Acute Stroke — Registrar Quick Reference

Decision support only — not a substitute for the live MAGICapp guideline, eTG, or your stroke consultant. Confirm every dose and eligibility against local protocol. Time windows are from last-known-well (LKW).

1 Reperfusion clock — time from last-known-well

4.5h

12h

18h

24h

IV thrombolysisdisabling deficit

TNK / alteplase ≤4.5h

Extended / wake-upperfusion-selected

Alteplase 4.5–9h · EXTEND / DWI-FLAIR

ThrombectomyICA / M1 / tandem

EVT <6h — proceed

Thrombectomy lateimaging-selected

EVT 6–24h · DAWN/DEFUSE-3 + large core

Lysis + EVT run in parallel — neither delays the other. Basilar occlusion → EVT regardless of band. CTA arch-to-vertex immediately on any EVT candidate; perfusion (CTP / MRI) only for the late & wake-up bands.

2 Effect sizes — corrected from the teaching slide

Intervention	Outcome	ARR %	NNT	Read it as
All stroke types
Stroke unit careCochrane 2007	Death / dependency	3.6	28	Highest population yield — no imaging, no procedure. Admit everyone.
Ischaemic stroke
Thrombolysis <4.5hEmberson 2014 · TNK ≡ alteplase (AcT, TRACE-2)	mRS 0–1	5.2–9.8	10–19	Earlier = larger ARR. TNK now an equal-footing alternative. Not for non-disabling minor stroke.
Thrombolysis 4.5–9h / WUSEXTEND 2019, pooled 2019	mRS 0–1	~10	10	Perfusion-mismatch only; core capped ~70mL. Enrolled cores were much smaller — mind haemorrhagic conversion.
Thrombectomy <6hMR CLEAN, ESCAPE, SWIFT-PRIME 2015	mRS 0–2	20	5	Functional independence. Proximal anterior LVO.
Thrombectomy 6–24hDAWN 2017, DEFUSE-3 2018 · large core: SELECT2, ANGEL-ASPECT	mRS 0–2 (CTP-sel) mRS 0–3 (large core)	32 16	3.1 6	Best-selected, smallest NNT. Large-core pooled TESLA missed primary — not a homogeneous group.
AspirinIST, CAST 1997	Recurrent stroke / death	0.9	111	Small per-patient, huge population — cheap and near-universal. Don't dismiss the big number.
HemicraniectomyVahedi 2007 pooled	Death	49	2	NNT 2 prevents death, not disability. Many survivors land at mRS 4 — say so when consenting.
Intracerebral haemorrhage
Intensive BP lowering <140INTERACT2 (Anderson 2013); ATACH-2 2016	Death / dependency	no sig. benefit		Slide was wrong here. INTERACT2 primary endpoint not significant (OR 0.87, 0.75–1.01); benefit was the softer ordinal mRS shift only. ATACH-2: no benefit, ?renal harm. Lower smoothly, don't crash to <140.
Anticoagulation reversalthe actual high-yield ICH move	Haematoma expansion	do it fast		The intervention the original slide omitted. See block 6 for agents.

3 Drugs & thresholds

Reperfusion & antithrombotic doses

TNK0.25 mg/kg, max 25 mg single IV bolus. Preferred for LVO; most ANZ units have switched.
Alteplase0.9 mg/kg, max 90 mg — 10% bolus over 1 min, remainder over 60 min.
Aspirin300 mg load → 100 mg/day. Once haemorrhage excluded; if lysed, wait 24h + repeat imaging.
DAPTAspirin + clopidogrel ×3 weeks for minor stroke / high-risk TIA (strengthened to strong rec, 2024 update).

Blood pressure targets

Lysis<185/110 before, and through first 24h. Won't settle → don't lyse.
No lysisPermissive. Only treat if >220/120, then drop ≤20% over 24h.
Post-EVTCommonly <180/105 (lower-certainty); avoid peri-procedural hypotension.
ICHSmooth controlled lowering; aggressive <140 not supported (INTERACT2 / ATACH-2). New ANZ acute-lowering rec + weak care-bundle rec, 2024.

4 Workflow, supportive care & the surgical calls

First 30 minutes

NCCTExclude bleed + established infarct.
CTAArch→vertex immediately on any EVT candidate. Don't delay lysis for it.
CTP/MRILate & wake-up only. DWI-FLAIR mismatch for unknown onset.

Supportive bundle

SwallowScreen before anything oral.
Gluc/TempKeep in range; treat fever.
VTEIPC, not heparin (CLOTS-3).
MobiliseEarly — but not high-dose <24h (AVERT).

Malignant MCA <48h

WhoLarge MCA infarct, age <60, declining GCS.
DoRefer for decompressive hemicraniectomy within 48h.
CounselConverts deaths to survival, often with disability — not to good function.

5 Intracerebral haemorrhage — the high-yield moves

Reverse the anticoagulant — urgently

DabigatranIdarucizumab 5 g IV (2 × 2.5 g). Also used before lysis if dabigatran on board.
Xa inhibitorPCC (e.g. Prothrombinex ~50 U/kg) ± andexanet where available (access/cost-limited in AU; ANNEXA-I thrombotic signal).
WarfarinVit K 10 mg IV + PCC.

Everything else

BPSmooth lowering; avoid extremes. Don't chase <140 aggressively.
NeurosurgCerebellar bleed / posterior-fossa compression / hydrocephalus → urgent referral ± EVD.
EvacuationRoutine supratentorial evacuation not beneficial (STICH / STICH II). Minimally-invasive still evolving.
BundleCare-bundle approach — new weak rec (2024).

Sources. Stroke Foundation. Australian & New Zealand Living Clinical Guidelines for Stroke Management, Ch.3 (Acute medical & surgical management); InformMe living-guideline updates, Dec 2024 cycle. Trials/SR: Emberson Lancet 2014 (alteplase IPD); AcT 2022 & TRACE-2 (tenecteplase non-inferiority); Ma EXTEND NEJM 2019 & Campbell pooled 2019; WAKE-UP 2018; MR CLEAN/ESCAPE/EXTEND-IA/SWIFT-PRIME/REVASCAT 2015; DAWN 2017, DEFUSE-3 2018; SELECT2 & ANGEL-ASPECT 2023 (large core); TESLA 2024; Vahedi pooled 2007 (hemicraniectomy); IST & CAST 1997 (aspirin); Anderson INTERACT2 NEJM 2013 (primary endpoint negative); ATACH-2 NEJM 2016; PRISMS 2018 & Doheim Neurology 2025 (minor non-disabling stroke); CLOTS-3; AVERT 2015. Note: ICH BP row corrects the original teaching slide, which carried the stroke-unit figures (ARR 3.6 / NNT 28) into the ICH row — almost certainly a copy-paste artefact.