The first ten minutes
- Non-contrast CT head immediately — the question it answers is not "is there a stroke" but "is there blood". CT is often normal early in ischaemic stroke, and that is expected
- Capillary glucose — hypoglycaemia is the great stroke mimic, along with seizure with Todd's paresis, migraine with aura, and functional presentations
- Establish the time last known well. This governs everything
Reperfusion
Intravenous thrombolysis (alteplase or tenecteplase) within 4.5 hours of onset.
Key contraindications: intracranial haemorrhage on imaging, active bleeding, recent intracranial or spinal surgery, head trauma or prior stroke within 3 months, blood pressure that cannot be brought below 185/110, platelets below 100, INR above 1.7, a DOAC taken within 48 hours.
Endovascular thrombectomy for large vessel occlusion within 6 hours, and up to 24 hours in selected patients with favourable perfusion imaging. Thrombectomy is given in addition to thrombolysis when both are indicated — you do not skip lysis to go to the angiography suite.
Blood pressure
Counter-intuitive and heavily examined:
- Not thrombolysed: permissive hypertension. Treat only above roughly 220/120, or with another indication (dissection, heart failure, hypertensive encephalopathy)
- Thrombolysed: keep below 180/105
- Haemorrhagic stroke: lower more actively, typically to a systolic of 140
In the first days
- Aspirin within 24–48 hours (and after 24 hours if thrombolysed)
- Dual antiplatelet therapy for 21 days after a minor stroke or high-risk TIA, then single agent
- Swallow screen before anything by mouth — an easy mark and a real cause of aspiration
- Stroke unit care, early mobilisation, VTE prophylaxis, glucose and temperature control
TIA
Neurological deficit without infarction on imaging. It is an emergency, not a reassurance: risk of stroke is highest in the first 48 hours.
Urgent work-up: carotid imaging, ECG and prolonged rhythm monitoring for AF, echocardiography where indicated, lipids and glucose.
Secondary prevention
Determined by the mechanism:
- Atrial fibrillation → anticoagulation, not antiplatelet. DOAC preferred over warfarin except in mechanical valves and moderate-severe mitral stenosis
- Symptomatic carotid stenosis 50–99% → endarterectomy, ideally within 2 weeks
- Small vessel or large artery disease → antiplatelet plus high-intensity statin
- Blood pressure control, diabetes control, smoking cessation, exercise
- Driving restrictions apply and must be discussed — a commonly missed part of the answer