National Clinical Guideline for Stroke in Secondary Care

Overview 

This specialist Guidelines summary covers acute care, management of ischaemic stroke, and secondary prevention strategies such as anticoagulation and antiplatelet treatment.

This summary is for secondary care cardiologists and neurologists. A summary for primary care is also available. Please refer to the full guideline for the complete set of recommendations, which covers the organisation of stroke services, rehabilitation and recovery, and implementation of the guideline. 

This guideline was produced by the Intercollegiate Stroke Working Party and SIGN, and is endorsed for use in clinical practice by the Royal College of Physicians of London and the Royal College of Physicians of Ireland.

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Organisation of Stroke Services 

Organisation of Inpatient Stroke Services

• Acute stroke services should provide specialist multidisciplinary care for diagnosis, hyperacute and acute treatments, normalisation of homeostasis, early rehabilitation, prevention of complications, and secondary prevention
• Acute stroke services should have management protocols for the admission pathway, including links with the ambulance service, emergency stroke treatments, acute imaging, neurological and physiological monitoring, swallowing assessment, hydration and nutrition, vascular surgical referrals, rehabilitation, end-of-life (palliative) care, secondary prevention, the prevention and management of complications, communication with people with stroke and their family or carers, and discharge planning
• People with a diagnosis of stroke that was not made on admission should be transferred without delay to the part of the stroke service most appropriate to their needs
• Patients with acute neurological symptoms that resolve completely within 24 hours of onset (for example, suspected transient ischaemic attack [TIA]) should be given aspirin 300 mg immediately, unless contraindicated, and be assessed urgently within 24 hours by a stroke specialist clinician in a neurovascular clinic or an acute stroke unit.

Transfers of Care—General Principles

• Transfers of care for people with stroke between different teams or organisations should:
  • occur at the appropriate time, without delay
  • not require the person to provide information already given
  • ensure that all relevant information is transferred, especially concerning medication
  • maintain a set of person-centred goals
  • preserve any decisions about medical care made in the person’s best interest
• People with strokes should be:
  • involved in decisions about transfers of their care if they are able
  • offered copies of written communication between organisations and teams involved in their care
• Organisations and teams regularly involved in caring for people with stroke should use a common, agreed-upon terminology and set of data collection measures, assessments, and documentation.

Acute Care 

For details on pre-hospital care, please refer to primary care summary.

Management of TIA and Minor Stroke—Assessment and Diagnosis

• Patients with acute focal neurological symptoms that resolve completely within 24 hours of onset (for example, suspected TIA) should be given aspirin 300 mg immediately, unless contraindicated, and assessed urgently within 24 hours by a stroke specialist clinician in a neurovascular clinic or an acute stroke unit
• Healthcare professionals should not use assessment tools such as the ABCD2 score to stratify the risk of TIA, inform the urgency of referral, or provide subsequent treatment options
• Patients with suspected TIA that occurred more than a week previously should be assessed by a stroke specialist clinician as soon as possible, within 7 days
• Patients with suspected TIA and their family or carers should receive information about the recognition of stroke symptoms and the action to be taken if they occur
• Patients with suspected TIA should be assessed by a stroke specialist clinician before a decision on brain imaging is made, except when haemorrhage requires exclusion in patients taking an anticoagulant or with a bleeding disorder, when unenhanced computed tomography (CT) should be performed urgently
• For patients with suspected TIA, magnetic resonance imaging (MRI) should be the principal brain imaging modality for detecting the presence and/or distribution of brain ischaemia
• For patients with suspected TIA in whom brain imaging cannot be undertaken within 7 days of symptoms, an MRI using a blood-sensitive sequence, for example, susceptibility-weighted imaging (SWI) or T2*-weighted imaging, should be the preferred means of excluding haemorrhage.

Management of TIA and Minor Stroke—Treatment and Vascular Prevention

• Patients with minor ischaemic stroke or TIA should receive treatment for secondary prevention as soon as the diagnosis is confirmed, including:
  • support to modify lifestyle factors (smoking, alcohol consumption, diet, exercise)
  • antiplatelet or anticoagulant therapy
  • high-intensity statin therapy
  • blood pressure-lowering therapy with a thiazide-like diuretic, long-acting calcium channel blocker, or angiotensin-converting enzyme inhibitor
• Patients with TIA or minor ischaemic stroke should be given antiplatelet therapy, provided there is neither a contraindication nor a high risk of bleeding. The following regimens should be considered as soon as possible:
  • for patients within 24 hours of onset of TIA or minor ischaemic stroke and with a low risk of bleeding, the following dual antiplatelet therapy should be given:
    • clopidogrel (initial dose 300 mg followed by 75 mg per day) plus aspirin (initial dose 300 mg followed by 75 mg per day for 21 days) followed by monotherapy with clopidogrel 75 mg once daily,
      OR
    • ticagrelor (initial dose 180 mg followed by 90 mg twice daily) plus aspirin (300 mg followed by 75 mg daily for 30 days) followed by antiplatelet monotherapy with ticagrelor 90 mg twice daily or clopidogrel 75 mg once daily, at the discretion of the prescriber
  • in patients with TIA or minor ischaemic stroke for whom dual antiplatelet therapy is not appropriate, clopidogrel 300 mg loading dose followed by 75 mg daily should be given
  • a proton pump inhibitor should be considered for concurrent use with dual antiplatelet therapy to reduce the risk of gastrointestinal haemorrhage
• For patients with recurrent TIA or stroke while taking clopidogrel, consideration should be given to clopidogrel resistance
• Patients with TIA or ischaemic stroke should receive high-intensity statin therapy (for example, atorvastatin 20–80 mg daily) started immediately
• Patients with non-disabling ischaemic stroke or TIA in atrial fibrillation (AF) should be anticoagulated as soon as intracranial bleeding has been excluded with an anticoagulant that has rapid onset, provided there are no other contraindications
• Patients with ischaemic stroke or TIA who, following specialist assessment, are considered candidates for carotid intervention should have carotid imaging performed within 24 hours of assessment. This includes carotid duplex ultrasound or computed tomography angiography (CTA) or magnetic resonance angiography (MRA)
• The degree of carotid artery stenosis should be reported using the North American Symptomatic Carotid Endarterectomy Trial (NASCET) method
• Patients with TIA or acute non-disabling ischaemic stroke with stable neurological symptoms who have symptomatic severe carotid stenosis of 50–99% (NASCET method) should:
  • be assessed and referred for carotid endarterectomy to be performed as soon as possible, within 7 days of the onset of symptoms, in a vascular surgical centre routinely participating in national audit
  • receive optimal medical treatment: control of blood pressure, antiplatelet treatment, cholesterol reduction through diet and medication, and lifestyle advice, including smoking cessation
• Patients with TIA or acute non-disabling ischaemic stroke who have mild or moderate carotid stenosis of <50% (NASCET method) should:
  • not undergo carotid intervention
  • receive optimal medical treatment: control of blood pressure, antiplatelet treatment, cholesterol reduction through diet and medication, and lifestyle advice, including smoking cessation
• Patients with recurrent attacks of transient focal neurological symptoms despite optimal medical treatment, in whom an embolic source has been excluded, should be reassessed for an alternative neurological diagnosis
• Patients who meet the criteria for carotid intervention but are unsuitable for open surgery (for example, inaccessible carotid bifurcation, re-stenosis following endarterectomy, radiotherapy-associated carotid stenosis) should be considered for carotid angioplasty and stenting
• Patients who have undergone carotid revascularisation should be reviewed post-operatively by a stroke clinician to optimise medical aspects of vascular secondary prevention.

Diagnosis and Treatment of Acute Stroke—Imaging

• Patients with suspected acute stroke should be admitted directly to a hyperacute stroke service and be assessed for emergency stroke treatment by a specialist clinician without delay
• Patients with suspected acute stroke should receive brain imaging as soon as possible (at most within 1 hour of arrival at the hospital)
• Interpretation of acute stroke imaging for decisions regarding reperfusion treatment should only be made by healthcare professionals who have received appropriate training
• Patients with ischaemic stroke who are potentially eligible for mechanical thrombectomy should have a CT angiogram from the aortic arch to the skull vertex immediately. This should not delay the administration of intravenous thrombolysis
• Patients with stroke with a delayed presentation for whom reperfusion is potentially indicated should have CT or MR perfusion as soon as possible (at most within 1 hour of arrival at the hospital). An alternative for patients who wake up with strokes is an MRI, which measures diffusion-weighted imaging fluid attenuated inversion recovery (DWI-FLAIR) mismatch
• MRI brain with stroke-specific sequences (DWI with SWI or T2*-weighted imaging) should be considered in patients with suspected acute stroke when there is diagnostic uncertainty.

Management of Ischaemic Stroke

• Patients with acute ischaemic stroke, regardless of age or stroke severity, in whom treatment can be started within 4.5 hours of known onset, should be considered for thrombolysis with alteplase or tenecteplase
• Patients with acute ischaemic stroke, regardless of age or stroke severity, who were last known to be well more than 4.5 hours earlier, should be considered for thrombolysis with alteplase if:
  • treatment can be started between 4.5–9 hours of known onset, or within 9 hours of the midpoint of sleep when they have woken with symptoms,
    AND
  • they have evidence from CT/MR perfusion (core-perfusion mismatch) or MRI (DWI-FLAIR mismatch) of the potential to salvage brain tissue (Table 1). This should be done irrespective of whether they have a large artery occlusion and require mechanical thrombectomy.

Table 1: Eligibility Criteria for Extending Thrombolysis to 4.5–9 hours and Wake-up Stroke

• Patients with acute ischaemic stroke who are otherwise eligible for treatment with thrombolysis should have their blood pressure reduced to <185/110 mmHg before treatment.
• Thrombolysis should only be administered within a well-organised stroke service that has:
  • processes throughout the emergency pathway to minimise delays to treatment and ensure that thrombolysis is administered as soon as possible after stroke onset
  • staff trained in the delivery of thrombolysis and monitoring for post-thrombolysis complications
  • nurse staffing levels equivalent to those required in level 1 or level 2 nursing care, with training in acute stroke and thrombolysis
  • timely access to appropriate imaging and trained staff
  • protocols in place for the management of post-thrombolysis complications
• Emergency medical staff, if appropriately trained and supported, should only administer thrombolysis for the treatment of acute ischaemic stroke, provided that patients can be subsequently managed within a hyperacute stroke service with appropriate neuroradiological and stroke specialist support
• Patients with acute ischaemic stroke eligible for mechanical thrombectomy should receive prior intravenous thrombolysis (unless contraindicated) irrespective of whether they have presented to an acute stroke centre or a thrombectomy centre. Every effort should be made to minimise processing times throughout the treatment pathway, and thrombolysis should not delay urgent transfer to a thrombectomy centre
• Patients with acute anterior circulation ischaemic stroke who were previously independent (mRS 0–2) should be considered for combination intravenous thrombolysis and intra-arterial clot extraction (using a stent retriever and/or aspiration techniques) if they have a proximal intracranial large artery occlusion causing a disabling neurological deficit (National Institutes of Health Stroke Scale [NIHSS] score of ≥6) and the procedure can begin within 6 hours of known onset
• Patients with acute anterior circulation ischaemic stroke and a contraindication to intravenous thrombolysis but not to thrombectomy who were previously independent should be considered for intra-arterial clot extraction (using a stent retriever and/or aspiration techniques) if they have a proximal intracranial large artery occlusion causing a disabling neurological deficit (NIHSS score of ≥6), and the procedure can begin within 6 hours of known onset
• Patients with acute anterior circulation ischaemic stroke and a proximal intracranial large artery occlusion (internal carotid artery [ICA] and/or the first segment of the middle cerebral artery [M1]) causing a disabling neurological deficit (NIHSS score of ≥6) of onset between 6 and 24 hours ago, including wake-up stroke, and with no previous disability (mRS 0 or 1) should be considered for intra-arterial clot extraction (using a stent retriever and/or aspiration techniques, combined with thrombolysis, if eligible) providing the following imaging criteria are met:
  • between 6 and 12 hours: an Alberta stroke programme early CT (ASPECTS) score of ≥3, irrespective of the core infarct size
  • between 12 and 24 hours: an ASPECTS score of ≥3 and a CT or MRI perfusion mismatch of >15 ml, irrespective of the core infarct size
• Clinicians interpreting brain imaging for eligibility for mechanical thrombectomy should have the appropriate knowledge and skills and should consider all the available information (for example, plain and angiographic images, colour maps, artificial intelligence [AI]-derived figures for core/penumbra, and mismatch overlays)
• Patients with acute ischaemic stroke in the posterior circulation within 12 hours of onset should be considered for mechanical thrombectomy (combined with thrombolysis, if eligible) if they have a confirmed intracranial vertebral or basilar artery occlusion and their NIHSS score is ≥10, combined with a favourable posterior circulation (PC)-ASPECTS score and Pons-Midbrain Index. Caution should be exercised when considering mechanical thrombectomy for patients presenting within 12–24 hours of onset and/or >80 years old, owing to the paucity of data in these groups
• The selection of anaesthetic technique for thrombectomy should be guided by local protocols for general anaesthesia, local anaesthesia, and conscious sedation. For further information, please refer to the full guideline
• Patients with middle cerebral artery (MCA) infarction who meet the criteria below should be considered for decompressive hemicraniectomy. Patients should be referred to neurosurgery within 24 hours of stroke onset and treated within 48 hours of stroke onset:
  • pre-stroke mRS score of 0 or 1
  • clinical deficits indicating infarction in the territory of the MCA
  • NIHSS score of >15
  • a decrease in the level of consciousness to a score of ≥1 on item 1a of the NIHSS
  • signs on CT of an infarct of at least 50% of the MCA territory, with or without additional infarction in the territory of the anterior or posterior cerebral artery on the same side, or infarct volume  >145 ml on MRI DWI
• Patients with acute ischaemic stroke treated with thrombolysis should be started on an antiplatelet agent after 24 hours unless contraindicated, once significant haemorrhage has been excluded
• Patients with disabling acute ischaemic stroke should be given aspirin 300 mg as soon as possible within 24 hours (unless contraindicated):
  • orally if they are not dysphagic
  • rectally or by enteral tube if they are dysphagic
  • afterwards, aspirin 300 mg daily should be continued until 2 weeks after the onset of stroke, at which time long-term antithrombotic treatment should be initiated. Patients being transferred to care at home before 2 weeks should start long-term treatment earlier
• Patients with acute ischaemic stroke reporting previous dyspepsia with an antiplatelet agent should be given a proton pump inhibitor in addition to aspirin
• Patients with acute ischaemic stroke who are allergic to or intolerant of aspirin should be given an alternative antiplatelet agent (for example, clopidogrel).

Management of Intracerebral Haemorrhage

• Patients with intracerebral haemorrhage (ICH) in association with vitamin K antagonist (VKA) treatment should have the anticoagulant urgently reversed with a combination of prothrombin complex concentrate and intravenous vitamin K
• Patients with ICH in association with direct oral anticoagulant (DOAC) treatment should have the anticoagulant urgently reversed. For patients taking dabigatran, idarucizumab should be used. If idarucizumab is unavailable, 4-factor prothrombin complex concentrate may be considered. For those taking factor Xa inhibitors, 4-factor prothrombin complex concentrate should be considered, and andexanet alfa may be considered in the context of a randomised controlled trial
• Patients with acute spontaneous ICH with a systolic blood pressure (BP) of 150–220 mmHg should be considered for urgent treatment within 6 hours of symptom onset using a locally agreed protocol for BP lowering, aiming to achieve a systolic BP between 130 and 139 mmHg within 1 hour and sustained for at least 7 days, unless:
  • the Glasgow Coma Scale score is ≤5
  • the haematoma is very large, and death is expected
  • a macrovascular or structural cause for the haematoma is identified
  • immediate surgery to evacuate the haematoma is planned, in which case BP should be managed according to a locally agreed protocol
• Patients with ICH should be admitted directly to a hyperacute stroke unit for monitoring of consciousness, and referred immediately for repeat brain imaging if deterioration occurs
• Patients with intracranial haemorrhage who develop hydrocephalus should be considered for surgical intervention, such as the insertion of an external ventricular drain
• Patients with ICH in whom the haemorrhage location or other imaging features suggest cerebral venous thrombosis should be investigated urgently with a CT or MR venogram
• The DIAGRAM score (or its components: age; ICH location; CTA result, where available; and the presence of white matter low attenuation [leukoaraiosis] on the admission non-contrast CT) should be considered to determine the likelihood of an underlying macrovascular cause and the potential benefit of intra-arterial cerebral angiography
• Early non-invasive cerebral angiography (CTA or MRA within 48 hours of onset) should be considered for all patients with acute spontaneous ICH aged 18–70 years who are independent, without a history of cancer, and not taking an anticoagulant, except if they are aged >45 years and have hypertension, and the haemorrhage is in the basal ganglia, thalamus, or posterior fossa
• If an early CTA or MRA is normal or inconclusive, an MRI or MRA with SWI should be considered at 3 months. Early CTA/MRA and MRI/MRA at 3 months may also be considered in patients not meeting these criteria where the probability of a macrovascular cause is felt to justify further investigation.

Management of Subarachnoid Haemorrhage

• Any person presenting with a sudden severe headache and an altered neurological state should have the diagnosis of subarachnoid haemorrhage investigated by:
  • immediate CT brain scan (also including CTA if a protocol is agreed upon with the neuroscience centre)
  • lumbar puncture 12 hours after ictus (or within 14 days if presentation is delayed) if the CT brain scan is negative and does not show any contraindications
  • spectrophotometry of the cerebrospinal fluid for xanthochromia
  • Patients with spontaneous subarachnoid haemorrhage should be referred immediately to a neuroscience centre and receive:
    • nimodipine 60 mg, 4 hourly, unless contraindicated
    • frequent neurological observation for signs of deterioration
• Following transfer to the neurosciences centre, patients with spontaneous subarachnoid haemorrhage should receive:
  • CTA or MRA (if this has not already been done by agreed protocol in the referring hospital) with or without intra-arterial angiography to identify the site of bleeding
  • specific treatment of any aneurysm related to the haemorrhage by endovascular embolisation or surgical clipping, if appropriate. Treatment to secure the aneurysm should be undertaken within 48 hours of ictus for patients of appropriate status (Hunt and Hess or World Federation of Neurological Sciences grades 1–3), or within a maximum of 48 hours of diagnosis if presentation was delayed
• After any immediate treatment, patients with subarachnoid haemorrhage should be monitored for the development of treatable complications, such as hydrocephalus and cerebral ischaemia
• After any immediate treatment, patients with subarachnoid haemorrhage should be assessed for hypertension treatment and smoking cessation
• Patients with residual symptoms or disabilities after definitive treatment of subarachnoid haemorrhage should receive specialist neurological rehabilitation, including appropriate clinical and neuropsychological support
• People with two or more first-degree relatives affected by aneurysmal subarachnoid haemorrhage and/or polycystic kidney disease should be referred to a neurovascular and/or neurogenetics specialist for information and advice regarding the risks and benefits of screening for cerebral aneurysms.

Cervical Artery Dissection

• Any patient suspected of cervical artery dissection should be investigated with CT or MR, including angiography
• Patients with acute ischaemic stroke suspected to be due to cervical arterial dissection should receive thrombolysis if they are otherwise eligible
• Patients with acute ischaemic stroke suspected to be due to cervical arterial dissection should be treated with either an anticoagulant or an antiplatelet agent for at least 3 months
• For patients with cervical arterial dissection treated with an anticoagulant, either a DOAC or a VKA may be used for three months
• For patients with acute ischaemic stroke or TIA secondary to cervical artery dissection, dual antiplatelet therapy with aspirin and clopidogrel may be considered for the first 21 days, to be followed by antiplatelet monotherapy until at least three months after onset.

Cerebral Venous Thrombosis

• Any patient suspected of cerebral venous thrombosis should be investigated with CT or MRI, including venography
• Patients with cerebral venous thrombosis (including those with secondary cerebral haemorrhage) should receive full-dose anticoagulation (initially full-dose heparin and then warfarin with a target international normalised ratio [INR] of 2–3) for at least three months, unless there are comorbidities that preclude their use.

Acute Stroke Care

• Patients with acute stroke should be admitted directly to a hyperacute stroke unit that has protocols to maintain normal physiological status and staff trained in their use
• Patients with acute stroke should have their clinical status monitored closely, including:
  • level of consciousness
  • blood glucose
  • blood pressure
  • oxygen saturation
  • hydration and nutrition
  • temperature
  • cardiac rhythm and rate
• Patients with acute stroke should only receive supplemental oxygen if their oxygen saturation is <95% and there is no contraindication
• Patients with acute stroke should have their hydration assessed using a standardised approach within 4 hours of arrival at the hospital, and should be reviewed regularly and managed so that normal hydration is maintained
• Patients with acute stroke should have their swallowing screened using a validated screening tool by a trained healthcare professional within 4 hours of arrival at the hospital and before being given any oral food, fluid, or medication
• Until a safe swallowing method is established, patients with dysphagia after an acute stroke should:
  • be immediately considered for alternative fluids
  • have a comprehensive specialist assessment of their swallowing
  • be considered for nasogastric tube feeding within 24 hours
  • be referred to a dietitian for specialist nutritional assessment, advice, and monitoring
  • receive adequate hydration, nutrition, and medication by alternative means
  • be referred to a pharmacist to review the formulation and administration of medication
• Patients with swallowing difficulties after acute stroke should only be given food, fluids, and medications in a form that can be swallowed without aspiration
• Patients with acute stroke should be treated to maintain a blood glucose concentration between 5 and 15 mmol/l, with close monitoring to avoid hypoglycaemia
• Patients with acute ischaemic stroke should only receive blood pressure-lowering treatment if there is an indication for emergency treatment, such as:
  • systolic blood pressure >185 mmHg or diastolic blood pressure >110 mmHg when the patient is otherwise eligible for treatment with thrombolysis
  • hypertensive encephalopathy
  • hypertensive nephropathy
  • hypertensive cardiac failure or myocardial infarction
  • aortic dissection
  • pre-eclampsia or eclampsia
• Patients with acute stroke admitted on antihypertensive medication should resume oral treatment once they are medically stable, and as soon as they can swallow medication safely
• Patients with acute ischaemic stroke should receive high-intensity statin treatment with atorvastatin (20–80 mg daily) as soon as they can swallow medication safely
• Patients with primary ICH should only be started on statin treatment based on their cardiovascular disease risk and not for secondary prevention of ICH.

Deep Vein Thrombosis and Pulmonary Embolism

• Patients with immobility after acute stroke should be offered intermittent pneumatic compression within 3 days of admission to the hospital for the prevention of deep vein thrombosis. Treatment should be continuous for 30 days or until the patient is mobile or discharged, whichever is sooner
• Patients with immobility after acute stroke should not be routinely given low molecular weight heparin or graduated compression stockings (either full-length or below-the-knee) for the prevention of deep vein thrombosis
• Patients with ischaemic stroke and symptomatic deep vein thrombosis or pulmonary embolism should receive anticoagulant treatment, provided there are no contraindications
• Patients with ICH and symptomatic deep vein thrombosis or pulmonary embolism should receive treatment with a vena caval filter.

Long-term Management and Secondary Prevention

For more information on blood pressure, lipid modification, and nutrition, please refer to the primary care summary.

Carotid Artery Stenosis 

• Following a stroke or TIA, the degree of carotid artery stenosis should be reported using the NASCET method
• People with non-disabling carotid artery territory stroke or TIA should be considered for carotid revascularisation, and if they agree with intervention:
  • they should have carotid imaging (duplex ultrasound, MRA, or CTA) performed urgently to assess the degree of stenosis
  • if the initial test identifies a relevant severe stenosis (≥50%), a second or repeat non-invasive imaging investigation should be performed to confirm the degree of stenosis. This confirmatory test should be carried out urgently to avoid delaying any intervention
• People with non-disabling carotid artery territory stroke or TIA should be considered for carotid revascularisation if the symptomatic internal carotid artery has a stenosis of ≥50%. The decision to offer carotid revascularisation should be:
  • based on individualised risk estimates taking account of factors such as the time from the event, gender, age, and the type of qualifying event
  • supported by risk tables or web-based risk calculators (for example, the Oxford University Stroke Prevention Research Unit calculator)
• People with non-disabling carotid artery territory stroke or TIA and carotid stenosis of <50% should not be offered revascularisation of the carotid artery
• Carotid endarterectomy for people with symptomatic carotid stenosis should be:
  • the treatment of choice, particularly for people who are ≥70 years of age, or for whom the intervention is planned within 7 days of stroke or TIA
  • performed in people who are neurologically stable and who are fit for surgery using either local or general anaesthetic, according to the person’s preference
  • performed as soon as possible and within 1 week of the first presentation
  • deferred for 72 hours in people treated with intravenous thrombolysis
  • only undertaken by a specialist surgeon in a vascular centre where the outcomes of carotid surgery are routinely audited
• Carotid angioplasty and stenting should be considered for people with symptomatic carotid stenosis who are:
  • unsuitable for open surgery (for example, high carotid bifurcation, symptomatic re-stenosis following endarterectomy, or radiotherapy-associated carotid stenosis),

    OR

  • <70 years of age and who have a preference for carotid artery stenting. The procedure should only be undertaken by an experienced operator in a vascular centre where the outcomes of carotid stenting are routinely audited
• People who have undergone carotid revascularisation should be reviewed post-operatively by a stroke physician to optimise medical aspects of vascular secondary prevention
• Patients with AF and symptomatic internal carotid artery stenosis should be managed for both conditions, unless there are contraindications.

Antiplatelet Treatment

• For long-term prevention of vascular events in people with ischaemic stroke or TIA without paroxysmal or permanent AF:
  • clopidogrel 75 mg daily should be the standard antithrombotic treatment
  • aspirin 75 mg daily should be used for those who are unable to tolerate clopidogrel; if a patient has a recurrent cardiovascular event on clopidogrel, clopidogrel resistance may be considered
• The combination of aspirin and clopidogrel is not recommended for long-term prevention of vascular events unless there is another indication, for example, acute coronary syndrome or recent coronary stent placement
• People with ischaemic stroke with acute haemorrhagic transformation should be treated with long-term antiplatelet or anticoagulant therapy unless the prescriber considers that the risks outweigh the benefits
• Patients who have a spontaneous (non-traumatic) ICH while taking an antithrombotic (antiplatelet or anticoagulant) medication for the prevention of occlusive vascular events may be considered for restarting antiplatelet treatment beyond 24 hours after ICH symptom onset
• Clinicians should consider the baseline risks of recurrent ICH and occlusive vascular events when making a decision about antiplatelet use after ICH outside of randomised controlled trials
• Whenever possible, patients with spontaneous (non-traumatic) ICH and a co-existent indication for antithrombotic medication treatment should be encouraged to participate in randomised controlled trials of antithrombotic therapy.

Anticoagulation

• For people with ischaemic stroke or TIA and paroxysmal, persistent, or permanent AF (valvular or non-valvular) or atrial flutter, oral anticoagulation should be the standard long-term treatment for stroke prevention. Anticoagulant treatment:
  • should not be given if brain imaging has identified significant haemorrhage
  • should not be initiated in people with severe hypertension (clinical BP of ≥180/120 mm/Hg), which should be treated first
  • may be considered for patients with moderate-to-severe stroke from 5–14 days after onset. Whenever possible, these patients should be offered participation in a trial of the timing of initiation of anticoagulation after stroke. Aspirin 300 mg daily should be used in the meantime
  • should be considered for patients with mild stroke earlier than 5 days if the prescriber considers the benefits to outweigh the risk of early intracranial haemorrhage. Aspirin 300 mg daily should be used in the meantime
  • should be initiated within 14 days of the onset of stroke in all those considered appropriate for secondary prevention
  • should be initiated immediately after a TIA once brain imaging has excluded haemorrhage, using an agent with a rapid onset (for example, DOAC in non-valvular AF or subcutaneous low molecular weight heparin while initiating a VKA for those with valvular AF)
  • should include measures to reduce bleeding risk, using a validated tool to identify modifiable risk factors
• First-line treatment for people with ischaemic stroke or TIA due to non-valvular AF should be anticoagulation with a DOAC
• People with ischaemic stroke or TIA in sinus rhythm should not receive anticoagulation unless there is another indication
• People with ischaemic stroke or TIA due to valvular/rheumatic AF or mechanical heart valve replacement and those with contraindications or intolerance to DOAC treatment should receive anticoagulation with adjusted-dose warfarin (target INR 2.5, range 2.0–3.0) with a target time in the therapeutic range of >72%
• For people with cardioembolic TIA or stroke for whom treatment with anticoagulation is considered inappropriate because of a high risk of bleeding:
  • antiplatelet treatment should not be used as an alternative when there are absolute contraindications to anticoagulation (for example, undiagnosed bleeding)
  • measures should be taken to reduce bleeding risk using a validated tool to identify modifiable risk factors. If, after intervention for relevant risk factors, the bleeding risk is considered too high for anticoagulation, antiplatelet treatment should not be routinely used as an alternative
  • a left atrial appendage occlusion device may be considered as an alternative, provided the short-term peri-procedural use of antiplatelet therapy is an acceptable risk
• People with cardioembolic TIA or stroke for whom treatment with anticoagulation is considered inappropriate for reasons other than the risk of bleeding may be considered for antiplatelet treatment to reduce the risk of recurrent vaso-occlusive disease
• People who initially present with a recurrent TIA or stroke should receive the same antithrombotic treatment as those who have had a single event. More intensive antiplatelet therapy or anticoagulation treatment should only be given as part of a clinical trial or in exceptional clinical circumstances.