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