For the clinician who meets an acute stroke a few times a year, or who is asked about one on a ward round: the two guidelines on one page. UK is the National Clinical Guideline for Stroke 2023 (NCGS) with NICE NG128 as amended in 2025 and TA990; US is the AHA/ASA acute guideline of January 2026 and the 2021 secondary prevention guideline. Doses should be confirmed against the BNF and the local thrombolysis protocol; the figures behind each row are in the clock chapter and the reference list.
1. Hyperacute: reperfusion by window
| Window and criteria | UK (NCGS 2023 / NG128 2025) | US (AHA/ASA 2026) |
|---|---|---|
| IVT 0–4.5 h, disabling deficit, ICH excluded | Offer alteplase or tenecteplase regardless of age or severity (TA990, TA264) | Class 1: tenecteplase 0.25 mg/kg or alteplase 0.9 mg/kg; no NIHSS floor; no advanced imaging required |
| IVT, non-disabling deficit | Not recommended; DAPT | Not recommended; DAPT preferred |
| IVT 4.5–9 h or wake-up, perfusion mismatch (CTP/MRP) or DWI-FLAIR mismatch | Consider (alteplase); CT/MR perfusion within 1 h of arrival | 2a |
| IVT 4.5–24 h, LVO, no EVT available | Not included | 2b (TRACE-III); not if EVT available (TIMELESS) |
| EVT 0–6 h, proximal anterior LVO | NIHSS ≥6, with IVT first if eligible, regardless of presenting hospital | Class 1 |
| EVT 6–24 h, anterior LVO | Consider on ASPECTS plus target or clinical mismatch (CTP/MRP), including wake-up | Class 1 with DAWN/DEFUSE 3 criteria; CT/CTA selection acceptable where perfusion unavailable |
| EVT, large core (ASPECTS 3–5 or core ≥50 mL) | Consider in selected patients (2023) | Recommended in selected patients (SELECT2, ANGEL-ASPECT) |
| EVT, basilar occlusion | NCGS: consider within 12 h. NG128 (2025): consider up to 24 h with salvageable tissue on imaging | Class 1 to 24 h with NIHSS ≥10 |
| Adjuncts to IVT | — | Argatroban, eptifibatide: not recommended (no benefit) |
| Transport | Nearest hyperacute stroke unit with pre-alert; network transfer for EVT | Direct to EVT-capable centre where transfer systems are weak; mobile stroke units where available |
IVT contraindications (both): ICH or SAH on imaging; BP >185/110 despite treatment; DOAC within 48 h (or abnormal drug-specific assay) or warfarin with INR >1.7; platelets <100; glucose <2.8 or >22 mmol/L; major surgery or trauma within 14 days; GI or GU bleeding within 21 days; ischaemic stroke within 3 months; prior ICH; intracranial neoplasm or AVM; aortic dissection; infective endocarditis. Not contraindications in 2026: age over 80, prior stroke with diabetes, seizure at onset with residual deficit attributable to stroke, mild but disabling deficit, menstruation, unruptured aneurysm under 10 mm. Post-IVT: BP <180/105 for 24 h; no antithrombotics for 24 h; repeat imaging before starting them.
2. Intracerebral haemorrhage: the first hour
| Item | UK | US |
|---|---|---|
| Blood pressure, SBP 150–220 within 6 h of onset | Target SBP 130–139 within 1 h, sustained 7 days; local protocol (labetalol or GTN infusion); not if immediate surgery planned | 130–140 safe and may be reasonable; avoid <130 and rapid drops; nicardipine or clevidipine |
| Warfarin | 4-factor PCC 25–50 IU/kg by INR plus IV vitamin K 5–10 mg; repeat INR at 30 min | Same |
| Dabigatran | Idarucizumab 5 g (2 × 2.5 g); PCC if unavailable | Idarucizumab |
| Apixaban, rivaroxaban, edoxaban | 4-factor PCC; andexanet alfa only within a trial | Andexanet (ANNEXA-I: more haemostatic efficacy, more thrombotic events) or PCC |
| Antiplatelet-associated ICH | Do not give platelet transfusion (PATCH) | Same |
| Haemostatics | No tranexamic acid (TICH-2) | Same |
| Surgery | Cerebellar ICH >3 cm or with brainstem compression or hydrocephalus; EVD for hydrocephalus; consider for lobar ICH in younger patients with deterioration | Same; minimally invasive evacuation within a trial or selected cases (ENRICH) |
| Aetiology | CTA/MRA within 48 h where a macrovascular cause is likely; delayed MRI at 2–3 months | Same |
| Seizure prophylaxis, steroids | Not routine | Not routine |
| Audit | SSNAP: reversal or antihypertensive within 1 h of arrival | — |
3. The ward: first 72 hours
| Item | UK | US |
|---|---|---|
| Stroke unit | Direct admission to a HASU within 4 h of arrival | Stroke unit care recommended |
| Swallow | Screen within 4 h by trained staff before oral intake; SLT assessment within 72 h if failed | Screen before oral intake |
| Antiplatelet | Aspirin 300 mg within 24 h (24 h after IVT, after repeat imaging), 2 weeks, then clopidogrel 75 mg; PR or NG if dysphagic | Aspirin 160–325 mg within 24–48 h |
| DAPT after minor stroke (NIHSS ≤3, or ≤5 for ticagrelor) or high-risk TIA (ABCD2 ≥4) | Clopidogrel 300 mg load then 75 mg plus aspirin 75 mg for 21 days, or ticagrelor 180 mg load then 90 mg bd plus aspirin for 30 days; start within 24 h; then monotherapy | Same; INSPIRES supports a start up to 72 h |
| BP, ischaemic, first 24 h | Treat only if >220/120, or >185/110 pre-IVT, or another emergency (hypertensive encephalopathy, aortic dissection, pre-eclampsia) | Same thresholds; after EVT, do not target SBP <140 even with TICI 3; intensive lowering after IVT not beneficial |
| Glucose | Maintain 5–15 mmol/L; treat hyperglycaemia | Treat to 140–180 mg/dL; tight 80–130 mg/dL not recommended (SHINE) |
| Oxygen, temperature | O2 only if SpO2 <94%; treat fever and find the source | Same |
| VTE prophylaxis | IPC from admission for anyone immobile (CLOTS 3); not GCS; LMWH not routine | IPC recommended; prophylactic heparin uncertain benefit |
| Mobilisation | Within 24 h, frequent short sessions; not very early high-dose (AVERT) | Same |
| Rehabilitation | Therapy assessments within 24 h; ≥3 h/day, 5 days/week of multidisciplinary therapy for those able | Defers to the rehabilitation guideline |
| Anticoagulation for AF | Within 5 days (mild), 5–14 days (moderate/severe); immediately after TIA; DOAC first line | Reasonable to start within 2–14 days by severity; earlier supported by ELAN, OPTIMAS and CATALYST |
| Carotid | Image within 24 h; CEA within 7 days for 50–99% symptomatic stenosis (NASCET); CAS where CEA unsuitable | CEA within 2 weeks for 70–99%, and 50–69% in selected; CAS alternative under 70 |
4. Aetiology and secondary prevention
| Item | UK | US |
|---|---|---|
| Rhythm monitoring | ≥24 h for all; prolonged (external patch or ILR) if cryptogenic and anticoagulation would follow | Same; long-term monitoring reasonable after cryptogenic stroke (CRYSTAL-AF, STROKE-AF) |
| Empirical anticoagulation for ESUS | Not recommended | Not recommended (NAVIGATE ESUS, RE-SPECT ESUS) |
| PFO | Closure within 6 months if <60, PFO with right-to-left shunt, no other cause | Same, with PASCAL classification; RoPE score |
| Long-term antiplatelet | Clopidogrel 75 mg; aspirin plus dipyridamole MR if intolerant; no long-term DAPT | Aspirin, clopidogrel or aspirin-dipyridamole; no long-term DAPT |
| Lipids | Atorvastatin 80 mg; LDL <1.8 mmol/L or non-HDL <2.5; add ezetimibe, then PCSK9 inhibitor or inclisiran (TA733, TA393/394) | High-intensity statin; LDL <70 mg/dL; ezetimibe, then PCSK9 inhibitor |
| Blood pressure | Clinic systolic <130 (home <125); 140–150 with severe bilateral carotid stenosis; start before discharge | <130/80; thiazide, ACEi/ARB, CCB |
| Glucose | Per NG28; no pioglitazone recommendation | Pioglitazone reasonable in insulin resistance without diabetes (IRIS); GLP-1 RA where indicated |
| Dissection | Antiplatelet or anticoagulant 3–6 months (CADISS, TREAT-CAD equivalent) | Same |
| Antiphospholipid syndrome | Warfarin, not a DOAC | Same |
| After ICH: restarting antithrombotics | Antiplatelet may be restarted (RESTART); anticoagulation for AF a specialist decision by ICH location (ENRICH-AF, PRESTIGE-AF); LAA occlusion alternative | Same |
| Genetic and rare causes | Dedicated NCGS sections on CADASIL, CAA and cerebral microbleeds; Fabry testing in cryptogenic young stroke with a clue | Within the young-stroke text |
| Review | 6-month structured review (national standard); annual thereafter | — |
5. Doses
| Agent | Dose | Note |
|---|---|---|
| Tenecteplase | 0.25 mg/kg IV bolus over 5–10 s, max 25 mg | TA990; not the 0.5 mg/kg MI dose |
| Alteplase | 0.9 mg/kg, max 90 mg; 10% as bolus, remainder over 60 min | TA264 |
| Aspirin | 300 mg od for 14 days (PR/NG if needed), then 75 mg if continued | |
| Clopidogrel | 300 mg load, then 75 mg od | CYP2C19 poor metabolisers respond less; ticagrelor is the alternative (CHANCE-2) |
| Ticagrelor | 180 mg load, then 90 mg bd with aspirin for 30 days | THALES; more bleeding than clopidogrel |
| Atorvastatin | 80 mg od | 40 mg if interactions or intolerance |
| Labetalol (UK acute BP) | 10–20 mg IV over 1–2 min, repeat, or infusion 1–2 mg/min | GTN infusion 1–12 mg/h as alternative; avoid sublingual nifedipine |
| Nicardipine (US) | 5 mg/h, titrate by 2.5 mg/h to 15 mg/h | Not routinely available in UK |
| PCC (Beriplex/Octaplex) | 25–50 IU/kg by INR, plus vitamin K 5–10 mg IV | Repeat INR at 30 min |
| Idarucizumab | 5 g IV (2 × 2.5 g) | Dabigatran only |
| DOAC for AF after stroke | Apixaban 5 mg bd (2.5 mg if 2 of: age ≥80, weight ≤60 kg, creatinine ≥133); rivaroxaban 20 mg od (15 if CrCl 15–49); edoxaban 60 mg od (30 if CrCl 15–50, ≤60 kg, or P-gp inhibitor); dabigatran 150 mg bd (110 if ≥80 or high bleeding risk) | Warfarin INR 2–3 for mechanical valves, mitral stenosis, APS |
6. The UK delivery gap, for the referral conversation
The 2024–25 Sentinel audit reports a median door-to-needle time in England of 56 minutes, up from 54; NCGS 2023 and GIRFT estimate 10–15% of strokes are eligible for thrombectomy and delivery remains well short of that, with 24/7 cover incomplete at some centres. The practical implications for a referring clinician: pre-alert on the way in; CTA at the first scan for anyone who could be an EVT candidate, not after IVT; call the network centre before the perfusion result if the CTA shows an LVO; and document the time last known well in the transfer letter as a clock time, not an interval.
Reference only. Local thrombolysis and thrombectomy protocols, the BNF and the SmPCs take precedence for any dosing decision. Class-of-recommendation labels are as the 2026 AHA/ASA summaries report them and should be confirmed against the full text.