Synopsis
Identify acute ischaemic stroke rapidly, localise the neurological syndrome, and obtain the brain and vascular imaging needed for safe reperfusion decisions without avoidable delay.
- Stroke should be suspected when a focal neurological deficit begins suddenly, even when FAST is negative, symptoms are mild, the patient is young or posterior circulation features dominate.
- Record the exact last-known-well time, not merely the discovery time; wake-up and unknown-onset strokes may still be eligible for advanced-imaging-selected reperfusion.
- Stabilise airway, breathing and circulation, check capillary glucose, temperature, oxygen saturation and seizure activity, but run these actions in parallel with emergency stroke-team activation.
Key red flags
Falling consciousness, vomiting, new pupillary asymmetry or progressive hemiplegia may indicate large infarction, haemorrhagic transformation, seizure or raised intracranial pressure and needs immediate reassessment.
Investigation priorities
Find immediate mimics and correct physiological variables that worsen cerebral injury.
Management branches
A new sudden focal neurological deficit is present or has only partly improved.
- Activate the acute stroke team, record last-known-well and discovery time, establish premorbid function and obtain a concise witness history.
- Assess airway, breathing, circulation, capillary glucose, oxygen saturation, temperature and seizure activity while securing intravenous access without delaying transfer.
Key medicines
AspirinGive 300 mg orally, rectally or by enteral tube once daily after intracranial haemorrhage has been excluded, generally within 24 hours; wait 24 hours after thrombolysis and re-image first.
Intravenous labetalolUse protocol-led intravenous boluses or infusion only when blood pressure exceeds a reperfusion threshold or another emergency indication exists; exact dosing follows local stroke policy.