Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.
2 min synopsisUK scopeSources checked 12 Sept 2026Clinical review pending
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Treat the brain event first
New or ongoing focal neurological deficit is an acute stroke emergency, even when carotid stenosis is already known.
Action: Activate the hyperacute stroke pathway immediately for brain imaging and reperfusion assessment; carotid prevention must not delay thrombectomy or thrombolysis decisions.
Synopsis
Recognise symptomatic extracranial carotid disease, start safe early prevention, and identify patients who need urgent endarterectomy assessment.
Treat new focal neurological symptoms as stroke first: use the emergency pathway, exclude haemorrhage and assess reperfusion eligibility before carotid prevention.
Suspected TIA needs immediate aspirin 300 mg daily unless contraindicated and immediate specialist referral for assessment within 24 hours; do not use ABCD2 to delay referral.
Stable non-disabling stroke or TIA with ipsilateral 50–99% NASCET symptomatic stenosis needs urgent vascular referral, best medical treatment and consideration of CEA, ideally within 14 days when suitable.
Key red flags
Ongoing weakness, aphasia, neglect, visual loss or reduced consciousness requires immediate acute stroke assessment.
A fluctuating or repeatedly recurring deficit may represent unstable cerebral perfusion or continuing embolisation and needs urgent specialist review.
A large infarct, haemorrhagic transformation, major disabling deficit or impaired consciousness changes the safety and timing of carotid intervention.
Active stroke deficit
Persistent or evolving focal neurological loss requires hyperacute stroke assessment before any preventive carotid decision.
High-risk brain injury
Large territorial infarction, haemorrhage, impaired consciousness or major disability raises perioperative haemorrhage risk and can justify deferral.
Investigation priorities
01
Urgent brain imagingFirst step
Exclude haemorrhage, assess infarct burden and support reperfusion decisions
Management branches
ManagementRecent stable TIA or minor stroke
Ipsilateral retinal or cerebral symptoms have resolved or stabilised without major disability
Refer immediately to a stroke specialist pathway; suspected TIA should be assessed within 24 hours and receives aspirin 300 mg daily unless contraindicated.
Obtain urgent brain and carotid imaging according to the presentation, documenting side, degree and NASCET or ECST measurement convention.
Key medicines
AspirinFor suspected TIA, give 300 mg orally once daily immediately unless contraindicated; after acute ischaemic stroke, give 300 mg within 24 hours once haemorrhage is excluded and continue to 14 days or earlier discharge review.Check active bleeding, aspirin hypersensitivity, previous severe aspirin dyspepsia, anticoagulants and planned reperfusion or surgery. Use a safe oral, enteral or rectal route after swallowing assessment; add a proton-pump inhibitor for previous aspirin-associated dyspepsia after checking interactions. After intravenous thrombolysis, withhold antiplatelets for the first 24 hours; reassess and obtain follow-up brain imaging excluding haemorrhage before initiation.
ClopidogrelFor the selected product, start within 24 hours of minor ischaemic stroke (NIHSS ≤3) or moderate-to-high-risk TIA (ABCD2 ≥4): clopidogrel 300 mg orally once as a loading dose, then 75 mg once daily with aspirin 75–100 mg once daily for 21 days, followed by single antiplatelet therapy. This eligibility criterion must not be used to delay any suspected-TIA referral; peri-CEA use follows the specialist carotid protocol.Do not apply this product DAPT regimen to non-minor stroke, planned thrombolysis, anticoagulation or CEA without specialist direction. Contraindications include active pathological bleeding and severe hepatic impairment. Review bleeding, blood count symptoms, interacting anticoagulants or NSAIDs, and avoid routine omeprazole or esomeprazole because CYP2C19 inhibition can reduce activation.
National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 12 Sept 2026; clinical approval remains outstanding.