{
  "schema_version": 1,
  "kind": "condition",
  "id": "stroke-emergency-referral",
  "name": "Stroke (Emergency Referral)",
  "category": "acute",
  "sources": "Ischemic Stroke - StatPearls (NCBI Bookshelf NBK499997) - https://www.ncbi.nlm.nih.gov/books/NBK499997/: \"An organized stroke protocol is highly recommended to expedite patient evaluation and treatment\", \"a plain CT scan of the head is recommended within 20 minutes of patient presentation to exclude hemorrhage\", and \"tPA or TNK should be considered if a thrombotic cerebrovascular accident (CVA) is identified within 4.5 hours of symptom onset.\" · ESO Guidelines for the management of ischaemic stroke 2021 · Egyptian National Drug Formulary - Cardiovascular 2024 (acetylsalicylic acid monograph, p111)",
  "review_status": "reviewed",
  "verified_against": "Ischemic Stroke - StatPearls (NCBI Bookshelf NBK499997) - https://www.ncbi.nlm.nih.gov/books/NBK499997/: \"An organized stroke protocol is highly recommended to expedite patient evaluation and treatment\", \"a plain CT scan of the head is recommended within 20 minutes of patient presentation to exclude hemorrhage\", and \"tPA or TNK should be considered if a thrombotic cerebrovascular accident (CVA) is identified within 4.5 hours of symptom onset.\" · Egyptian National Drug Formulary - Cardiovascular 2024 (acetylsalicylic acid monograph, p111)",
  "verified_date": "2026-08",
  "treatments": [
    {
      "id": 1732,
      "generic": "Acetylsalicylic acid",
      "line": 1,
      "is_adjunct": false,
      "form": "oral.solid",
      "strength_mg": 300.0,
      "adult_dose": "NOT IN THE CLINIC AND NOT BEFORE THE SCAN. Once a haemorrhage has been excluded and the thrombolysis decision has been made: 75 to 150 mg once daily; up to 300 mg daily may be needed acutely, for a short period.",
      "adult_duration": "Within 24 to 48 hours of symptom onset - but 24 hours after intravenous alteplase if that was given - and continued",
      "dose_source": "Egyptian National Drug Formulary - Cardiovascular 2024 (acetylsalicylic acid monograph, p111)",
      "rationale": "The cited article recommends antiplatelet treatment with aspirin within 24 to 48 hours of symptom onset, and gives no amount. The Egyptian formulary names ischaemic stroke and transient ischaemic attack among the vascular indications for acetylsalicylic acid and gives 75 to 150 mg once daily, with up to 300 mg for a short time in acute cases.",
      "cautions": [
        "THIS IS NOT A REASON TO DELAY THE AMBULANCE, AND NOT SOMETHING TO GIVE BEFORE IT ARRIVES. It is printed so that a GP knows what the patient will be started on and when, not so that it is started here.",
        "IMAGING FIRST. Aspirin is for ischaemic stroke. Given in a haemorrhage it makes the bleed worse, and only a scan tells the two apart.",
        "TIMING AROUND THROMBOLYSIS IS NOT OPTIONAL. The article states that aspirin is typically delayed until 24 hours after intravenous alteplase, and that intravenous aspirin must not be given within 90 minutes of starting it.",
        "THE CLOCK IS THE POINT OF THE REFERRAL, NOT THE TABLET. The article gives alteplase at 0.9 mg/kg (10% as a bolus over a minute, maximum 90 mg over 60 minutes), or a single tenecteplase bolus of 0.25 mg/kg (maximum 25 mg) in a patient eligible for thrombectomy. Those are hospital decisions inside a narrow window - which is why the transfer comes first and this drug does not delay it.",
        "DUAL ANTIPLATELET THERAPY IS A DEFINED SUBGROUP, NOT THE DEFAULT. The article limits aspirin with clopidogrel started within 24 hours to minor, non-cardioembolic ischaemic stroke in a patient who did not receive alteplase.",
        "Do not give in hypersensitivity to NSAIDs, in asthma with rhinitis and nasal polyps, or in active peptic ulceration."
      ],
      "peds_mgkg_low": null,
      "peds_mgkg_high": null,
      "peds_max_mg": null,
      "peds_basis": null,
      "peds_unit": null,
      "peds_note": "Stroke in a child is a different problem with different causes and is not covered here. The formulary's standing rule applies: do not give aspirin under 18 in a child who has or is recovering from chickenpox or an influenza-like illness, because of Reye's syndrome.",
      "peds_min_weight_kg": null,
      "peds_max_weight_kg": null,
      "peds_age_min_months": null,
      "peds_age_max_months": null,
      "peds_age_bands": null,
      "peds_doses": null,
      "brands": [
        {
          "trade_name": "ASPOCID 300 MG 200 TABS.",
          "scientific_name": null,
          "normalized_ingredient": null,
          "manufacturer": "CID",
          "price_egp": 80.0,
          "pack_count": 200,
          "unit_price": 0.4,
          "strength_mg": 300.0,
          "exact_strength": true,
          "exact_form": true,
          "discontinued": false,
          "also_contains": null
        }
      ],
      "condition_id": "stroke-emergency-referral"
    },
    {
      "id": 1733,
      "generic": "Referral & safety-netting (no drug therapy)",
      "line": 1,
      "is_adjunct": false,
      "form": null,
      "strength_mg": null,
      "adult_dose": "Call emergency services immediately for urgent transport to a hyperacute stroke centre for emergency brain CT or MRI and revascularisation assessment (intravenous thrombolysis / mechanical thrombectomy). Do NOT give aspirin and do NOT lower the blood pressure in primary care - the aspirin entry above is what the patient is started on AFTER the scan has excluded a haemorrhage and after the thrombolysis decision, not before.",
      "adult_duration": "Immediate emergency transfer",
      "dose_source": "Ischemic Stroke - StatPearls (NCBI Bookshelf NBK499997) - https://www.ncbi.nlm.nih.gov/books/NBK499997/: \"An organized stroke protocol is highly recommended to expedite patient evaluation and treatment\", \"a plain CT scan of the head is recommended within 20 minutes of patient presentation to exclude hemorrhage\", and \"tPA or TNK should be considered if a thrombotic cerebrovascular accident (CVA) is identified within 4.5 hours of symptom onset.\"",
      "rationale": "Acute stroke is a time-critical emergency requiring emergency neuroimaging to differentiate ischemic from hemorrhagic stroke before any antithrombotic or antihypertensive treatment is initiated.",
      "cautions": [
        "TIME-CRITICAL EMERGENCY: Transport immediately to a stroke center capable of brain CT/MRI and IV thrombolysis (within 4.5 hours of onset) or mechanical thrombectomy (within 6-24 hours).",
        "DO NOT administer aspirin, NSAIDs, anticoagulants, or antiplatelet therapy prior to neuroimaging excluding intracranial hemorrhage.",
        "DO NOT acutely lower blood pressure in primary care pre-hospital setting. Rapid blood pressure reduction impairs cerebral perfusion to the ischemic penumbra; acute hypertensive management (>220/120 mmHg) is performed only in hospital after CT/MRI neuroimaging (NICE NG128 / ESO).",
        "Check point-of-care capillary blood glucose immediately to rule out hypoglycemia, which mimics acute stroke."
      ],
      "peds_mgkg_low": null,
      "peds_mgkg_high": null,
      "peds_max_mg": null,
      "peds_basis": null,
      "peds_unit": null,
      "peds_note": "Pediatric stroke requires immediate emergency transport to a tertiary pediatric intensive care unit with pediatric neurovascular capabilities.",
      "peds_min_weight_kg": null,
      "peds_max_weight_kg": null,
      "peds_age_min_months": null,
      "peds_age_max_months": null,
      "peds_age_bands": null,
      "peds_doses": null,
      "brands": [],
      "condition_id": "stroke-emergency-referral"
    }
  ]
}