Stroke: early management (warning signs, pre-hospital phase, initial hospital phase, indications for intravenous thrombolysis and mechanical thrombectomy)

Objectives 

• Identify information aimed at the general public to raise awareness of the warning signs and the importance of seeking urgent emergency care. 

• Optimise the pre-hospital and initial in-hospital care pathway of patients suspected of having a stroke, in order to be able to provide the best care to as many stroke patients as possible. 

• Provide early multidisciplinary care in a stroke unit as quickly as possible to reduce the frequency and severity of functional sequelae associated with stroke. If this is not possible, arrange care in a healthcare organisation that has an established care pathway for patients suspected of having a stroke, in coordination with a stroke unit. 

• Improve the professional practices of physicians involved in handling medical emergencies specifically emergency medicine physicians (in France, these are physicians who are called via the emergency helpline on 15), and all professionals involved in the initial treatment of strokes, including transient ischaemic attacks (TIAs). 

• Specify the indications for treating acute ischaemic stroke (2025 update). 

Key messages 

• Stroke is an absolute emergency. 

• Any sudden neurological deficit, whether temporary or prolonged, requires an immediate call to the medical emergency helpline on 15. 

• The physician handling the call should prioritise referring any patients displaying signs of stroke to a stroke unit.  

• Patients with signs suggestive of a stroke should undergo brain imaging tests, preferably a Magnetic Resonance Imaging (MRI) scan, as soon as possible. 

• In the event of ischaemic stroke, revascularisation treatments (intravenous thrombolysis and mechanical thrombectomy) should be initiated as soon as possible after a neurovascular opinion. 

Target 

The recommendations are aimed at all healthcare professionals and other individuals involved in the management of stroke patients, in particular: 

• general practitioners, 

• neurologists, emergency physicians, intensive care specialists, fire and rescue service physicians, radiologists and neuroradiologists, neurosurgeons, cardiologists, internal medicine specialists, geriatric specialists, angiologists, physical medicine and rehabilitation specialists, as well as nursing home coordinating physicians, 

• paramedical professionals (nurses, nursing assistants, physiotherapists, speech therapists, etc.) in emergency departments, stroke units and other departments receiving stroke patients, nursing staff in nursing homes, 

• medical emergency service helpline (15) staff including auxiliary medical dispatchers, 

• first responders and ambulance personnel. 

This guideline outlines the awareness-raising and information/training elements for the general public and professionals involved in the caring for stroke patients. It also details the steps to be taken in the pre-hospital phase following the observation of stroke symptoms. 

Initial hospital phase 

Hospital admission 

The in-hospital stroke pathway should be organised in advance and coordinated with all relevant parties, including emergency physicians, neurologists, radiologists, biologists, intensive care specialists. Written procedures should also be formalised. The pathway should prioritise rapid access to stroke specialist expertise and brain imaging in order to optimise the organisation of structural and functional aspects. 

• Upon arrival at a healthcare organisation with a stroke unit, patients should be seen by a stroke specialist. 

• Healthcare organisations that receive stroke patients but do not have a dedicated stroke unit should collaborate with one to develop care pathway for patients suspected of having a stroke. 

• If they were not performed in the pre-hospital phase, an electrocardiogram and standard laboratory tests, including haemostasis, a complete blood count and capillary glucose levels, should be performed urgently. Blood pressure, heart rate, oxygen saturation, and temperature should be monitored. 

Brain and vascular imaging 

• Patients suspected of having an acute stroke should have priority 24/7 access to brain imaging, with MRI scans being favoured wherever possible. Care protocols for these patients should be formalised and agreed upon by the relevant parties. 

• An investigation of the cervical arteries should be carried out as soon as possible in the event of any ischaemic stroke. 

Indications for intravenous thrombolysis and mechanical thrombectomy (2025 update) 

• The update to the clinical practice guidelines outlines the eligibility criteria for intravenous (IV) thrombolysis in patients who awake with stroke symptoms or have an unclear time of onset. It also clarifies the role of tenecteplase within the current care pathway and specifies the indications for IV thrombolysis in cases of minor stroke. 

• The indications for mechanical thrombectomy have also been added.