Attention to ABC (National stroke foundation recommend treating hypertension if >220/120)

Investigation - CTB to confirm or exclude haemorrhage and confirm dx

Most evidence for IV recombinant tissue plasminogen activator (Alteplase)

Reduces death and disability but is associated with a risk of intracranial haemorrhage

Indications - Ischaemic stoke of <4.5 hrs duration (CT shown no haemorrhage or any non vascular cause for stroke)

Contraindications - stroke or head trauma within 3/12, hx intracranial bleed, major surgery within 14 days, GI/GU haemorrhage within 30 days, MI within 30 days, HTN>180/110, Coagulopathy, seizure at onset of stroke)

Risk of vascular damage or dissection with potential worsening symptoms

Indications - ischaemic stroke in a large vessel, failure or CI to thrombolysis or outside time window

Contraindications - tortuous vessels, pre-existing coagulopathy, established infarct on CT, contrast allergy

Requires selective catheterisation of the target vessel and delivery of a concentrated dose of thrombolysis

Greater rates of recanulisation but no evidence this impacts death or disability

Indications - Ischaemic stroke <6 hrs duration, CI to IV thrombolysis (e.g. recent surgery)