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NeurologyICD-10: I63

Stroke: Current Treatment Guidelines & Management

15 million strokes per year worldwide; leading cause of disability and second leading cause of death globally.

AHA 2021

What is Stroke?

Stroke is defined as a focal neurological deficit caused by cerebral infarction (ischaemic stroke, 85%), intracerebral haemorrhage (10%), or subarachnoid haemorrhage (5%). Transient ischaemic attack (TIA) is a brief episode of neurological dysfunction without infarction, but with high early stroke risk (ABCD2 score-guided). Stroke is a medical emergency requiring immediate assessment and treatment to minimise infarct growth ("time is brain").

Pathophysiology

Ischaemic stroke results from thrombotic or embolic occlusion of cerebral arteries. Large vessel occlusion (LVO) of ICA, M1/M2 MCA, basilar artery requires thrombectomy. Small vessel disease causes lacunar infarcts. Cardioembolic stroke (AF, valvular disease, endocarditis) accounts for ~30%. Penumbral tissue surrounding the infarct core is salvageable with timely reperfusion — driving the urgency of thrombolysis and thrombectomy.

Clinical Features & Symptoms

  • FAST: Facial drooping, Arm weakness, Speech disturbance, Time to call emergency
  • Sudden unilateral limb weakness or sensory loss
  • Sudden speech difficulty (dysphasia, dysarthria)
  • Sudden visual disturbance (hemianopia, diplopia)
  • Sudden severe headache (subarachnoid haemorrhage: "thunderclap")
  • Sudden dizziness, ataxia, vertigo (posterior circulation)
  • Sudden altered consciousness

Diagnosis

Non-contrast CT brain immediately to exclude haemorrhage. CT angiography for LVO assessment if thrombolysis/thrombectomy candidate. MRI-DWI is gold standard for ischaemic stroke confirmation. Blood glucose, ECG (AF), FBC, coagulation, cholesterol, HbA1c. Carotid imaging (duplex/CTA) for anterior circulation TIA/stroke. Echocardiography and cardiac monitoring (48h telemetry) for cardioembolic source.

Current Treatment Guidelines

IV thrombolysis (alteplase)

Class I, Level A

IV alteplase 0.9 mg/kg (max 90 mg) within 4.5 hours of symptom onset in eligible patients. Absolute contraindications: haemorrhage on CT, anticoagulation (INR >1.7 or NOAC within 48h), recent surgery. Tenecteplase (0.25 mg/kg) now an alternative (AHA 2021).

Endovascular thrombectomy (EVT)

Class I, Level A

Mechanical thrombectomy for LVO (ICA, M1/M2, basilar) within 24 hours of last known well. Extends treatment window vs thrombolysis alone. Can be combined with IV alteplase (drip-and-ship or mothership). DAWN and DEFUSE-3 established 16–24h window.

Antiplatelet therapy

Class I, Level A

Aspirin 300 mg within 24 hours (not if thrombolysed — wait 24h). Dual antiplatelet therapy (aspirin + clopidogrel or ticagrelor) for 21 days in minor stroke/high-risk TIA (POINT, CHANCE trials), then single antiplatelet long-term.

Anticoagulation for AF-related stroke

Class I, Level A

NOACs preferred for cardioembolic stroke prevention in AF. Timing: start 1–3–6–12 days rule based on stroke severity (1 day for TIA, 3 days for minor stroke, 6 days for moderate, 12 days for severe). Avoid early anticoagulation in large infarcts (haemorrhagic transformation risk).

BP management

Class I, Level A

Target BP <130/80 mmHg long-term for secondary prevention. Avoid aggressive acute BP lowering unless >185/110 mmHg (thrombolysis threshold) or hypertensive encephalopathy. ACE-I or ARB preferred.

Statin therapy

Class I, Level A

High-intensity statin (atorvastatin 80 mg or rosuvastatin 20–40 mg) for all ischaemic stroke regardless of baseline LDL. Target LDL <1.8 mmol/L (70 mg/dL). SPARCL trial: atorvastatin reduced recurrent stroke by 16%.

Monitoring & Treatment Targets

NIHSS score at admission and at 24h. BP <130/80 mmHg long-term. LDL <1.8 mmol/L (<70 mg/dL). HbA1c <53 mmol/mol (7%). Anticoagulation for AF. Carotid endarterectomy within 2 weeks if ≥50–99% stenosis and TIA/minor stroke.

Key Clinical Trials

DAWNNEJM, 2018

Thrombectomy 6–24h after last known well improved functional independence at 90 days vs medical therapy alone (49% vs 13%, p<0.001) in patients with clinical-imaging mismatch

POINTNEJM, 2018

Dual antiplatelet therapy (aspirin + clopidogrel) for 90 days reduced major ischaemic events by 25% vs aspirin alone after TIA or minor stroke (HR 0.75, p<0.001)

Clinical Guidelines

AHA 2021

AHA/ASA Guideline for the Prevention of Stroke in Patients with Stroke and TIA 2021

External Resources

AHA/ASA Stroke Prevention Guidelines 2021ESO Stroke GuidelinesWHO Stroke

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Frequently Asked Questions

What is the time window for stroke thrombolysis?

IV alteplase can be given within 4.5 hours of stroke symptom onset (or last known well). The greatest benefit is within 3 hours. Tenecteplase (0.25 mg/kg IV bolus) is now an AHA Class IIa alternative and simpler to administer. Endovascular thrombectomy extends the treatment window to 24 hours for large vessel occlusions with salvageable tissue on perfusion imaging.

When should anticoagulation be started after AF-related stroke?

The 1-3-6-12 rule: for TIA start NOACs at day 1; for minor stroke at day 3; for moderate stroke at day 6; for severe stroke at day 12. Earlier anticoagulation risks haemorrhagic transformation of large infarcts. NOACs are preferred over warfarin for non-valvular AF-related stroke (superior efficacy and safety profile).

Medical disclaimer: This content is intended for qualified healthcare professionals and does not constitute medical advice. Always apply clinical judgment and refer to current local guidelines and institutional protocols.