1. Immediate assessment and stabilization
   • Time last known well, FAST/neurologic examination, blood glucose, vital signs, oxygen only if hypoxic, IV access.
   • Urgent non-contrast CT or MRI to distinguish ischemic stroke from intracerebral hemorrhage.
   • CT/MR angiography when large-vessel occlusion is suspected.
2. Acute ischemic stroke
   • IV thrombolysis for eligible patients within the appropriate time window after imaging and contraindication screening.
   • Mechanical thrombectomy for eligible large-vessel occlusion, including selected patients with later presentation based on advanced imaging.
   • Antiplatelet therapy after hemorrhage is excluded and at the correct interval after thrombolysis.
   • Manage fever, hypoglycemia/hyperglycemia, blood pressure, aspiration risk, and complications.
3. Intracerebral hemorrhage
   • Urgent blood-pressure management.
   • Reverse anticoagulation where applicable.
   • Neurosurgical or neurocritical-care assessment for selected hematomas, hydrocephalus, raised intracranial pressure, or cerebellar hemorrhage.
4. TIA and secondary prevention
   • Identify the cause: atrial fibrillation, carotid stenosis, small-vessel disease, arterial dissection, etc.
   • Antiplatelet or anticoagulation as indicated, statin therapy, BP and diabetes control, smoking cessation, and carotid intervention for selected symptomatic stenosis.
5. Rehabilitation and supportive care
   • Early swallow screening, nutrition, DVT prevention, pressure-area care, communication assessment, physiotherapy, occupational therapy, speech therapy, and mood/cognitive screening.

• Acute ischemic stroke protocol
• Hemorrhagic stroke management
• Thrombolysis and thrombectomy
• Secondary prevention and rehabilitation

Stroke management: practical overview

1. Acute ischemic stroke protocol

A. First minutes

1. ABCDE stabilization
   • Protect airway, give oxygen only if hypoxic, treat seizures if present.
   • Check capillary glucose immediately. Hypoglycemia can mimic stroke.
   • Establish IV access, obtain blood count, electrolytes/renal function, coagulation tests, ECG, and cardiac monitoring. Do not delay reperfusion therapy for laboratory tests unless anticoagulant use or another concern makes testing necessary.
2. Focused history and examination
   • Last known well, current anticoagulant/antiplatelet use, recent bleeding/surgery, prior stroke, baseline function.
   • Perform NIHSS and screen for disabling deficit.
3. Urgent imaging
   • Non-contrast head CT, or MRI where rapidly available, to exclude intracranial hemorrhage.
   • CT angiography from arch to vertex when large-vessel occlusion is possible.
   • CT perfusion or MRI diffusion/perfusion is often used in wake-up stroke or later presentations to identify salvageable brain tissue.
4. Admit to a stroke unit
   • Stroke-unit care, early complication prevention, and multidisciplinary assessment improve outcomes. Key supportive measures are airway protection, prevention of aspiration, temperature control, and careful neurologic observation. Bradley and Daroff's Neurology in Clinical Practice, p. 1405.

B. General acute care

• Keep nil by mouth until formal swallow screening, especially with dysphagia, dysarthria, facial weakness, or impaired consciousness.
• Treat fever and correct significant hypo- or hyperglycemia.
• Avoid unnecessary aggressive BP lowering in ischemic stroke unless there is an indication such as eligibility for thrombolysis, aortic dissection, acute coronary syndrome, hypertensive emergency, or hemorrhage.
• Prevent complications: aspiration pneumonia, DVT, pressure injury, urinary retention, delirium, seizures, cerebral edema, and falls.
• Patients with a large infarct need close monitoring because cerebral edema often peaks around 48 to 96 hours. The Washington Manual of Medical Therapeutics, p. 1022.

2. Thrombolysis and thrombectomy

A. Intravenous thrombolysis

• Brain imaging excludes bleeding.
• Symptoms are clinically disabling and consistent with ischemic stroke.
• BP is below 185/110 mmHg before treatment and maintained below 180/105 mmHg for 24 hours afterward.
• Exclude major contraindications, especially active bleeding, recent high-risk intracranial procedure or major trauma, severe coagulopathy, or clinically significant anticoagulant effect.

• Monitor in a stroke unit/ICU setting with frequent neurologic and BP checks.
• Avoid antiplatelet and anticoagulant therapy for the first 24 hours unless a specialist determines otherwise.
• Repeat CT/MRI at about 24 hours, or urgently if neurologic deterioration, severe headache, vomiting, or acute hypertension suggests symptomatic intracranial hemorrhage.

B. Mechanical thrombectomy

• It should be done as fast as possible and should not be delayed while waiting to see whether IV thrombolysis works.
• For a patient eligible for both treatments, give IV thrombolysis first and proceed rapidly to thrombectomy.
• Standard selection is strongest within the first 6 hours.
• Selected patients with anterior-circulation LVO and favorable advanced imaging may benefit 6 to 24 hours after last known well.
• Older age alone is not a reason to withhold treatment. Decisions consider baseline function, infarct core, disability severity, vessel anatomy, bleeding risk, and goals of care.

3. Hemorrhagic stroke management

A. Spontaneous intracerebral hemorrhage

Immediate priorities

1. CT head urgently, then CTA/MRA when cause, spot sign, vascular lesion, or surgery is being considered.
2. ABCDE stabilization and transfer to a facility with neurocritical-care and neurosurgical capability when appropriate.
3. Frequent neurologic observations, repeat imaging if deterioration or hematoma expansion is suspected.
4. Manage raised intracranial pressure and hydrocephalus where present.
5. Treat fever, seizures when they occur, glucose abnormalities, aspiration risk, and immobility complications.

Blood-pressure management

• Carefully lower markedly elevated BP with titratable IV medication while avoiding sudden excessive reduction or hypotension.
• The exact target depends on presenting BP, hematoma characteristics, ICP, renal status, and local protocol.
• Current practice follows the 2022 AHA/ASA spontaneous ICH guideline, which emphasizes organized systems of care, BP treatment, management of coagulopathy, and neurosurgical assessment.

Reverse anticoagulation urgently

• Warfarin: 4-factor prothrombin complex concentrate plus IV vitamin K.
• Dabigatran: idarucizumab where available.
• Factor Xa inhibitors such as apixaban/rivaroxaban: andexanet alfa where appropriate and available, or 4-factor PCC according to protocol.
• Heparin: protamine.
• Platelet transfusion is not routinely appropriate solely for antiplatelet-associated spontaneous ICH, except in selected circumstances such as planned urgent neurosurgery.

Neurosurgery

• Cerebellar hemorrhage with neurologic deterioration, brainstem compression, hydrocephalus, or substantial mass effect.
• Obstructive hydrocephalus that may require external ventricular drainage.
• Selected superficial lobar hematomas or deteriorating patients in whom evacuation is considered.
• Suspected vascular malformation, aneurysm, tumor, or other structural cause.

B. Subarachnoid hemorrhage

• Non-contrast CT urgently. If CT is negative but suspicion remains high, the further diagnostic pathway is guided by timing and local expertise, often CT angiography and sometimes lumbar puncture.
• Stabilize, involve neurosurgery/interventional neuroradiology early, secure a ruptured aneurysm by coiling or clipping when indicated, and use specialist-directed vasospasm prevention and monitoring.
• This differs from primary ICH and needs a dedicated SAH protocol.

4. Secondary prevention after TIA or stroke

A. Establish the cause

• Continuous ECG/telemetry and sometimes prolonged rhythm monitoring for paroxysmal atrial fibrillation.
• Echocardiography when cardioembolism is suspected.
• Carotid imaging for symptomatic carotid stenosis.
• Lipids, HbA1c, BP assessment, and cause-specific tests in selected patients, such as dissection, thrombophilia, vasculitis, or patent foramen ovale evaluation.

B. Antithrombotic therapy

• Non-cardioembolic ischemic stroke/TIA: long-term single antiplatelet therapy is typical, such as aspirin or clopidogrel.
• Minor ischemic stroke or high-risk TIA: short-course dual antiplatelet therapy may be used in carefully selected patients, then changed to single antiplatelet therapy. Long-term dual therapy increases bleeding risk and is generally avoided.
• Atrial fibrillation or another major cardioembolic source: oral anticoagulation is usually indicated once the timing is judged safe, considering infarct size, hemorrhagic transformation risk, and bleeding risk.
• Carotid disease: symptomatic severe carotid stenosis may require urgent carotid endarterectomy or selected stenting in addition to best medical treatment.

C. Risk-factor management

• BP: treat hypertension and aim for individualized long-term control.
• Lipids: high-intensity statin therapy is commonly used after atherosclerotic ischemic stroke unless contraindicated.
• Diabetes: optimize glycemic management while avoiding hypoglycemia.
• Stop smoking, limit alcohol, maintain healthy weight, exercise safely, address diet, and assess/treat obstructive sleep apnea.
• Review contraception or hormone therapy when relevant.

5. Rehabilitation and long-term care

Key distinction

• Ischemic stroke: reopen the vessel quickly if eligible.
• Hemorrhagic stroke: control bleeding, BP, ICP, and anticoagulant effect.
• Every stroke: stroke-unit care, swallowing safety, early rehabilitation, cause-based prevention, and caregiver support.

1. Acute ischemic stroke protocol: ABCDE, glucose, urgent CT/CTA, stroke-unit admission, swallow screen, supportive care.
2. Thrombolysis and thrombectomy: eligibility, time windows, alteplase/tenecteplase, BP thresholds, large-vessel occlusion and endovascular treatment.
3. Hemorrhagic stroke management: urgent CT, BP control, anticoagulant reversal, ICP/hydrocephalus treatment, neurosurgical referral.
4. Secondary prevention and rehabilitation: cause work-up, antiplatelet versus anticoagulation, statin/BP/diabetes/smoking management, PT/OT/speech therapy and dysphagia care.