroke causes contralateral leg weakness and sensory loss more than arm or face, with possible urinary incontinence and personality change.
- Middle cerebral artery: Supplies the lateral surface: face and arm areas, and speech areas.
- Posterior cerebral artery: Supplies the occipital lobe (vision) and inferior temporal lobe.
- Basilar artery: Supplies the brainstem and cerebellum.
- Anterior choroidal artery: Supplies the internal capsule and optic tract.
7. A patient has weakness and sensory loss of the left leg more than the arm, with urinary incontinence and apathy. Which artery is occluded?
Answer: Right anterior cerebral artery. The anterior cerebral artery supplies the medial surface of the frontal and parietal lobes, where the leg and foot are represented (paracentral lobule), plus the micturition centre and frontal behaviour areas. Occlusion causes contralateral leg-predominant weakness and sensory loss, incontinence and abulia. MCA: face and arm more than leg, aphasia (dominant) or neglect. PCA: contralateral homonymous hemianopia with macular sparing.
- Right middle cerebral artery: Face and arm predominant.
- Left anterior cerebral artery: Would affect the right leg.
- Right posterior cerebral artery: Visual field loss.
- Basilar artery: Brainstem signs, coma.
References and dose sources
- NICE NG128: Stroke and TIA in over 16s, diagnosis and initial management
- National Clinical Guideline for Stroke for the UK and Ireland (2023)
- NICE TA990: Tenecteplase for acute ischaemic stroke
- AHA/ASA guideline for early management of acute ischaemic stroke
- AHA/ASA guideline for spontaneous intracerebral haemorrhage
- Alteplase dosing: Drugs.com: Alteplase dosage (see also our alteplase dose page)
- Tenecteplase dosing: Drugs.com: Tenecteplase dosage (see also our tenecteplase dose page)
- Labetalol dosing: Drugs.com: Labetalol dosage (see also our labetalol dose page)
- Aspirin dosing: Drugs.com: Aspirin dosage (see also our aspirin dose page)
- Clopidogrel dosing: Drugs.com: Clopidogrel dosage (see also our clopidogrel dose page)
- Atorvastatin dosing: Drugs.com: Atorvastatin dosage (see also our atorvastatin dose page)
International guidance is linked where it reflects good practice. Where your hospital’s protocol differs, follow your hospital.