What are the immediate management steps for a patient presenting with an acute ischaemic stroke?

Immediate management steps for a patient presenting with an acute ischaemic stroke:

• Emergency admission: Arrange immediate emergency admission to an acute stroke facility or hyperacute stroke unit for anyone with suspected acute ischaemic stroke. Ensure the hospital receives advanced notification of arrival including time of onset, symptom evolution, current condition, and medications, especially anticoagulants.
• Initial assessment and monitoring: While awaiting transfer, monitor and manage airway, breathing, and circulation (ABCs). Give supplemental oxygen only if oxygen saturation is below 95% and there are no contraindications.
• Exclude intracerebral haemorrhage: Do not start anticoagulation or antiplatelet treatment until intracerebral haemorrhage has been excluded by urgent brain imaging, ideally within 1 hour of hospital arrival.
• Brain imaging: Perform urgent brain imaging with non-enhanced CT immediately if thrombolysis or thrombectomy is considered, or if there are clinical indications such as anticoagulant use, bleeding tendency, depressed consciousness, or fluctuating symptoms.
• Thrombolysis: Administer alteplase as soon as possible within 4.5 hours of symptom onset if intracranial haemorrhage is excluded and no contraindications exist. This should be done within a well-organised stroke service with trained staff and immediate access to imaging.
• Thrombectomy: Consider mechanical thrombectomy within 6 hours of symptom onset for patients with confirmed proximal anterior circulation occlusion, alongside intravenous thrombolysis if appropriate.
• Blood glucose and blood pressure management: Maintain blood glucose between 4 and 11 mmol/L. Blood pressure management should be individualized, especially if intracerebral haemorrhage is excluded.
• Admission to specialist stroke unit: Admit all patients with suspected acute stroke directly to a specialist acute stroke unit for multidisciplinary assessment and care.

These steps ensure rapid diagnosis, exclusion of haemorrhage, and timely initiation of reperfusion therapies to improve outcomes in acute ischaemic stroke.

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