Hours across, treatments down, measured from the time the person was last known well. "Yes" means the guideline recommends it for eligible patients; "consider" means it is allowed with imaging or other criteria; "no" means it is outside the guidance. The numbers are the absolute benefit and harm from the clock chapter. Print this and keep it with the emergency chapter.
Ischaemic stroke: a blocked artery
| Treatment | 0–90 min | 90 min–3 h | 3–4.5 h | 4.5–6 h | 6–9 h | 9–24 h | Beyond 24 h |
|---|---|---|---|---|---|---|---|
| Thrombolysis (tenecteplase 0.25 mg/kg, max 25 mg, or alteplase) Disabling deficit, no bleed on CT, no contraindication |
Yes UK & US Odds of good outcome 2.55 |
Yes UK & US Odds 1.64 |
Yes UK & US Odds 1.34; ~14 treated per extra good outcome |
Consider UK & US With perfusion or MRI mismatch (EXTEND, WAKE-UP) |
Consider UK & US Same criteria; 35.4% v 29.5% free of disability, bleeding 6.2% v 0.9% |
US: may help if occlusion and no thrombectomy (TRACE-III: 33.0% v 24.2%) UK: no |
No |
| Thrombectomy, anterior circulation Large-vessel occlusion on angiography |
Yes UK & US, to 6 h, with thrombolysis first if eligible 46% independent v 26.5%; about 1 extra per 2.6 treated (HERMES) |
Consider UK & US, 6–24 h, with imaging showing salvageable brain DAWN 49% v 13%; DEFUSE 3 45% v 17% |
No | ||||
| Thrombectomy, large core Large area already infarcted on CT |
Consider UK & US in selected patients SELECT2 20% v 7%; ANGEL-ASPECT 30% v 11.6% |
No | |||||
| Thrombectomy, basilar artery | Yes US to 24 h (stroke scale 10 or more) UK: NICE consider to 24 h with imaging; NCGS 2023 said 12 h ATTENTION and BAOCHE: about 46% good outcome v 23–24% |
No | |||||
| Aspirin, then two antiplatelets for a minor stroke or TIA | Within 24 h of onset once a bleed is excluded (24 h after thrombolysis). Minor stroke / high-risk TIA: clopidogrel with aspirin 21 days or ticagrelor with aspirin 30 days, started within 24 h and useful to 72 h | ||||||
Haemorrhagic stroke: a bleed
| Action | Within 1 hour of arrival | First 6 hours | First 7 days |
|---|---|---|---|
| Blood pressure (if systolic 150–220) | UK: to 130–139. US: 130–140 is safe and may help; not below 130, not fast | Start within 6 h of onset for the benefit | UK: hold there for 7 days |
| Anticoagulant reversal | Warfarin: prothrombin complex concentrate + vitamin K. Dabigatran: idarucizumab. Apixaban / rivaroxaban / edoxaban: UK prothrombin complex concentrate; US andexanet | Documented plan for whether and when to restart | |
| Glucose and temperature | Corrected as part of the bundle (INTERACT3) | ||
| Surgery | Cerebellar bleed with brainstem pressure; hydrocephalus | Neurosurgical opinion for large lobar bleeds in younger people | |
| Cause | CT or MR angiography within 48 h where a structural cause is likely | ||
| Not given | Tranexamic acid, routine antiepileptics, routine steroids | ||
Either kind: the first 72 hours
| Within 1 h | Within 4 h | Within 24 h | Within 72 h |
|---|---|---|---|
| CT (and angiography); glucose; the reperfusion or bleed decision | Swallow screen before anything by mouth; admission to a stroke unit | Aspirin if ischaemic; carotid imaging; therapy assessments; heart monitoring started; sitting out and standing if able | Specialist swallow assessment if screened positive; feeding plan; leg sleeves for anyone who cannot walk; rehabilitation at three hours a day (UK); anticoagulation timing decided if atrial fibrillation found |
Blood pressure in an ischaemic stroke is left alone in the first 24 hours unless above 220/120, or above 185/110 before thrombolysis; and it is not pushed below 140 after thrombectomy (US 2026). "Free of disability" means a modified Rankin score of 0–1; "independent" means 0–2; for the basilar trials, "good outcome" means 0–3.