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  • 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.
  • This guideline replaces CG68.
  • This guideline is the basis of QS2.

Rapid recognition of symptoms and diagnosis

Prompt recognition of symptoms of stroke and transient ischaemic attack

  • 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)

Initial management of suspected and confirmed TIA

  • 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 use scoring systems, such as ABCD2, to assess risk of subsequent stroke or to inform urgency of referral for people who have had a suspected or confirmed TIA
  • Offer secondary prevention, in addition to aspirin, as soon as possible after the diagnosis of TIA is confirmed

Pharmacological treatments and thrombectomy for people with acute stroke

Aspirin and anticoagulant treatment

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[A]
  • Do not use anticoagulation treatment routinely[B] for the treatment of acute stroke

Statin treatment

  • Immediate initiation of statin treatment is not recommended in people with acute stroke[C]
  • Continue statin treatment in people with acute stroke who are already receiving statins

Maintenance or restoration of homeostasis

Supplemental oxygen therapy

  • Give supplemental oxygen to people who have had a stroke only if their oxygen saturation drops below 95%. The routine use of supplemental oxygen is not recommended in people with acute stroke who are not hypoxic

Blood sugar control

  • Maintain a blood glucose concentration between 4 and 11 mmol/litre in people with acute stroke
  • Provide optimal insulin therapy, which can be achieved by the use of intravenous insulin and glucose, to all adults with type 1 diabetes with threatened or actual stroke. Critical care and emergency departments should have a protocol for such management

[This recommendation is from the NICE guideline on type 1 diabetes.]


[A] 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.

[B] There may be a subgroup of people for whom the risk of venous thromboembolism outweighs the risk of haemorrhagic transformation. People considered to be at particularly high risk of venous thromboembolism include anyone with complete paralysis of the leg, a previous history of venous thromboembolism, dehydration or comorbidities (such as malignant disease), or who is a current or recent smoker. Such people should be kept under regular review if they are given prophylactic anticoagulation.

[C] The consensus of the committee is that it would be safe to start statins after 48 hours.

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© NICE 2018. Stroke and transient ischaemic attack in over 16s: diagnosis and initial management. Available from: www.nice.org.uk/guidance/ng128. All rights reserved. Subject to Notice of rights.

NICE guidance is prepared for the National Health Service in England. All NICE guidance is subject to regular review and may be updated or withdrawn. NICE accepts no responsibility for the use of its content in this product/publication.

Published date: 01