Suspected acute stroke (adult)
Sudden focal neurological deficit. Activate code stroke now.
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Emergency MedicineEmergency
Acute Ischemic Stroke Management (AHA/ASA 2026; ANZ Living Guidelines)
Acute Ischemic Stroke Management (AHA/ASA 2026; ANZ Living Guidelines): Suspected acute stroke (adult) → Immediate assessment → Non-contrast CT brain an...
Pathway Overview
19 steps
Algorithm Steps
19 total
01Start 02Action Immediate assessment
ABC, glucose, IV access, weight and time last known well. Do not delay imaging.
- Record time last known well (not time found). Woke with symptoms: note time went to sleep.
- Blood glucose now. Below 3.3 mmol/L: treat, then reassess (can mimic stroke).
- Ask about anticoagulants and the time of the last dose.
- Weight (measure or estimate) for the thrombolytic dose.
- FBC, coags, EUC. Wait for INR and platelets only if on an anticoagulant or coagulopathy is suspected.
- 12-lead ECG. Do not delay thrombolysis for it.
03Action Non-contrast CT brain and CT angiography
Aim: imaging within 20 min of arrival. Do not delay thrombolysis for CTA or perfusion imaging.
- Non-contrast CT: excludes haemorrhage and some mimics
- CTA from aortic arch to vertex if thrombectomy may be an option
- Beyond 4.5 h or woke with symptoms: CT perfusion or MRI
- Extensive clear hypodensity: recheck onset time; no thrombolysis
04Decision Haemorrhage on CT?
Any intracranial haemorrhage excludes thrombolysis.
- If Yes
05Warning Haemorrhage on CT: no thrombolysis
Manage as intracerebral haemorrhage. Go to the ICH pathway.
- Do not give thrombolysis, antiplatelet or anticoagulant
- On an anticoagulant: reverse it urgently
- Lower SBP to about 140 mmHg (not much below); neurosurgical review
06End Go to intracerebral haemorrhage pathway
Stroke unit or ICU care.
If No07Action NIHSS and deficit severity
Score the NIHSS. Decide if the deficit is disabling.
- NIHSS 6 or more, or cortical signs (aphasia, neglect, gaze deviation): suspect LVO; get CTA
- Disabling deficit: thrombolysis is indicated whatever the NIHSS score
- Non-disabling minor deficit: no thrombolysis; see antiplatelet advice in stroke unit care
08Decision Last known well 4.5 h ago or less?
Yes: check bleeding risk and contraindications. No: check the extended window.
- If Yes
09Warning Before thrombolysis: anticoagulant, BP, pregnancy
These can make thrombolysis harmful. Check each one first. Pregnant or recently delivered: urgent stroke and obstetric advice; consider thrombectomy.
- INR above 1.7 or platelets below 100 x10^9/L: do not thrombolyse.
- DOAC in last 48 h or treatment-dose LMWH in last 24 h: do not thrombolyse unless a stroke specialist advises.
- BP 185/110 mmHg or above: lower it first. If it stays high, do not thrombolyse.
10Decision Eligible for thrombolysis (none of the items below)?
Not eligible if any: bleed on CT, prior ICH, anticoagulant or INR/platelet limit, ischaemic stroke, severe head injury or brain or spinal surgery in 3 months, active bleeding, endocarditis, arch dissection, BP not controlled, non-disabling deficit. Senior stroke review if unsure.
- Haemorrhage or extensive clear hypodensity on CT; symptoms suggest SAH
- Previous intracerebral haemorrhage
- INR above 1.7, platelets below 100 x10^9/L, DOAC in 48 h, treatment-dose LMWH in 24 h, heparin in 48 h with raised APTT
- Ischaemic stroke, severe head injury, or intracranial or spinal surgery in last 3 months
- GI cancer; GI or urinary tract bleed in last 21 days; active internal bleeding
- Infective endocarditis, aortic arch dissection, intra-axial brain tumour
- BP stays 185/110 mmHg or above despite treatment
- Non-disabling deficit
- Not a reason on its own: age over 80, severe stroke, diabetes with prior stroke (senior review)
- If Yes
11Action No contraindication: IV thrombolysis (adult)
Tenecteplase 0.25 mg/kg (max 25 mg) single IV bolus over 5-10 s, OR alteplase 0.9 mg/kg (max 90 mg; 1 mg/mL after reconstitution): 10% IV bolus, rest over 60 min. 4.5-9 h or wake-up mismatch: alteplase (tenecteplase only on stroke specialist advice).
- Tenecteplase: use the 25 mg stroke vial (5 mg/mL after 5 mL water). Stroke dose is lower than the heart attack dose. Not in a dextrose line.
- BP below 180/105 mmHg for 24 h after. Do not target SBP below 140 mmHg.
- Tongue or lip swelling (more likely with an ACE inhibitor): stop infusion, protect airway, treat angioedema
- No antiplatelet or anticoagulant for 24 h. Repeat CT or MRI at 24 h before starting.
- Target door-to-needle 60 min or less. Do not wait for thrombectomy transfer.
12Warning During and after thrombolysis: watch for bleeding
Neuro worse, new headache, vomiting or sudden BP rise: stop infusion and get urgent CT.
- Stop any alteplase infusion still running. Urgent non-contrast CT.
- Send FBC, INR, APTT, fibrinogen, group and hold
- Bleed on CT: cryoprecipitate and tranexamic acid per local protocol; urgent stroke, haematology and neurosurgical advice
13Decision Large vessel occlusion on CTA?
ICA, M1, proximal or dominant M2, basilar, or tandem occlusion. No LVO: go to stroke unit care.
- If Yes
14Action LVO: urgent thrombectomy referral
Thrombectomy if it can start within 24 h of last known well. Call the neurointervention team now. No thrombectomy on site: transfer to a thrombectomy centre.
- Give IV thrombolysis first if eligible. Neither treatment should delay the other.
- BP 185/110 mmHg or less before and during the procedure. After recanalisation, do not target SBP below 140 mmHg.
- 0-6 h, anterior LVO: NIHSS 6 or more, pre-stroke mRS 0-1, ASPECTS 3-10
- 6-24 h, anterior LVO: select by imaging. Large core (ASPECTS 3-5, no major mass effect): age under 80, NIHSS 6 or more, pre-stroke mRS 0-1
- 0-6 h, anterior LVO, NIHSS 6 or more, also reasonable: ASPECTS 0-2 (age under 80, pre-stroke mRS 0-1, no major mass effect), or pre-stroke mRS 2 with ASPECTS 6 or more
- Basilar occlusion within 24 h: NIHSS 10 or more, pre-stroke mRS 0-1, PC-ASPECTS 6 or more
- Weigh pre-stroke function, frailty and patient wishes
15Action Stroke unit care (all patients)
Admit to a stroke unit.
- After thrombolysis: neuro and BP checks every 15 min for 2 h, every 30 min for 6 h, then hourly to 24 h
- Swallow screen within 4 h of arrival and before any oral food, fluid or medicine
- No reperfusion treatment: aspirin 300 mg once CT excludes haemorrhage (non-oral route if swallow screen fails)
- After thrombolysis: antiplatelet only after 24 h imaging excludes bleeding. After thrombectomy: timing per stroke team.
- Minor stroke (NIHSS 3 or less) or high-risk TIA, not cardioembolic, no thrombolysis: aspirin plus clopidogrel within 24 h for 21 days (other groups: see secondary prevention)
- No thrombolysis and BP 220/120 mmHg or above: lower by no more than 20% in 24 h
- Glucose: treat above 10 mmol/L; avoid tight control (4.0-7.5 mmol/L)
- Immobile: intermittent pneumatic compression for VTE prevention
- Early physiotherapy, OT and speech pathology
16Action Early secondary prevention
Start before discharge. Dual antiplatelet only for selected minor stroke or high-risk TIA without thrombolysis or AF.
- Minor stroke (NIHSS 3 or less) or high-risk TIA, no thrombolysis, no anticoagulant indication: aspirin 300 mg plus clopidogrel 300-600 mg load within 24 h, then aspirin 100-150 mg plus clopidogrel 75 mg daily for 21 days, then one antiplatelet
- Large-artery cause (50% or more symptomatic stenosis), no thrombolysis, no AF: NIHSS 4-5 within 24 h, or NIHSS 5 or less or high-risk TIA at 24-72 h: aspirin plus clopidogrel for 21 days is reasonable (stroke team)
- All others without AF, including after thrombolysis: single antiplatelet, not dual
- AF: anticoagulant, not dual antiplatelet; timing by stroke size and bleeding risk (stroke team)
- High-intensity statin
- Symptomatic carotid stenosis 50-99%: urgent vascular review; endarterectomy ideally within 2 weeks
- Long-term BP target below 130/80 mmHg once stable
17Outcome Follow-up and rehabilitation
mRS at 90 days. Discuss goals of care if severe disability.
If No- Path rejoins step 15Shared downstream outcome
If No18Action Contraindicated or outside window: no IV thrombolysis
Record the reason. Still assess for thrombectomy.
- DOAC in last 48 h: stroke specialist may advise reversal then thrombolysis, or thrombectomy if LVO
- LVO at 4.5-24 h and no thrombectomy access: IV thrombolysis may be considered (stroke specialist decision)
- Start antiplatelet after the thrombectomy decision and swallow screen (see stroke unit care)
- Path rejoins step 13Shared downstream outcome
If No19Decision Over 4.5 h: salvageable brain on imaging?
Senior stroke decision. Perfusion mismatch up to 9 h (wake-up: 9 h from midpoint of sleep), or MRI DWI-FLAIR mismatch. Not if immediate thrombectomy is planned. Yes: contraindication check, then alteplase. No: no thrombolysis; assess for thrombectomy.
- If Yes
- Path rejoins step 09Shared downstream outcome
If No- Path rejoins step 18Shared downstream outcome
Guideline Source
2026 Guideline for the Early Management of Patients With Acute Ischemic Stroke (AHA/ASA); Australian and New Zealand Living Clinical Guidelines for Stroke Management, Chapter 3
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Check the full thrombolysis contraindication list and local protocol; anticoagulant timing (DOAC 48 h, LMWH 24 h) is critical
- Adults only; children, pregnancy and posterior circulation stroke need specialist stroke advice
- Extended-window thrombolysis and thrombectomy selection need perfusion imaging and a stroke specialist
- ICH management is not covered; use the ICH pathway
Contraindicated Populations
pediatricchildren under 18 years
Applicable Regions
AUNZUSEUInternational
AU: ANZ Living Clinical Guidelines for Stroke Management apply. Tenecteplase 25 mg stroke vial (Metalyse 25 mg) is TGA-registered for AIS within 4.5 h (2025). Use the local code stroke and telestroke network.
EU: ESO guidelines are largely concordant.
NZ: ANZ Living Clinical Guidelines for Stroke Management apply; follow the regional stroke network protocol.
US: Follow the 2026 AHA/ASA guideline.
International: Thrombectomy may not be available in all centres; use a transfer or telestroke network.
Version 2Next review: 2027-09-30
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Frequently Asked Questions
What is the Acute Ischemic Stroke Management (AHA/ASA 2026; ANZ Living Guidelines)?
The Acute Ischemic Stroke Management (AHA/ASA 2026; ANZ Living Guidelines) is a emergency clinical algorithm for Emergency Medicine. It provides a structured decision tree to guide clinical decision-making, based on 2026 Guideline for the Early Management of Patients With Acute Ischemic Stroke (AHA/ASA); Australian and New Zealand Living Clinical Guidelines for Stroke Management, Chapter 3.
What guideline is the Acute Ischemic Stroke Management (AHA/ASA 2026; ANZ Living Guidelines) based on?
This algorithm is based on 2026 Guideline for the Early Management of Patients With Acute Ischemic Stroke (AHA/ASA); Australian and New Zealand Living Clinical Guidelines for Stroke Management, Chapter 3 (DOI: 10.1161/STR.0000000000000513).
What are the limitations of the Acute Ischemic Stroke Management (AHA/ASA 2026; ANZ Living Guidelines)?
Known limitations include: Check the full thrombolysis contraindication list and local protocol; anticoagulant timing (DOAC 48 h, LMWH 24 h) is critical; Adults only; children, pregnancy and posterior circulation stroke need specialist stroke advice; Extended-window thrombolysis and thrombectomy selection need perfusion imaging and a stroke specialist; ICH management is not covered; use the ICH pathway. Individual patient factors may require deviation from these recommendations.
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