• Urgently admit all people with suspected acute stroke:
• Particular urgency is necessary for people who might be suitable for thrombolysis or whose clinical condition is poor (e.g. depressed level of consciousness, progressing symptoms, severe headache).
• A small number of people have severe comorbidity and might not benefit from admission. If, after discussion with the person and their family or carer, a decision is made not to admit, the reasons for this should be clearly documented.
• Do not start antiplatelet treatment until haemorrhagic stroke has been ruled out by a brain scan.

• Thrombolysis is less effective the longer the delay:
• The deadline for thrombolysis is 3 hours from the start of symptoms. However, some units will treat up to 4.5 hours from start of symptoms, as recent evidence suggests that there may still be some benefit.
• Brain imaging is required before thrombolysis can be given.
• Therefore, if the person might be eligible for thrombolysis:
• Ensure that ambulance control understands the urgency of the situation and that the person needs to be taken immediately to the nearest hospital with facilities for stroke thrombolysis.
• Ensure that the hospital is warned to expect the person.
• If you are consulted over the telephone and the symptoms are suggestive of acute stroke, tell the person or carer to dial 999.
• Use the FAST test to screen for symptoms of acute stroke — see the section on Diagnosis with ongoing symptoms.

These recommendations are in line with guidelines issued by the National Institute for Health and Clinical Excellence (NICE) and the Royal College of Physicians Intercollegiate Stroke Working Party (RCP ICSWP) [Intercollegiate Stroke Working Party, 2008; National Collaborating Centre for Chronic Conditions, 2008], and the National Stroke Strategy [DH, 2007]:

• The National Stroke Strategy is based on evidence that a more urgent response to both stroke and transient ischaemic attack (TIA) saves lives and reduces long-term disability.
• Rapid recognition of acute stroke or TIA and immediate admission:
• Rapid recognition of acute stroke or TIA and immediate admission are necessary because people who are eligible for thrombolysis should have treatment started within 3 hours of the start of their symptoms, and brain imaging needs to be performed to confirm eligibility for thrombolysis.
• Antiplatelet therapy:
• A Cochrane systematic review found strong evidence for the benefits of aspirin (160 mg to 300 mg given as soon as is practicable and continued daily) in people with suspected acute ischaemic stroke:
• This evidence applies chiefly to people seen within 48 hours of stroke onset, in whom intracranial haemorrhage had been excluded or was thought to be clinically unlikely, and who had no definite contraindications to aspirin.
• Aspirin therapy was associated with a significant reduction in the number of people who died or were left dependent, or who had symptomatic pulmonary embolism or recurrent stroke.
• There was a small but statistically significant increase in the number of symptomatic intracranial haemorrhages and major extracranial haemorrhages.
• Because antiplatelet therapy increases the risk of intracranial haemorrhage, it should not be given until haemorrhagic stroke has been ruled out. The NICE and RCP ICSWP guidelines recommend that a brain scan be used to rule out haemorrhagic stroke.
• Thrombolysis with alteplase:
• Thrombolysis with alteplase in acute ischaemic stroke has been shown to significantly improve outcome in selected people treated within 3 hours of onset of symptoms. The evidence is reviewed in a NICE Technology Appraisal [NICE, 2007].
• Evidence from a randomized controlled trial published after the NICE and RCP ICSWP guidelines suggests that intravenous alteplase administered between 3 hours and 4.5 hours after the onset of symptoms of acute ischaemic stroke significantly improves disability outcomes [Hacke et al, 2008].
• The authors emphasized that their trial does not provide evidence that it is safe to delay treatment that can be given in a shorter time frame — the delay in starting treatment must be kept as short as possible because the benefits of thrombolysis decrease as the delay in giving it increases.