Stroke & Acute Ward Management
“Time is brain.” Every minute lost, millions of neurons die. Recognise FAST. Act fast. Every second counts.
Ischaemic vs haemorrhagic, thrombolysis, thrombectomy, swallow safety, and the lifelong medications that prevent the next one.
Two Types — And Only One Can Be Thrombolysed
“Stroke” means brain tissue is damaged because its blood supply has failed. But there are two completely different causes — and mixing them up could be fatal:
- Ischaemic (~85%): A clot blocks a vessel — from local plaque rupture or something that travelled from the heart (often AF). Brain tissue beyond it is starved. This is the one we can sometimes unblock.
- Haemorrhagic (~15%): A vessel bursts — blood leaks into or around the brain. Pressure rises, tissue is destroyed. Giving clot-busting drugs here makes the bleed catastrophic. That is why the CT scan comes first — always.
Face drooping Arm weakness Speech slurred/strange Time to call 999/alert HASU
Swallow screen first — always. Over half of stroke patients can’t swallow safely. Aspiration pneumonia is a major killer. Nothing by mouth until assessed — water, tablets, tea — nothing.
Reopening the Vessel — The Golden Windows
For ischaemic stroke only — and only if the patient arrives in time. The penumbra — tissue that’s struggling but still alive — can be saved if flow is restored quickly.
Alteplase / Tenecteplase — Within 4.5 Hours
What it does: Breaks down the clot from the inside. Restores blood flow to the penumbra.
Watch for — THESE CANNOT BE MISSED:
- Signs of brain bleed — sudden headache, falling consciousness, one-sided weakness getting worse → STOP infusion, call doctor immediately
- General bleeding — gums, bruising, black stools, vomiting blood
- Swelling of lips/tongue — angioedema, more likely if on ACE inhibitors
- Strict blood pressure control — too high = bleed risk; too low = poor brain perfusion
Endovascular Retrieval — Up to 24 Hours
What it does: Catheter through the groin or wrist up to the brain — physically pulls out large clots that drugs can’t shift. Best for major vessel blockages.
Watch for post-procedure: Bleeding/bruising at access site, leg/arm kept still as instructed, pulses checked, neurological observations frequent. Reperfusion injury — blood returning too fast can cause swelling or bleeding.
Stopping the Next One — Lifelong Protection
The acute phase passes — but the risk never goes away. These patients need medication for life. Your job: help them understand why, and what to watch for.
Aspirin → Clopidogrel (often with Dipyridamole)
When: Ischaemic stroke not caused by AF. Loading dose of aspirin 300mg immediately (once bleed ruled out), then clopidogrel long-term.
Watch for: Indigestion, bruising, bleeding gums, black stools. PPI (omeprazole) often prescribed alongside to protect the stomach lining.
DOACs (Apixaban, Rivaroxaban) or Warfarin
When: Stroke caused by clots forming in the heart (AF). Antiplatelets aren’t strong enough here — need full anticoagulation.
Watch for: Bleeding risk always. DOACs — renal function matters, doses change with kidney results. Warfarin — regular INR checks, consistent vitamin K intake, avoid cranberry juice. Timing of start is carefully decided — too soon and the stroke area could bleed.
High-Dose Statin + Blood Pressure Control
Atorvastatin 80mg: Doesn’t just lower cholesterol — stabilises plaque so it doesn’t rupture and block another vessel. Take at night for best effect. Report muscle pain/weakness promptly.
Blood pressure: Lowered gradually — too fast and you reduce flow to already vulnerable areas. Postural checks when starting new medication.
📖 Trusted Guidelines & References
Standards to cite and share — updated and current:
- NICE NG128 — Stroke & TIA in Over 16s (last reviewed Mar 2026) — UK gold standard: FAST recognition, CT timelines, thrombolysis windows, secondary prevention choices.
- British National Formulary (BNF) — Doses, contraindications, loading regimens, and interactions for all stroke medications.
- Stroke Association UK — Rehabilitation, communication support, swallow safety, and patient resources.
Written by: Daniel Hancock, Registered Nurse
Focus: Acute stroke recognition, HASU care, medication safety
Published: September 2026 | Last reviewed: September 2026
For: UK student nurses — supervised learning only
⚠️ NICE NG128 is the current UK reference. Always confirm thrombolysis eligibility, medication timing, and swallow protocols with the stroke team — every patient is different.