Suspected Acute Stroke
Sudden focal neurological deficit: activate code stroke
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Acute Ischemic Stroke - Neurology Pathway (AHA/ASA 2026)
Acute Ischemic Stroke - Neurology Pathway (AHA/ASA 2026): Suspected Acute Stroke → Code Stroke: Assess and Image at Once → Haemorrhage on CT? → Haemorrh...
Pathway Overview
18 steps
Algorithm Steps
18 total
01Start 02Action Code Stroke: Assess and Image at Once
Do not delay CT or thrombolysis for blood results unless coagulopathy is suspected
- Record last known well (LKW) time; wake-up stroke: last time seen well
- Capillary glucose now: below 3.3 mmol/L, treat, then reassess (can mimic stroke)
- Non-contrast CT brain with CT angiography (arch to vertex) in one visit; CT perfusion per local protocol
- NIHSS, weight (for dose), anticoagulant use and time of last dose
- Airway and breathing; oxygen only if SpO2 below 92% (target 92-96%). Risk of hypercapnia (e.g. COPD): only if below 88%, target 88-92%
- Bloods: FBC, coagulation, electrolytes, renal function
- Targets: CT within 25 min of arrival; thrombolysis within 60 min
03Decision Haemorrhage on CT?
Intracranial haemorrhage excludes thrombolysis
- If Yes
04Warning Haemorrhage on CT: No Thrombolysis
Intracranial haemorrhage: use the ICH pathway (subarachnoid haemorrhage: SAH pathway)
- Reverse anticoagulants at once per ICH protocol
- ICH: lower systolic BP to about 140 mmHg, not substantially below
- Urgent neurosurgical review (cerebellar bleed, hydrocephalus)
05End Haemorrhage: Continue on ICH or SAH Pathway
This pathway covers ischaemic stroke only
If No06Action No Haemorrhage: Assess for Reperfusion Now
Assess thrombolysis and thrombectomy (EVT) in parallel
- Is the deficit disabling? Minor non-disabling deficit: thrombolysis not recommended; see antiplatelets in stroke unit care
- Time from LKW
- CTA: large vessel occlusion? Call the EVT team now
- Pre-stroke function, frailty and patient wishes; age alone is not a bar
07Decision In a Thrombolysis Time Window?
Yes: within 4.5 h of LKW, or 4.5-9 h (wake-up: from midpoint of sleep) with CT perfusion or MRI mismatch on stroke specialist review
- If Yes
08Warning Do Not Thrombolyse If
Adults only: children need the paediatric stroke team. Pregnancy: senior stroke and obstetric decision.
- Suspected aortic dissection or infective endocarditis: no thrombolysis (risk of death or brain bleed)
- Warfarin with INR above 1.7, treatment-dose LMWH within 24 h, heparin with high aPTT, platelets below 100 x10^9/L or active bleeding: no thrombolysis
- DOAC within 48 h, timing unknown or impaired renal function: thrombolyse only if drug-specific test is normal or after idarucizumab (dabigatran); otherwise EVT alone if LVO
09Action Check Other Thrombolysis Contraindications
Stroke specialist decision; review before giving
- Extensive clear hypodensity on CT (more than 1/3 of MCA territory): no thrombolysis; recheck onset time
- BP above 185/110 mmHg that cannot be lowered: do not start
- Relative (weigh risk): prior ICH; ischaemic stroke, major head trauma or cranial or spinal surgery within 3 months
- Relative: other major surgery or trauma within 14 days; GI or urinary tract bleed within 21 days; intra-axial brain tumour
- Not contraindications: age over 80, meningioma, unruptured aneurysm, cervical artery dissection, menstruation
- Seizure at onset: thrombolyse only if imaging confirms stroke
- Glucose above 10 mmol/L: treat in parallel; do not delay thrombolysis
10Decision Eligible for Thrombolysis?
No contraindication, disabling deficit, inside the window
- If Yes
11Action Eligible: Adult IV Thrombolysis
Give as soon as possible; do not wait for EVT. Tenecteplase or alteplase within 4.5 h; alteplase for 4.5-9 h or wake-up mismatch unless immediate EVT is planned.
- BP below 185/110 mmHg before, and below 180/105 mmHg for 24 h after (labetalol or clevidipine per local protocol; no labetalol in asthma, COPD, bradycardia or heart block)
- Tenecteplase 0.25 mg/kg (max 25 mg) single IV bolus over 5-10 s; use the 25 mg stroke vial (5 mg/mL), not the cardiac dosing table
- OR alteplase 0.9 mg/kg (max 90 mg): 10% IV bolus, then the rest by infusion over 60 min (1 mg/mL)
- No antiplatelets or anticoagulants for 24 h (except for stent); repeat CT or MRI at 24 h before starting them
- Neuro and BP checks every 15 min for 2 h, every 30 min for 6 h, then hourly to 24 h
12Warning During or After Thrombolysis: Stop If
New neuro decline, severe headache, vomiting, acute BP rise or tongue or lip swelling: stop the infusion at once
- Suspected brain bleed: urgent CT; FBC, coagulation, fibrinogen; cryoprecipitate (keep fibrinogen at 1.5 g/L or more) and tranexamic acid per protocol
- Call haematology and neurosurgery
- Orolingual angioedema (higher risk with ACE inhibitors): protect the airway (may need intubation), treat per angioedema protocol
13Decision Large Vessel Occlusion on CTA?
ICA, M1, proximal or dominant M2, basilar, or tandem cervical carotid plus intracranial occlusion. Decide for all patients, thrombolysed or not.
- If Yes
14Action LVO: Endovascular Thrombectomy (EVT)
Disabling deficit and EVT can start within 24 h of LKW. Usual criteria: NIHSS 6 or more, independent before stroke (mRS 0-1); outside these, specialist decision. Give thrombolysis too if eligible; neither should delay the other.
- No EVT on site: transfer at once to an EVT centre
- 0-6 h: ASPECTS 3-10 (pre-stroke mRS 2: reasonable if ASPECTS 6 or more). 6-24 h: select by imaging (ASPECTS, or perfusion or clinical-core mismatch as in DAWN and DEFUSE-3)
- Large core (ASPECTS 3-5 or core 50 mL or more), NIHSS 6 or more, independent before stroke (mRS 0-1), no major mass effect: EVT within 6 h; 6-24 h only if also under 80. ASPECTS 0-2: specialist decision
- Basilar occlusion: clear benefit if NIHSS 10 or more, mRS 0-1 and PC-ASPECTS 6 or more; NIHSS below 10: specialist decision
- Weigh pre-stroke function, frailty, comorbidity and patient wishes
- Medium or distal occlusion (non-dominant M2, M3, ACA, PCA): routine EVT did not help in 2025 trials
- Beyond 24 h: specialist decision if imaging shows salvageable brain
- After EVT: do not lower systolic BP below 140 mmHg (harm in trials)
15Action All Patients: Stroke Unit Care
Admit to a stroke unit. After EVT: keep BP at or below 180/105 mmHg for 24 h, but do not target systolic below 140 mmHg. No aspirin during EVT.
- BP, no thrombolysis or EVT: lower only if above 220/120 mmHg, by about 15% (no more than 20%) in 24 h. Lower sooner if a comorbid condition needs it (e.g. acute heart failure, aortic dissection)
- No reperfusion therapy: aspirin 300 mg as soon as CT excludes haemorrhage (not by mouth until the swallow screen is passed). Already on an anticoagulant: no routine added aspirin (more bleeding); stroke team plans
- After thrombolysis: antiplatelet only after 24 h and repeat imaging (stent: neurointerventionist plan)
- After EVT without thrombolysis: antiplatelet timing by the stroke team after post-EVT imaging
- Swallow screen within 4 h and before any oral food, fluid or medicine
- Minor stroke (NIHSS 3 or less) or high-risk TIA, no reperfusion therapy, 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 to day 21
- Glucose: monitor for 72 h; treat above 10 mmol/L; do not aim for tight control (4-7.5 mmol/L)
- Temperature at least 4 times a day for 72 h; treat fever
- Immobile: intermittent pneumatic compression for VTE prevention
16Warning Neuro Decline: Repeat CT, Call Neurosurgery
Brain swelling after large infarct can be fatal
- Malignant MCA infarct, age 60 or under: urgent neurosurgery for hemicraniectomy, ideally within 48 h; over 60: selected patients
- Large cerebellar infarct with brainstem compression or hydrocephalus: urgent decompressive surgery
- No corticosteroids for brain oedema; osmotherapy while awaiting neurosurgery
17Action Find the Cause and Start Prevention
Within the admission
- MRI brain if the diagnosis or mechanism is unclear
- Carotid imaging (CTA already done, or duplex); symptomatic 50-99% stenosis: urgent vascular review, surgery if eligible ideally within 2 weeks
- Cardiac monitoring for at least 24 h; longer if no cause found
- Echocardiography if a cardiac source is suspected
- HbA1c and lipids; start a high-intensity statin if atherosclerosis may have contributed
- Atrial fibrillation: plan anticoagulant start with the stroke team (timing by infarct size)
- Young or no cause found: look for dissection, PFO and thrombophilia
18Outcome Expected Benefit
Earlier treatment gives better outcomes
- EVT: about 1 in 2.6 patients treated has less disability (HERMES)
- Thrombolysis benefit falls with every minute of delay
- Target: door to needle 60 min or less; start EVT as fast as possible
If No- Path rejoins step 15Shared downstream outcome
If No- Path rejoins step 13Shared downstream outcome
If No- Path rejoins step 13Shared 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
- Adults only: children with suspected stroke need the paediatric stroke team.
- Thrombolysis and EVT decisions need a stroke specialist (on site or telestroke) and the local code stroke protocol.
- Haemorrhagic stroke: use the intracerebral haemorrhage pathway.
- NIHSS can underestimate disabling posterior circulation stroke.
Contraindicated Populations
Children under 18: paediatric stroke teamIntracranial haemorrhage: ICH or SAH pathwayPregnancy: thrombolysis and EVT only after senior stroke and obstetric review
Applicable Regions
AUNZUSEU
AU: Australian and New Zealand Living Clinical Guidelines for Stroke Management apply. Tenecteplase 25 mg (METALYSE 25 mg) is TGA-registered for acute ischaemic stroke. IV nicardipine is not available; use labetalol or clevidipine. Units mmol/L and x10^9/L; aspirin 300 mg.
US: AHA/ASA 2026 guideline applies; glucose target 140-180 mg/dL (7.8-10 mmol/L).
Version 2Next review: 2027-09-30
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Related Resources
Frequently Asked Questions
What is the Acute Ischemic Stroke - Neurology Pathway (AHA/ASA 2026)?
The Acute Ischemic Stroke - Neurology Pathway (AHA/ASA 2026) is a emergency clinical algorithm for Neurology. 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 - Neurology Pathway (AHA/ASA 2026) 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 - Neurology Pathway (AHA/ASA 2026)?
Known limitations include: Adults only: children with suspected stroke need the paediatric stroke team.; Thrombolysis and EVT decisions need a stroke specialist (on site or telestroke) and the local code stroke protocol.; Haemorrhagic stroke: use the intracerebral haemorrhage pathway.; NIHSS can underestimate disabling posterior circulation stroke.. Individual patient factors may require deviation from these recommendations.
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