1 Guidance

The following guidance is based on the best available evidence. The full guideline gives details of the methods and the evidence used to develop the guidance.

1.1 Rapid recognition of symptoms and diagnosis

There is evidence that rapid treatment improves outcome after stroke or TIA. The recommendations in this section cover the rapid diagnosis of people who have had sudden onset of symptoms that are indicative of stroke and TIA. How to identify risk of subsequent stroke in people who have had a TIA is also covered.

1.1.1 Prompt recognition of symptoms of stroke and TIA

1.1.1.1 In people with sudden onset of neurological symptoms a validated tool, such as FAST (Face Arm Speech Test), should be used outside hospital to screen for a diagnosis of stroke or TIA.

1.1.1.2 In people with sudden onset of neurological symptoms, hypoglycaemia should be excluded as the cause of these symptoms.

1.1.1.3 People who are admitted to accident and emergency (A&E) with a suspected stroke or TIA should have the diagnosis established rapidly using a validated tool, such as ROSIER (Recognition of Stroke in the Emergency Room).

1.1.2 Assessment of people who have had a suspected TIA, and identifying those at high risk of stroke

1.1.2.1 People who have had a suspected TIA (that is, they have no neurological symptoms at the time of assessment [within 24 hours]) should be assessed as soon as possible for their risk of subsequent stroke using a validated scoring system[9], such as ABCD2.

1.1.2.2 People who have had a suspected TIA who are at high risk of stroke (that is, with an ABCD2 score of 4 or above) should have:

  • aspirin (300 mg daily) started immediately

  • specialist assessment[10] and investigation within 24 hours of onset of symptoms

  • measures for secondary prevention introduced as soon as the diagnosis is confirmed, including discussion of individual risk factors.

1.1.2.3 People with crescendo TIA (two or more TIAs in a week) should be treated as being at high risk of stroke, even though they may have an ABCD2 score of 3 or below.

1.1.2.4 People who have had a suspected TIA who are at lower risk of stroke (that is, an ABCD2 score of 3 or below) should have:

  • aspirin (300 mg daily) started immediately

  • specialist assessment[10] and investigation as soon as possible, but definitely within 1 week of onset of symptoms

  • measures for secondary prevention introduced as soon as the diagnosis is confirmed, including discussion of individual risk factors.

1.1.2.5 People who have had a TIA but who present late (more than 1 week after their last symptom has resolved) should be treated as though they are at lower risk of stroke.

1.2 Imaging in people who have had a suspected TIA or non-disabling stroke

While all people with symptoms of acute stroke need urgent brain scanning, there is less evidence to recommend brain scanning in those people whose symptoms have completely resolved by the time of assessment. This section contains recommendations about which people with suspected TIA need brain imaging and the type of imaging that is most helpful.

Some people who have had a stroke or TIA have narrowing of the carotid artery that may require surgical intervention. Carotid imaging is required to define the extent of carotid artery narrowing. Sections 1.2.3 and 1.2.4 cover the optimum timing of carotid imaging, and the selection of appropriate patients for, and timing of, carotid endarterectomy. The use of carotid stenting was also reviewed by the GDG. However, no evidence for early carotid stenting was found on which the GDG felt they could base a recommendation. For more information, see chapter 6 of the full guideline.

1.2.1 Suspected TIA – referral for urgent brain imaging

1.2.1.1 People who have had a suspected TIA (that is, whose symptoms and signs have completely resolved within 24 hours) should be assessed by a specialist (within 1 week of symptom onset) before a decision on brain imaging is made.

1.2.1.2 People who have had a suspected TIA who are at high risk of stroke (for example, an ABCD2 score of 4 or above, or with crescendo TIA) in whom the vascular territory or pathology is uncertain[11] should undergo urgent brain imaging[12] (preferably diffusion-weighted MRI [magnetic resonance imaging]).

1.2.1.3 People who have had a suspected TIA who are at lower risk of stroke (for example, an ABCD2 score of less than 4) in whom the vascular territory or pathology is uncertain[11] should undergo brain imaging[13] (preferably diffusion-weighted MRI).

1.2.2 Type of brain imaging for people with suspected TIA

1.2.2.1 People who have had a suspected TIA who need brain imaging (that is, those in whom vascular territory or pathology is uncertain) should undergo diffusion-weighted MRI except where contraindicated[14], in which case CT (computed tomography) scanning should be used.

1.2.3 Early carotid imaging in people with acute non-disabling stroke or TIA

1.2.3.1 All people with suspected non-disabling stroke or TIA who after specialist assessment are considered as candidates for carotid endarterectomy should have carotid imaging within 1 week of onset of symptoms. People who present more than 1 week after their last symptom of TIA has resolved should be managed using the lower-risk pathway.

1.2.4 Urgent carotid endarterectomy and carotid stenting

1.2.4.1 People with stable neurological symptoms from acute non-disabling stroke or TIA who have symptomatic carotid stenosis of 50–99% according to the NASCET (North American Symptomatic Carotid Endarterectomy Trial) criteria, or 70–99% according to the ECST (European Carotid Surgery Trialists' Collaborative Group) criteria, should:

  • be assessed and referred for carotid endarterectomy within 1 week of onset of stroke or TIA symptoms

  • undergo surgery within a maximum of 2 weeks of onset of stroke or TIA symptoms

  • receive best medical treatment (control of blood pressure, antiplatelet agents, cholesterol lowering through diet and drugs, lifestyle advice).

1.2.4.2 People with stable neurological symptoms from acute non-disabling stroke or TIA who have symptomatic carotid stenosis of less than 50% according to the NASCET criteria, or less than 70% according to the ECST criteria, should:

  • not undergo surgery

  • receive best medical treatment (control of blood pressure, antiplatelet agents, cholesterol lowering through diet and drugs, lifestyle advice).

1.2.4.3 Carotid imaging reports should clearly state which criteria (ECST or NASCET) were used when measuring the extent of carotid stenosis.

1.3 Specialist care for people with acute stroke

This section provides recommendations about the optimum care for people with acute stroke: where they should be cared for and how soon they should undergo brain imaging.

1.3.1 Specialist stroke units

1.3.1.1 All people with suspected stroke should be admitted directly to a specialist acute stroke unit[15] following initial assessment, either from the community or from the A&E department.

1.3.2 Brain imaging for the early assessment of people with acute stroke

1.3.2.1 Brain imaging should be performed immediately[16] for people with acute stroke if any of the following apply:

  • indications for thrombolysis or early anticoagulation treatment

  • on anticoagulant treatment

  • a known bleeding tendency

  • a depressed level of consciousness (Glasgow Coma Score below 13)

  • unexplained progressive or fluctuating symptoms

  • papilloedema, neck stiffness or fever

  • severe headache at onset of stroke symptoms.

1.3.2.2 For all people with acute stroke without indications for immediate brain imaging, scanning should be performed as soon as possible[17].

1.4 Pharmacological treatments for people with acute stroke

Urgent treatment has been shown to improve outcome in stroke. This section contains recommendations about urgent pharmacological treatment in people with acute stroke.

1.4.1 Thrombolysis with alteplase

1.4.1.1 Alteplase is recommended within its marketing authorisation for treating acute ischaemic stroke in adults if:

  • treatment is started as early as possible within 4.5 hours of onset of stroke symptoms, and

  • intracranial haemorrhage has been excluded by appropriate imaging techniques[18].

1.4.1.2 Alteplase should be administered only within a well organised stroke service with:

  • staff trained in delivering thrombolysis and in monitoring for any complications associated with thrombolysis

  • level 1 and level 2 nursing care staff trained in acute stroke and thrombolysis[19]

  • immediate access to imaging and re-imaging, and staff trained to interpret the images.

1.4.1.3 Staff in A&E departments, if appropriately trained and supported, can administer alteplase[20] for the treatment of acute ischaemic stroke provided that patients can be managed within an acute stroke service with appropriate neuroradiological and stroke physician support.

1.4.1.4 Protocols should be in place for the delivery and management of thrombolysis, including post-thrombolysis complications.

1.4.2 Aspirin and anticoagulant treatment

People with acute ischaemic stroke

1.4.2.1 All people presenting with acute stroke who have had a diagnosis of primary intracerebral haemorrhage excluded by brain imaging should, as soon as possible but certainly within 24 hours, be given:

  • aspirin 300 mg orally if they are not dysphagic or

  • aspirin 300 mg rectally or by enteral tube if they are dysphagic.

    Thereafter, aspirin 300 mg should be continued until 2 weeks after the onset of stroke symptoms, at which time definitive long-term antithrombotic treatment should be initiated. People being discharged before 2 weeks can be started on long-term treatment earlier.

1.4.2.2 Any person with acute ischaemic stroke for whom previous dyspepsia associated with aspirin is reported should be given a proton pump inhibitor in addition to aspirin.

1.4.2.3 Any person with acute ischaemic stroke who is allergic to or genuinely intolerant of aspirin[21] should be given an alternative antiplatelet agent.

1.4.2.4 Anticoagulation treatment should not be used routinely[22] for the treatment of acute stroke.

People with acute venous stroke

1.4.2.5 People diagnosed with cerebral venous sinus thrombosis (including those with secondary cerebral haemorrhage) should be given full-dose anticoagulation treatment (initially full-dose heparin and then warfarin [INR 2–3]) unless there are comorbidities that preclude its use.

People with stroke associated with arterial dissection

1.4.2.6 People with stroke secondary to acute arterial dissection should be treated with either anticoagulants or antiplatelet agents, preferably as part of a randomised controlled trial to compare the effects of the two treatments.

People with acute ischaemic stroke associated with antiphospholipid syndrome

1.4.2.7 People with antiphospholipid syndrome who have an acute ischaemic stroke should be managed in same way as people with acute ischaemic stroke without antiphospholipid syndrome[23].

Reversal of anticoagulation treatment in people with haemorrhagic stroke

1.4.2.8 Clotting levels in people with a primary intracerebral haemorrhage who were receiving anticoagulation treatment before their stroke (and have elevated INR) should be returned to normal as soon as possible, by reversing the effects of the anticoagulation treatment using a combination of prothrombin complex concentrate and intravenous vitamin K.

1.4.3 Anticoagulation treatment for other comorbidities

1.4.3.1 People with disabling ischaemic stroke who are in atrial fibrillation should be treated with aspirin 300 mg for the first 2 weeks before considering anticoagulation treatment.

1.4.3.2 In people with prosthetic valves who have disabling cerebral infarction and who are at significant risk of haemorrhagic transformation, anticoagulation treatment should be stopped for 1 week and aspirin 300 mg substituted.

1.4.3.3 People with ischaemic stroke and symptomatic proximal deep vein thrombosis or pulmonary embolism should receive anticoagulation treatment in preference to treatment with aspirin unless there are other contraindications to anticoagulation.

1.4.3.4 People with haemorrhagic stroke and symptomatic deep vein thrombosis or pulmonary embolism should have treatment to prevent the development of further pulmonary emboli using either anticoagulation or a caval filter.

1.4.4 Statin treatment

1.4.4.1 Immediate initiation of statin treatment is not recommended in people with acute stroke[24].

1.4.4.2 People with acute stroke who are already receiving statins should continue their statin treatment.

1.5 Maintenance or restoration of homeostasis

A key element of care for people with acute stroke is the maintenance of cerebral blood flow and oxygenation to prevent further brain damage after stroke. This section contains recommendations on oxygen supplementation, maintenance of normoglycaemia, and acute blood pressure manipulation.

1.5.1 Supplemental oxygen therapy

1.5.1.1 People who have had a stroke should receive supplemental oxygen 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.

1.5.2 Blood sugar control

1.5.2.1 People with acute stroke should be treated to maintain a blood glucose concentration between 4 and 11 mmol/litre.

1.5.2.2 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[25].

1.5.3 Blood pressure control

1.5.3.1 Anti-hypertensive treatment in people with acute stroke is recommended only if there is a hypertensive emergency with one or more of the following serious concomitant medical issues:

  • hypertensive encephalopathy

  • hypertensive nephropathy

  • hypertensive cardiac failure/myocardial infarction

  • aortic dissection

  • pre-eclampsia/eclampsia

  • intracerebral haemorrhage with systolic blood pressure over 200 mmHg.

1.5.3.2 Blood pressure reduction to 185/110 mmHg or lower should be considered in people who are candidates for thrombolysis.

1.6 Nutrition and hydration

Many people with acute stroke are unable to swallow safely, and may require supplemental hydration and nutrition. This section provides recommendations on assessment of swallowing, hydration and nutrition.

1.6.1 Assessment of swallowing function

1.6.1.1 On admission, people with acute stroke should have their swallowing screened by an appropriately trained healthcare professional before being given any oral food, fluid or medication.

1.6.1.2 If the admission screen indicates problems with swallowing, the person should have a specialist assessment of swallowing, preferably within 24 hours of admission and not more than 72 hours afterwards.

1.6.1.3 People with suspected aspiration on specialist assessment, or who require tube feeding or dietary modification for 3 days, should be:

  • re-assessed and considered for instrumental examination

  • referred for dietary advice.

1.6.1.4 People with acute stroke who are unable to take adequate nutrition and fluids orally should:

  • receive tube feeding with a nasogastric tube within 24 hours of admission

  • be considered for a nasal bridle tube or gastrostomy if they are unable to tolerate a nasogastric tube

  • be referred to an appropriately trained healthcare professional for detailed nutritional assessment, individualised advice and monitoring.

1.6.2 Oral nutritional supplementation

1.6.2.1 All hospital inpatients on admission should be screened for malnutrition and the risk of malnutrition. Screening should be repeated weekly for inpatients[26].

1.6.2.2 Screening should assess body mass index (BMI) and percentage unintentional weight loss and should also consider the time over which nutrient intake has been unintentionally reduced and/or the likelihood of future impaired nutrient intake. The Malnutrition Universal Screening Tool (MUST), for example, may be used to do this[26].

1.6.2.3 When screening for malnutrition and the risk of malnutrition, healthcare professionals should be aware that dysphagia, poor oral health and reduced ability to self-feed will affect nutrition in people with stroke.

1.6.2.4 Screening for malnutrition and the risk of malnutrition should be carried out by healthcare professionals with appropriate skills and training[26].

1.6.2.5 Routine nutritional supplementation is not recommended for people with acute stroke who are adequately nourished on admission.

1.6.2.6 Nutrition support should be initiated for people with stroke who are at risk of malnutrition. This may include oral nutritional supplements, specialist dietary advice and/or tube feeding.

1.6.2.7 All people with acute stroke should have their hydration assessed on admission, reviewed regularly and managed so that normal hydration is maintained.

1.7 Early mobilisation and optimum positioning of people with acute stroke

Early mobilisation is considered a key element of acute stroke care. Sitting up will help to maintain oxygen saturation and reduce the likelihood of hypostatic pneumonia.

1.7.1.1 People with acute stroke should be mobilised as soon as possible (when their clinical condition permits) as part of an active management programme in a specialist stroke unit.

1.7.1.2 People with acute stroke should be helped to sit up as soon as possible (when their clinical condition permits).

1.8 Avoidance of aspiration pneumonia

Aspiration pneumonia is a complication of stroke that is associated with increased mortality and poor outcomes.

1.8.1.1 In people with dysphagia, food and fluids should be given in a form that can be swallowed without aspiration, following specialist assessment of swallowing.

1.9 Surgery for people with acute stroke

There is evidence that neurosurgical treatment may be indicated for a very small number of carefully selected people with stroke. This section contains recommendations for surgical intervention in people with intracerebral haemorrhage or severe middle cerebral artery infarction.

1.9.1 Surgical referral for acute intracerebral haemorrhage

1.9.1.1 Stroke services should agree protocols for the monitoring, referral and transfer of people to regional neurosurgical centres for the management of symptomatic hydrocephalus.

1.9.1.2 People with intracranial haemorrhage should be monitored by specialists in neurosurgical or stroke care for deterioration in function and referred immediately for brain imaging when necessary.

1.9.1.3 Previously fit people should be considered for surgical intervention following primary intracranial haemorrhage if they have hydrocephalus.

1.9.1.4 People with any of the following rarely require surgical intervention and should receive medical treatment initially:

  • small deep haemorrhages

  • lobar haemorrhage without either hydrocephalus or rapid neurological deterioration

  • a large haemorrhage and significant comorbidities before the stroke

  • a score on the Glasgow Coma Scale of below 8 unless this is because of hydrocephalus

  • posterior fossa haemorrhage.

1.9.2 Surgical referral for decompressive hemicraniectomy

1.9.2.1 People with middle cerebral artery infarction who meet all of the criteria below should be considered for decompressive hemicraniectomy. They should be referred within 24 hours of onset of symptoms and treated within a maximum of 48 hours.

  • Aged 60 years or under.

  • Clinical deficits suggestive of infarction in the territory of the middle cerebral artery, with a score on the National Institutes of Health Stroke Scale (NIHSS) of above 15.

  • Decrease in the level of consciousness to give a score of 1 or more on item 1a of the NIHSS.

  • Signs on CT of an infarct of at least 50% of the middle cerebral artery territory, with or without additional infarction in the territory of the anterior or posterior cerebral artery on the same side, or infarct volume greater than 145 cm3 as shown on diffusion-weighted MRI.

1.9.2.2 People who are referred for decompressive hemicraniectomy should be monitored by appropriately trained professionals skilled in neurological assessment.

More information

You can also see this guideline in the NICE pathways on stroke and blood transfusion.

To find out what NICE has said on topics related to this guideline, see our web page on stroke and transient ischaemic attack.

See also the guideline committee's discussion and the evidence reviews (in the full guideline), and information about how the guideline was developed, including details of the committee.



[9] These scoring systems exclude certain populations that may be at particularly high risk of stroke, such as those with recurrent TIAs and those on anticoagulation treatment, who also need urgent evaluation. They also may not be relevant to patients who present late.

[10] Specialist assessment includes exclusion of stroke mimics, identification of vascular treatment, identification of likely causes, and appropriate investigation and treatment.

[11] Examples where brain imaging is helpful in the management of TIA are: people being considered for carotid endarterectomy where it is uncertain whether the stroke is in the anterior or posterior circulation; people with TIA where haemorrhage needs to be excluded, for example long duration of symptoms or people on anticoagulants; where an alternative diagnosis (for example migraine, epilepsy or tumour) is being considered.

[12] The GDG felt that urgent brain imaging is defined as imaging that takes place 'within 24 hours of onset of symptoms'. This is in line with the National Stroke Strategy.

[13] The GDG felt that brain imaging in people with a lower risk of stroke should take place 'within 1 week of onset of symptoms'. This is in line with the National Stroke Strategy.

[14] Contraindications to MRI include people who have any of the following: a pacemaker, shrapnel, some brain aneurysm clips and heart valves, metal fragments in eyes, severe claustrophobia.

[15] An acute stroke unit is a discrete area in the hospital that is staffed by a specialist stroke multidisciplinary team. It has access to equipment for monitoring and rehabilitating patients. Regular multidisciplinary team meetings occur for goal setting.

[16] The GDG felt that 'immediately' is defined as 'ideally the next slot and definitely within 1 hour, whichever is sooner', in line with the National Stroke Strategy.

[17] The GDG felt that 'as soon as possible' is defined as 'within a maximum of 24 hours after onset of symptoms'.

[18] This recommendation is from NICE's guidance on alteplase for treating acute ischaemic stroke.

[19] See NHS Data Dictionary, 'Critical care level' [online].

[20] In accordance with its marketing authorisation.

[21] 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.

[22] 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.

[23] There was insufficient evidence to support any recommendation on the safety and efficacy of anticoagulants versus antiplatelets for the treatment of people with acute ischaemic stroke associated with antiphospholipid syndrome.

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

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

[26] This recommendation is adapted from 'Nutrition support in adults: oral nutrition support, enteral tube feeding and parenteral nutrition' (NICE clinical guideline 32).

  • National Institute for Health and Care Excellence (NICE)