Red flags
- Bleed on CT — exclude before lytic
- BP >185/110 — treat first
- Contraindications (recent surgery, ICH history, INR >1.7)
First steps
- ABCDE + NIH stroke scale
- Non-contrast CT within 30 min
- CT angiography for LVO
- Glucose, coag, ECG, troponin
Key investigations
- Non-contrast CT, CT angio
- Glucose (exclude hypoglycaemia — stroke mimic)
- INR, platelets, U&E
Differentials
- Hypoglycaemia
- Todd paresis
- Migraine with aura
- Conversion
Initial management
- Alteplase 0.9 mg/kg (max 90) if <4.5 h, no contraindication
- OR tenecteplase 0.25 mg/kg (max 25)
- Mechanical thrombectomy for LVO up to 24 h (imaging-selected)
- BP <185/110 pre-lytic; 24 h post-lytic
- Aspirin 300 mg 24 h post-lytic
Referral
- Stroke unit
- Interventional neuroradiology for thrombectomy
AI clinical assessment
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