Recommendations

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.

Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off-label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

NICE has also produced patient decision aids on decompressive hemicraniectomy.

1.1 Rapid recognition of symptoms and diagnosis

Prompt recognition of symptoms of stroke and transient ischaemic attack

1.1.1 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). [2008]

1.1.2 Exclude hypoglycaemia in people with sudden onset of neurological symptoms as the cause of these symptoms. [2008]

1.1.3 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). [2008]

Initial management of suspected and confirmed TIA

1.1.4 Offer aspirin (300 mg daily), unless contraindicated, to people who have had a suspected TIA, to be started immediately. [2019]

1.1.5 Refer immediately people who have had a suspected TIA for specialist assessment and investigation, to be seen within 24 hours of onset of symptoms. [2019]

1.1.6 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. [2019]

1.1.7 Offer secondary prevention, in addition to aspirin, as soon as possible after the diagnosis of TIA is confirmed. [2008, amended 2019]

To find out why the committee made the 2019 recommendation on offering aspirin and how it might affect practice, see rationale and impact.

To find out why the committee made the other 2019 recommendations on initial management of suspected and confirmed TIA and how they might affect practice, see rationale and impact.

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

Suspected TIA

1.2.1 Do not offer CT brain scanning to people with a suspected TIA unless there is clinical suspicion of an alternative diagnosis that CT could detect. [2019]

1.2.2 After specialist assessment in the TIA clinic, consider MRI (including diffusion-weighted and blood-sensitive sequences) to determine the territory of ischaemia, or to detect haemorrhage or alternative pathologies. If MRI is done, perform it on the same day as the assessment. [2019]

To find out why the committee made the 2019 recommendations on imaging for people who have had a suspected TIA and how they might affect practice, see rationale and impact.

Carotid imaging

1.2.3 Everyone with TIA who after specialist assessment is considered as a candidate for carotid endarterectomy should have urgent carotid imaging. [2008, amended 2019]

Urgent carotid endarterectomy

1.2.4 Ensure that people with stable neurological symptoms from acute non-disabling stroke or TIA who have symptomatic carotid stenosis of 50 to 99% according to the NASCET (North American Symptomatic Carotid Endarterectomy Trial) criteria:

  • are assessed and referred urgently for carotid endarterectomy to a service following current national standards[1]

  • receive best medical treatment (control of blood pressure, antiplatelet agents, cholesterol lowering through diet and drugs, lifestyle advice). [2008, amended 2019]

1.2.5 Ensure that 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 European Carotid Surgery Trial (ECST) criteria:

  • do not have surgery

  • receive best medical treatment (control of blood pressure, antiplatelet agents, cholesterol lowering through diet and drugs, lifestyle advice). [2008]

1.2.6 Ensure that carotid imaging reports clearly state which criteria (ECST or NASCET) were used when measuring the extent of carotid stenosis. [2008]

1.3 Specialist care for people with acute stroke

Specialist stroke units

1.3.1 Admit everyone with suspected stroke directly to a specialist acute stroke unit[2] after initial assessment, from either the community, the emergency department, or outpatient clinics. [2008]

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

1.3.2 Perform brain imaging immediately[3] with a non-enhanced CT for people with suspected acute stroke if any of the following apply:

  • indications for thrombolysis or thrombectomy

  • 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.

    If thrombectomy might be indicated, perform imaging with CT contrast angiography following initial non-enhanced CT. Add CT perfusion imaging (or MR equivalent) if thrombectomy might be indicated beyond 6 hours of symptom onset. [2008, amended 2019]

1.3.3 Perform scanning as soon as possible and within 24 hours of symptom onset in everyone with suspected acute stroke without indications for immediate brain imaging. [2008]

1.4 Pharmacological treatments and thrombectomy for people with acute stroke

Thrombolysis with alteplase for people with acute ischaemic stroke

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

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

  • intracranial haemorrhage has been excluded by appropriate imaging techniques. [2008]

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

1.4.2 Administer alteplase only within a well organised stroke service with:

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

  • nursing staff trained in acute stroke and thrombolysis to provide level 1 and level 2 care[4]

  • immediate access to imaging and re-imaging, and staff trained to interpret the images. [2008, amended 2019]

1.4.3 Staff in emergency departments, if appropriately trained and supported, can administer alteplase[5] for the treatment of ischaemic stroke provided that patients can be managed within an acute stroke service with appropriate neuroradiological and stroke physician support. [2008]

1.4.4 Ensure that protocols are in place for delivering and managing intravenous thrombolysis, including post-thrombolysis complications. [2008]

Thrombectomy for people with acute ischaemic stroke

1.4.5 Offer thrombectomy[6] as soon as possible and within 6 hours of symptom onset, together with intravenous thrombolysis (if not contraindicated and within the licensed time window), to people who have:

  • acute ischaemic stroke and

  • confirmed occlusion of the proximal anterior circulation demonstrated by computed tomographic angiography (CTA) or magnetic resonance angiography (MRA)

    taking into account the factors in recommendation 1.4.8. [2019]

1.4.6 Offer thrombectomy[6] as soon as possible to people who were last known to be well between 6 hours and 24 hours previously (including wake-up strokes):

  • who have acute ischaemic stroke and confirmed occlusion of the proximal anterior circulation demonstrated by CTA or MRA and

  • if there is the potential to salvage brain tissue, as shown by imaging such as CT perfusion or diffusion-weighted MRI sequences showing limited infarct core volume

    taking into account the factors in recommendation 1.4.8. [2019]

1.4.7 Consider thrombectomy[6] together with intravenous thrombolysis (where not contraindicated and within the licensed time window) as soon as possible for people last known to be well up to 24 hours previously (including wake-up strokes):

  • who have acute ischaemic stroke and confirmed occlusion of the proximal posterior circulation (that is, basilar or posterior cerebral artery) demonstrated by CTA or MRA and

  • if there is the potential to salvage brain tissue, as shown by imaging such as CT perfusion or diffusion-weighted MRI sequences showing limited infarct core volume

    taking into account the factors in recommendation 1.4.8. [2019]

1.4.8 Take into account the person's overall clinical status and the extent of established infarction on initial brain imaging to inform decisions about thrombectomy. Select people who have (in addition to the factors in recommendations 1.4.5 to 1.4.7):

  • a pre-stroke functional status of less than 3 on the modified Rankin scale and

  • a score of more than 5 on the National Institutes of Health Stroke Scale (NIHSS). [2019]

To find out why the committee made the 2019 recommendations on thrombectomy for people with acute ischaemic stroke and how they might affect practice, see rationale and impact.

Aspirin and anticoagulant treatment

People with acute ischaemic stroke

1.4.9 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. [2008]

1.4.10 Offer a proton pump inhibitor, in addition to aspirin, to anyone with acute ischaemic stroke for whom previous dyspepsia associated with aspirin is reported. [2008]

1.4.11 Offer an alternative antiplatelet agent to anyone with acute ischaemic stroke who is allergic to or genuinely intolerant of aspirin[7]. [2008]

1.4.12 Do not use anticoagulation treatment routinely[8] for the treatment of acute stroke. [2008]

People with acute venous stroke

1.4.13 Offer people diagnosed with cerebral venous sinus thrombosis (including those with secondary cerebral haemorrhage) full-dose anticoagulation treatment (initially full-dose heparin and then warfarin [international normalised ratio 2 to 3]) unless there are comorbidities that preclude its use. [2008]

People with stroke associated with arterial dissection

1.4.14 Offer either anticoagulants or antiplatelet agents to people who have stroke secondary to acute arterial dissection. [2008, amended 2019]

People with acute ischaemic stroke associated with antiphospholipid syndrome

1.4.15 Manage acute ischaemic stroke associated with antiphospholipid syndrome in the same way as acute ischaemic stroke without antiphospholipid syndrome[9]. [2008]

Reversal of anticoagulation treatment in people with haemorrhagic stroke

1.4.16 Return clotting levels to normal as soon as possible in people with a primary intracerebral haemorrhage who were receiving warfarin before their stroke (and have elevated international normalised ratio). Do this by reversing the effects of the warfarin using a combination of prothrombin complex concentrate and intravenous vitamin K. [2008, amended 2019]

Anticoagulation treatment for other comorbidities

1.4.17 Ensure that people with disabling ischaemic stroke who are in atrial fibrillation are treated with aspirin 300 mg for the first 2 weeks before anticoagulation treatment is considered. [2008]

1.4.18 For people with prosthetic valves who have disabling cerebral infarction and who are at significant risk of haemorrhagic transformation, stop anticoagulation treatment for 1 week and substitute aspirin 300 mg. [2008]

1.4.19 Ensure that people with ischaemic stroke and symptomatic proximal deep vein thrombosis or pulmonary embolism receive anticoagulation treatment in preference to treatment with aspirin unless there are other contraindications to anticoagulation. [2008]

1.4.20 Treat people who have haemorrhagic stroke and symptomatic deep vein thrombosis or pulmonary embolism to prevent the development of further pulmonary emboli using either anticoagulation or a caval filter. [2008]

Statin treatment

1.4.21 Immediate initiation of statin treatment is not recommended in people with acute stroke[10]. [2008]

1.4.22 Continue statin treatment in people with acute stroke who are already receiving statins. [2008]

1.5 Maintenance or restoration of homeostasis

Supplemental oxygen therapy

1.5.1 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. [2008]

Blood sugar control

1.5.2 Maintain a blood glucose concentration between 4 and 11 mmol/litre in people with acute stroke. [2008]

1.5.3 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. [2008]

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

Blood pressure control for people with acute intracerebral haemorrhage

1.5.4 Offer rapid blood pressure lowering to people with acute intracerebral haemorrhage who do not have any of the exclusions listed in recommendation 1.5.6 and who:

  • present within 6 hours of symptom onset and

  • have a systolic blood pressure between 150 and 220 mmHg.

    Aim for a systolic blood pressure target of 130 to 140 mmHg within 1 hour of starting treatment and maintain this blood pressure for at least 7 days. [2019]

1.5.5 Consider rapid blood pressure lowering for people with acute intracerebral haemorrhage who do not have any of the exclusions listed in recommendation 1.5.6 and who:

  • present beyond 6 hours of symptom onset or

  • have a systolic blood pressure greater than 220 mmHg. [2019]

    Aim for a systolic blood pressure target of 130 to 140 mmHg within 1 hour of starting treatment and maintain this blood pressure for at least 7 days. [2019]

1.5.6 Do not offer rapid blood pressure lowering to people who:

  • have an underlying structural cause (for example, tumour, arteriovenous malformation or aneurysm)

  • have a score on the Glasgow Coma Scale of below 6

  • are going to have early neurosurgery to evacuate the haematoma

  • have a massive haematoma with a poor expected prognosis. [2019]

To find out why the committee made the 2019 recommendations on blood pressure control for people with acute intracerebral haemorrhage and how they might affect practice, see rationale and impact.

Blood pressure control for people with acute ischaemic stroke

1.5.7 Anti-hypertensive treatment in people with acute ischaemic 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. [2008, amended 2019]

1.5.8 Blood pressure reduction to 185/110 mmHg or lower should be considered in people who are candidates for intravenous thrombolysis. [2008]

1.6 Nutrition and hydration

Assessment of swallowing function

1.6.1 On admission, ensure that people with acute stroke have their swallowing screened by an appropriately trained healthcare professional before being given any oral food, fluid or medication. [2008]

1.6.2 If the admission screen indicates problems with swallowing, ensure that the person has a specialist assessment of swallowing, preferably within 24 hours of admission and not more than 72 hours afterwards. [2008]

1.6.3 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. [2008]

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

  • receive tube feeding with a nasogastric tube within 24 hours of admission unless they have had thrombolysis

  • 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

  • have their oral medication reviewed to amend either the formulation or the route of administration. [2008, amended 2019]

Oral nutritional supplementation

1.6.5 Screen all hospital inpatients on admission for malnutrition and the risk of malnutrition. Repeat screening weekly for inpatients. [2008]

[This recommendation is adapted from the NICE guideline on nutrition support for adults.]

1.6.6 Screening should assess body mass index (BMI) and percentage unintentional weight loss. It should also consider the time over which a 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. [2008]

[This recommendation is adapted from the NICE guideline on nutrition support for adults.]

1.6.7 When screening for malnutrition and the risk of malnutrition, be aware that dysphagia, poor oral health and reduced ability to self-feed will affect nutrition in people with stroke. [2008]

1.6.8 Screening for malnutrition and the risk of malnutrition should be carried out by healthcare professionals with appropriate skills and training. [2008]

[This recommendation is adapted from the NICE guideline on nutrition support for adults.]

1.6.9 Routine nutritional supplementation is not recommended for people with acute stroke who are adequately nourished on admission. [2008]

1.6.10 Start nutrition support for people with stroke who are at risk of malnutrition. This may include oral nutritional supplements, specialist dietary advice and/or tube feeding. [2008]

Hydration

1.6.11 Assess, on admission, the hydration of everyone with acute stroke. Review hydration regularly and manage it so that normal hydration is maintained. [2008]

1.7 Optimal positioning and early mobilisation for people with acute stroke

Optimal positioning

1.7.1 Assess the individual clinical needs and personal preferences of people with acute stroke to determine their optimal head position. Take into account factors such as their comfort, physical and cognitive abilities and postural control. [2019]

To find out why the committee made the 2019 recommendation on optimal positioning for people with acute stroke and how it might affect practice, see rationale and impact.

Early mobilisation

1.7.2 Help people with acute stroke to sit out of bed, stand or walk as soon as their clinical condition permits as part of an active management programme in a specialist stroke unit. [2019]

1.7.3 If people need help to sit out of bed, stand or walk, do not offer high-intensity mobilisation in the first 24 hours after symptom onset. [2019]

To find out why the committee made the 2019 recommendations on early mobilisation for people with acute stroke and how they might affect practice, see rationale and impact.

1.8 Avoiding aspiration pneumonia

1.8.1 To avoid aspiration pneumonia, give food, fluids and medication to people with dysphagia in a form that can be swallowed without aspiration, after specialist assessment of swallowing. (See recommendation 1.6.2.) [2008]

1.9 Surgery for people with acute stroke

Acute intracerebral haemorrhage

1.9.1 Stroke services should agree protocols for monitoring, referring and transferring people to regional neurosurgical centres for the management of symptomatic hydrocephalus. [2008]

1.9.2 People with intracerebral haemorrhage should be monitored by specialists in neurosurgical or stroke care for deterioration in function and referred immediately for brain imaging when necessary. [2008]

1.9.3 Previously fit people should be considered for surgical intervention following primary intracerebral haemorrhage if they have hydrocephalus. [2008]

1.9.4 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. [2008]

Decompressive hemicraniectomy

1.9.5 Consider decompressive hemicraniectomy (which should be performed within 48 hours of symptom onset) for people with acute stroke who meet all of the following criteria:

  • clinical deficits that suggest infarction in the territory of the middle cerebral artery, with a score above 15 on the NIHSS

  • decreased level of consciousness, with 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

    • with infarct volume greater than 145 cm3, as shown on diffusion-weighted MRI scan. [2019]

1.9.6 Discuss the risks and benefits of decompressive hemicraniectomy with people or their family members or carers (as appropriate), taking into account their functional status before the stroke, and their wishes and preferences. [2019]

NICE has produced patient decision aids to support discussions about decompressive hemicraniectomy.

1.9.7 People who are referred for decompressive hemicraniectomy should be monitored by appropriately trained professionals skilled in neurological assessment. [2008]

To find out why the committee made the 2019 recommendations on surgical referral for decompressive hemicraniectomy for people with acute stroke and how they might affect practice, see rationale and impact.

Terms used in this guideline

This section defines terms that have been used in a particular way for this guideline. For other definitions, see the NICE glossary.

High-intensity mobilisation

High-intensity mobilisation refers to the very early mobilisation intervention from the AVERT trial. (Further details of the intervention performed in the trial can be found in the evidence review on very early mobilisation.) It includes mobilisation that:

  • begins within the first 24 hours of stroke onset

  • includes at least 3 additional out-of-bed sessions compared with usual care

  • focuses on sitting, standing and walking (that is, out of bed) activity.



[2] 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.

[3] The committee felt that 'immediately' is defined as 'ideally the next slot and definitely within 1 hour, whichever is sooner'.

[4] See NHS Data Dictionary, Critical care level.

[5] In accordance with its marketing authorisation.

[6] At the time of publication (May 2019), not all devices with a CE mark for thrombectomy are intended by the manufacturer for use as recommended here. The healthcare professional should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. Medicines and Healthcare products Regulatory Agency (MHRA) advice remains to use CE-marked devices for their intended purpose where possible. See guidance on off-label use of a medical device for further information.

[7] 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.

[8] 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.

[9] 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.

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

  • National Institute for Health and Care Excellence (NICE)