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Stroke and transient ischaemic attack in over 16s: diagnosis and initial management
NICE guideline [NG128]Published: 01 May 2019 Last updated: 13 April 2022
This guideline covers interventions in the acute stage of a stroke or transient ischaemic attack (TIA). It offers the best clinical advice on the diagnosis and acute management of stroke and TIA in the 48 hours after onset of symptoms.
Use a validated tool, such as FAST (Face Arm Speech Test), outside hospital to screen people with sudden onset of neurological symptoms for a diagnosis of stroke or transient ischaemic attack (TIA).
Exclude hypoglycaemia in people with sudden onset of neurological symptoms as the cause of these symptoms.
For people who are admitted to the emergency department with a suspected stroke or TIA, establish the diagnosis rapidly using a validated tool, such as ROSIER (Recognition of Stroke in the Emergency Room).
Offer aspirin (300 mg daily), unless contraindicated, to people who have had a suspected TIA, to be started immediately.
Refer immediately people who have had a suspected TIA for specialist assessment and investigation, to be seen within 24 hours of onset of symptoms.
Do not offer CT brain scanning to people with a suspected TIA unless there is clinical suspicion of an alternative diagnosis that CT could detect.
Everyone with TIA who after specialist assessment is considered as a candidate for carotid endarterectomy should have urgent carotid imaging.
Perform brain imaging immediately with a non-enhanced CT for people with suspected acute stroke if any of the following apply (see additional information):
indications for thrombolysis or thrombectomy
on anticoagulant treatment
a known bleeding tendency
a depressed level of consciousness (Glasgow Coma Score below 13)
unexplained progressive or fluctuating symptoms
papilloedema, neck stiffness or fever
severe headache at onset of stroke symptoms.
If thrombectomy might be indicated, perform imaging with CT contrast angiography following initial non-enhanced CT. Add CT perfusion imaging (or MR equivalent) if thrombectomy might be indicated beyond 6 hours of symptom onset.
Alteplase is recommended within its marketing authorisation for treating acute ischaemic stroke in adults if:
treatment is started as soon as possible within 4.5 hours of onset of stroke symptoms and
intracranial haemorrhage has been excluded by appropriate imaging techniques.
Staff in emergency departments, if appropriately trained and supported, can administer alteplase for the treatment of ischaemic stroke provided that patients can be managed within an acute stroke service with appropriate neuroradiological and stroke physician support.
Offer thrombectomy as soon as possible and within 6 hours of symptom onset, together with intravenous thrombolysis (if not contraindicated and within the licensed time window), to people who have:
acute ischaemic stroke and
confirmed occlusion of the proximal anterior circulation demonstrated by computed tomographic angiography (CTA) or magnetic resonance angiography (MRA)
taking into account the factors in recommendation 1.4.8 (see additional information).
People with acute ischaemic stroke
Offer the following as soon as possible, but certainly within 24 hours, to everyone presenting with acute stroke who has had a diagnosis of intracerebral haemorrhage excluded by brain imaging:
aspirin 300 mg orally if they do not have dysphagia or
aspirin 300 mg rectally or by enteral tube if they do have dysphagia.
Continue aspirin daily 300 mg until 2 weeks after the onset of stroke symptoms, at which time start definitive long-term antithrombotic treatment. Start people on long-term treatment earlier if they are being discharged before 2 weeks.
Offer a proton pump inhibitor, in addition to aspirin, to anyone with acute ischaemic stroke for whom previous dyspepsia associated with aspirin is reported.
Offer an alternative antiplatelet agent to anyone with acute ischaemic stroke who is allergic to or genuinely intolerant of aspirin. (Aspirin intolerance is defined as either of the following: proven hypersensitivity to aspirin-containing medicines, or history of severe dyspepsia induced by low-dose aspirin.)
Do not use anticoagulation treatment routinely for the treatment of acute stroke (see additional information).
People with acute venous stroke
Offer people diagnosed with cerebral venous sinus thrombosis (including those with secondary cerebral haemorrhage) full-dose anticoagulation treatment (initially full-dose heparin and then warfarin [international normalised ratio 2 to 3]) unless there are comorbidities that preclude its use.
People with stroke associated with arterial dissection
Offer either anticoagulants or antiplatelet agents to people who have stroke secondary to acute arterial dissection.
People with acute ischaemic stroke associated with antiphospholipid syndrome
Manage acute ischaemic stroke associated with antiphospholipid syndrome in the same way as acute ischaemic stroke without antiphospholipid syndrome (see additional information).
Reversal of anticoagulation treatment in people with haemorrhagic stroke
Return clotting levels to normal as soon as possible in people with a primary intracerebral haemorrhage who were receiving warfarin before their stroke (and have elevated international normalised ratio). Do this by reversing the effects of the warfarin using a combination of prothrombin complex concentrate and intravenous vitamin K.
Anticoagulation treatment for other comorbidities
Ensure that people with disabling ischaemic stroke who are in atrial fibrillation are treated with aspirin 300 mg for the first 2 weeks before anticoagulation treatment is considered.
For people with prosthetic valves who have disabling cerebral infarction and who are at significant risk of haemorrhagic transformation, stop anticoagulation treatment for 1 week and substitute aspirin 300 mg.
Ensure that people with ischaemic stroke and symptomatic proximal deep vein thrombosis or pulmonary embolism receive anticoagulation treatment in preference to treatment with aspirin unless there are other contraindications to anticoagulation.
Treat people who have haemorrhagic stroke and symptomatic deep vein thrombosis or pulmonary embolism to prevent the development of further pulmonary emboli using either anticoagulation or a caval filter.
Consider rapid blood pressure lowering for people with acute intracerebral haemorrhage who do not have any of the exclusions listed in recommendation 1.5.7 and who:
present within 6 hours of symptom onset and
have a systolic blood pressure of between 150 and 220 mmHg.
1.5.5 Taking into account the risk of harm, consider rapid blood pressure lowering on a case-by-case basis for people with acute intracerebral haemorrhage who do not have any of the exclusions listed in recommendation 1.5.7 and who:
present beyond 6 hours of symptom onset or
have a systolic blood pressure greater than 220 mmHg.
1.5.6 When rapidly lowering blood pressure in people with acute intracerebral haemorrhage, aim to reach a systolic blood pressure of 140 mmHg or lower while ensuring that the magnitude drop does not exceed 60 mmHg within 1 hour of starting treatment.
1.5.7 Do not offer rapid blood pressure lowering to people who:
have an underlying structural cause (for example, tumour, arteriovenous malformation or aneurysm)
have a score on the Glasgow Coma Scale of below 6
are going to have early neurosurgery to evacuate the haematoma
have a massive haematoma with a poor expected prognosis.
Anti-hypertensive treatment in people with acute ischaemic stroke is recommended only if there is a hypertensive emergency with one or more of the following serious concomitant medical issues:
hypertensive encephalopathy
hypertensive nephropathy
hypertensive cardiac failure/myocardial infarction
aortic dissection
pre-eclampsia/eclampsia.
Blood pressure reduction to 185/110 mmHg or lower should be considered in people who are candidates for intravenous thrombolysis.
Stroke services should agree protocols for monitoring, referring and transferring people to regional neurosurgical centres for the management of symptomatic hydrocephalus.
People with intracerebral haemorrhage should be monitored by specialists in neurosurgical or stroke care for deterioration in function and referred immediately for brain imaging when necessary.
Previously fit people should be considered for surgical intervention following primary intracerebral haemorrhage if they have hydrocephalus.
People with any of the following rarely require surgical intervention and should receive medical treatment initially:
small deep haemorrhages
lobar haemorrhage without either hydrocephalus or rapid neurological deterioration
a large haemorrhage and significant comorbidities before the stroke
a score on the Glasgow Coma Scale of below 8 unless this is because of hydrocephalus
posterior fossa haemorrhage.