NICE NG128 2022: stroke and TIA diagnosis and initial management

Who it applies to

Adults and young people over 16 presenting with suspected acute stroke or TIA in emergency, ambulance, or primary care settings.

Key recommendations

• Use a validated tool such as FAST to recognise possible stroke in the community and out-of-hospital settings.
• Use ROSIER to assess suspected acute stroke in emergency department or acute settings, recognising it does not exclude posterior circulation stroke.
• Admit all suspected acute stroke patients directly to a specialist acute stroke unit, bypassing other assessment areas where possible.
• Perform urgent brain imaging (usually non-contrast CT) immediately for patients who may be candidates for thrombolysis or thrombectomy, or have other urgent indications, and within 1 hour of arrival where possible.
• Offer intravenous thrombolysis (alteplase) to eligible patients within the licensed time window once haemorrhage is excluded and strict inclusion/exclusion criteria are met.
• Consider mechanical thrombectomy, with or without thrombolysis, as soon as possible for confirmed proximal large artery occlusion in the anterior circulation, and consider it for selected posterior circulation occlusions.
• Offer people with acute ischaemic stroke aspirin as soon as haemorrhage has been excluded by imaging, usually started within 24 hours.
• Assess people with suspected TIA using a validated clinical approach and arrange urgent specialist assessment, generally within 24 hours of symptom onset.
• Do not use scoring systems, such as ABCD2, to assess the risk of subsequent stroke or to inform the urgency of referral for suspected TIA.
• Arrange early carotid imaging for people with suspected TIA or non-disabling stroke who could be candidates for carotid endarterectomy.
• Screen all stroke patients for swallowing difficulties before oral intake, using a validated swallow screening tool.

What is new in this edition

• Updated and expanded guidance on mechanical thrombectomy, including extended time windows and wider patient selection using imaging criteria, compared with the original 2019 recommendations.
• Removed the use of ABCD2 scoring for TIA triage decisions, recommending all suspected TIAs be assessed urgently within 24 hours.

Practice points for students

• FAST is for public and prehospital recognition; ROSIER is for structured hospital assessment, and neither reliably detects posterior circulation stroke.
• Thrombolysis requires brain imaging first to exclude haemorrhage before alteplase is given.
• Suspected TIA needs urgent specialist review, generally within 24 hours, and ABCD2 should not be used to inform the urgency of this referral.
• All stroke patients should have swallow screening before anything is given orally, due to aspiration risk.
• Thrombectomy decisions depend on vessel imaging confirming large artery occlusion, not clinical severity alone.

Condition

Other guidelines on this topic

• 2026 Guideline for the Early Management of Patients With Acute Ischemic Stroke: A Guideline From the American Heart Association/American Stroke AssociationAHA/ASA2026Official guideline

Independent educational summary written by the WhiteCoat Pro editorial team with AI assistance and checked by a second AI model. It does not reproduce the guideline text, tables or figures, and it is not affiliated with or endorsed by NICE. It is not medical advice: always read the original guideline before applying it to patients.