⏱️ The overriding concept in hyperacute care is that "time is brain." Rapid assessment and intervention are crucial. There are two main patient streams:
- 🚀 Those suitable for urgent, active therapies.
- 🛏️ Those needing general physiological support and prevention of complications.
Urgent therapies include:
- 💉 Stroke Thrombolysis and 🩻 Mechanical Thrombectomy.
- 🛑 Reversal of anticoagulation in intracerebral haemorrhage (ICH).
- 🧠 Decompression or external ventricular drainage (EVD) for malignant swelling or hydrocephalus.

⏱️ Time is Brain: Every minute of untreated large vessel stroke costs ~1.9 million neurons. Target: CT within 1 hour and thrombolysis within 30 minutes of arrival.

Hospital Care

👩‍⚕️ Stroke-trained staff should rapidly assess patients. Immediate CT is essential for management direction.
🎯 Aim for thrombolysis within 20 minutes of arrival by:
- 👋 Greeting patient and taking paramedic handover.
- 🕒 Establishing time of onset and contraindications (esp. anticoagulation).
- 💻 Booking on systems while history/exam done en route to CT.
📊 Post-CT: confirm BP, verify weight, and run quick checklist before Alteplase.
🔄 Continuous pathway improvement helps reduce door-to-needle times.

Actions	Comments
🫁 ABC	Airway, breathing, circulation first. Oxygen only if hypoxic. Consider ITU if GCS < 9. Record NIHSS score.
🩸 Blood Glucose	Treat hypoglycaemia immediately (fingerstick test acceptable).
💉 Assess for Thrombolysis	rt-PA within 3 h (>80y) or 4.5 h (<80y). Door-to-needle target: <30 min.
🩻 Assess for Thrombectomy	Mechanical thrombectomy if CTA shows LVO. Best <6 h, can extend to 16–24 h in select cases.
🧠 Haemorrhage / Raised ICP	Consult neurosurgery. Consider EVD, sub-occipital craniectomy (cerebellar bleed), or hemicraniectomy (malignant MCA).
🧪 Haemorrhage with Coagulopathy	Reverse anticoagulation: PCC + Vit K (Warfarin), Praxbind (Dabigatran), platelets if thrombocytopenia.

Key Information for Thrombolysis/Thrombectomy Referral

Actions	Comments
👶/👵 Age	<80y → 4.5h window; ≥80y → 3h window.
🕒 Time Since Last Well	Use last well time if onset unclear.
💊 Anticoagulation	Contraindicates thrombolysis ❌ but not thrombectomy ✔️.
📊 NIHSS Score	Reperfusion rarely offered if NIHSS <4 (minor) or >25 (very severe).
🏃 Premorbid State	Benefit less likely if already mRS 4–5 (high dependency).
🩻 CT Report	Avoid referral if CT shows haemorrhage, tumour, or extensive infarction.
⚕️ Comorbidities	Advanced malignancy / recent trauma may contraindicate treatment.
🩺 Blood Pressure	Must be <185/110 mmHg before Alteplase.

Managing and Preventing Early Complications

Managing & Preventing Early Complications
🥤 Swallow Assessment	Screen within 4 h to prevent aspiration pneumonia.
🍽️ Feeding	NG tube if swallow unsafe.
🦵 VTE Prevention	IPC stockings first-line. Avoid LMWH until ICH excluded.
💧 Hydration	IV fluids to prevent dehydration.
🛏️ Skin Care	Regular turns to prevent pressure sores.
🚽 Bowel Care	Prevent constipation.
💪 Shoulder Protection	Support joint to avoid subluxation.
🏃 Therapy	Early mobilisation & rehabilitation.
⚡ Seizure Management	Treat promptly; seizures may indicate large infarct.
🦠 Infection	Treat UTIs & chest infections early.
💧 Bladder Care	Promote continence; avoid catheters if possible.

📊 Exam pearls: - BP must be <185/110 before thrombolysis. - Hypo- or hyperglycaemia worsens outcome. - Seizures at onset → consider stroke mimic. - Swallow screen within 4 h is a national quality standard.

Schematic of a Pathway

FAST positive → CT within 1 h → Thrombolysis if eligible (<4.5 h) → CTA for thrombectomy if LVO → Admit to HASU for monitoring & prevention.

The content on this website is provided for educational and informational purposes only to support exam preparation (e.g., MLA, MRCP, USMLE) and learning. This is NOT medical advice, diagnosis, treatment, or professional guidance. It does not replace consultation with a qualified healthcare professional, official guidelines (e.g., NICE, GMC, BNF), or supervised clinical practice. Always verify information with current, authoritative sources. Makindo and its contributors accept no liability for any reliance on this content, including errors, omissions, or any resulting harm, loss, or consequences. By using this site, you agree to these terms.

Hyperacute Stroke Care Pathway

Introduction

Hospital Care

Key Information for Thrombolysis/Thrombectomy Referral

Managing and Preventing Early Complications

Schematic of a Pathway

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