Acute management

Keep temperature between 36.5°C and 37°C

Treat acute seizures

For haemorrhagic stroke

Immediate referral to a centre with neurosurgical facilities (?for drainage)

For cerebellar stroke presenting in coma

Referral to a centre with neurosurgical facilities (?for drainage hydrocephalus or decompression)

For large middle cerebral artery territory lesions presenting in coma

Referral to a centre with neurosurgical facilities (?for decompression)

For stroke in sickle cell disease

Exchange transfusion

For ischaemic stroke occurring in hospital and imaged within three hours

Consider intravenous tissue plasminogen activator

For venous sinus thrombosis, extracranial arterial dissection, and known prothrombotic disorder

Heparin acutely

Warfarin for three to six months

For strokes secondary to other mechanisms

Early prophylaxis with low dose aspirin (1 mg/kg)

For all

Early rehabilitation by team comprising nursing staff, physiotherapist, occupational therapist, speech therapist, and psychologist

Prevention of recurrence

For sickle cell disease

Regular transfusion (4–6 weekly) to keep haemoglobin S < 20%

For moyamoya

Consider revascularisation, particularly if transient ischaemic attacks or cognitive decline

For homozygotes for the thermolabile methylene tetrahydrofolate reductase gene

B complex vitamin supplementation

For those with an important prothrombotic disorder or extracranial arterial dissection

Consider warfarin (discuss with haematologist in individual case)

For others with stroke in a vascular distribution and/or cerebrovascular disease

Low dose aspirin 1 mg/kg