After the reperfusion decision, the next three days are where most of the remaining avoidable harm happens, and it happens quietly: a chest infection from swallowing that was not checked, a clot in the leg, a blood pressure lowered too enthusiastically, a patient on a general ward when a stroke unit bed existed. The list below is what the UK and US guidelines say should happen and by when, written so that a patient or family member can tell whether it did.
1. The first hour
| What | When | Why |
|---|---|---|
| CT head, and CT angiography of the neck and brain arteries if a large-vessel blockage is possible | Immediately on arrival for anyone who could be treated; within an hour for everyone | Bleed or blockage decides everything; the angiogram decides thrombectomy |
| Perfusion imaging, or MRI, for people outside the standard windows or with an uncertain onset time | Within an hour of arrival (UK) | It is what opens the 6–24-hour thrombectomy and the late thrombolysis windows |
| Reperfusion decision: thrombolysis, thrombectomy, transfer | Door-to-needle target under 30 minutes in the best units; England averaged 56 minutes in 2024–25 | See the clock |
| For a bleed: blood pressure to 130–139 and any anticoagulant reversed | Within one hour | The bundle that limits the bleed growing |
| Finger-prick glucose | On arrival | Low sugar mimics a stroke; high sugar worsens one |
| Direct admission to a hyperacute stroke unit | Within four hours of arrival (UK standard) | Stroke unit care reduces death and dependency on its own |
2. The first day
Swallowing
A swallow screen within four hours of arrival, before any food, drink or tablet by mouth, by a trained nurse; a specialist speech and language assessment within 72 hours if the screen is failed. Around half of people with an acute stroke have some difficulty swallowing, and aspiration pneumonia is one of the commonest avoidable causes of death in the first weeks. Someone who fails the screen is kept nil by mouth with fluids and medicines by another route, and fed by tube if the problem lasts.
Antiplatelet
Aspirin 300 mg (UK) or 160–325 mg (US) within 24 hours of an ischaemic stroke once a bleed is excluded, continued for two weeks then changed to the long-term drug. If thrombolysis was given, the first dose waits 24 hours and a repeat scan. For a minor stroke or high-risk TIA, two antiplatelets together for a short period cut the early recurrence rate substantially: clopidogrel with aspirin for 21 days (CHANCE and POINT), or ticagrelor with aspirin for 30 days (THALES), started within 24 hours, and INSPIRES showed benefit even when started up to 72 hours after onset. After that, one drug, usually clopidogrel in the UK. Longer courses of two drugs add bleeding without adding benefit.
Blood pressure
The instinct is to treat a high reading. In the first 24 hours of an ischaemic stroke the guidance is leave it alone unless it is above 220/120, or above 185/110 in someone about to receive thrombolysis (and then below 180/105 for the following 24 hours), or another emergency demands it. High pressure is often the brain protecting its own supply. New in 2026: several trials tested pushing the pressure down after thrombectomy and found it did harm, so the American guideline now says do not aim below 140 systolic after thrombectomy, even when the artery has been fully reopened, and more intensive lowering after thrombolysis does not help either. Long-term blood pressure treatment starts once the patient is stable, usually within days, with a much lower target; that belongs to the prevention chapter.
Glucose, temperature, oxygen
Keep blood glucose in the ordinary range (UK: 5–15 mmol/L) and treat it if higher. The 2026 American guideline is explicit that tight control to 80–130 mg/dL (4.4–7.2 mmol/L) is not recommended: it does not improve outcomes and causes severe hypoglycaemia. Treat a fever and look for its cause. Oxygen only if saturations are below 94%; routine oxygen does not help and may harm.
Clot prevention
A stroke patient who cannot move a leg is at high risk of a deep vein thrombosis. The evidence is specific about what works: intermittent pneumatic compression (inflatable sleeves on the legs) reduced DVT from 12.1% to 8.5% in the CLOTS 3 trial and improved survival. Compression stockings did not work (CLOTS 1 and 2). Heparin injections reduce clots but increase bleeding into the brain, so they are not routine after a stroke. If a patient who cannot walk has no sleeves on their legs, ask why.
Early mobilisation, but not too early
Sitting out and standing within 24 to 48 hours is standard and prevents chest infections, clots and pressure sores. The AVERT trial tested something more aggressive — out of bed within 24 hours with frequent, intensive sessions — and found it made outcomes slightly worse (46% had a favourable outcome against 50% with usual care). The lesson both guidelines drew is early, frequent, short sessions rather than early, long ones.
3. The first 72 hours
- A stroke unit bed, throughout. Care on a dedicated unit with a specialist team reduces death and dependency by about a fifth compared with a general ward, independent of any drug. Every UK hospital receiving strokes should have one; a patient boarding on another ward is a gap to raise.
- Specialist assessments: physiotherapy, occupational therapy and, where needed, speech and language therapy within 24 hours of admission (UK); a formal swallow assessment within 72 hours if screened positive; a mood and cognition screen before discharge planning.
- Continence, skin, hydration and nutrition assessed and managed; catheters avoided unless needed; a feeding plan within 72 hours for anyone not eating.
- Rehabilitation intensity. The 2023 UK guideline asks for at least three hours a day, five days a week of therapy across the disciplines for anyone able to take part, from the acute unit onward. That figure is often not met, and the Sentinel audit reports on it.
- Anticoagulation timing if atrial fibrillation is found. UK: within five days for a mild stroke, five to fourteen days for a moderate or severe one; trials in 2023 and 2024 (ELAN, OPTIMAS) showed earlier starting is safe. Immediately after a TIA once a bleed is excluded.
- The cause-finding starts now, not at outpatients: carotid imaging within 24 hours, because surgery for a severe symptomatic narrowing should happen within seven days; heart monitoring from admission; bloods including a full lipid profile and HbA1c. See finding the cause.
4. For a bleed, specifically
- Blood pressure held at 130–139 systolic for seven days (UK).
- Reversal completed, and a documented plan for whether and when any antithrombotic is restarted.
- Neurosurgical opinion for a cerebellar bleed, hydrocephalus, or a large lobar bleed in a younger person.
- CT or MR angiography within 48 hours where a structural cause (an aneurysm, a malformation) is likely, particularly in younger people and lobar bleeds.
- No routine antiepileptic drugs, no routine steroids, no tranexamic acid.
5. Where UK and US guidance differ
- Blood pressure after thrombectomy. The 2026 US rule (not below 140) is explicit and new; UK guidance says avoid aggressive lowering without the number. In substance the same.
- Glucose. The US now says tight control is harmful; the UK range of 5–15 mmol/L was already loose.
- Rehabilitation intensity. The UK three-hours-a-day standard is more demanding than anything in the US acute guideline, which defers to the rehabilitation guideline.
- Antiplatelet timing after thrombolysis. Both wait 24 hours; the US allows earlier in specific circumstances.
- The four-hour stroke-unit standard is a UK audit measure with no direct US equivalent.