NICE vs RCP: Management of Stroke (2025)

This guide provides a comparative overview of the key recommendations from the National Institute for Health and Care Excellence (NICE) guideline NG236 and the Royal College of Physicians (RCP) National Clinical Guideline for Stroke (2023). Both documents are essential reading for UK clinicians managing stroke patients. While their overarching principles are aligned, differences in scope, detail, and practical emphasis exist. This comparison focuses on the acute and early management phases to highlight these nuances for clinical practice.

See how this translates to practice: Explore our Clinical governance features, visit the Patient Safety Hub, or review Clinical Safety & Assurance for enterprise rollout.

Diagnosis and Initial Assessment

The immediate recognition and assessment of stroke are critical for time-sensitive treatments. Both guidelines emphasise the use of the FAST (Face, Arms, Speech, Time) test for public and pre-hospital identification.

NICE (NG236)

• Imaging: Recommends immediate brain imaging for all patients with suspected acute stroke. Non-contrast CT is the first-line modality to exclude haemorrhage.
• Hyperacute Assessment: Stresses the use of a validated scale, such as the NIHSS (National Institutes of Health Stroke Scale), to assess stroke severity.
• Vessel Imaging: Advises that for patients being considered for thrombectomy, CT or MR angiography should be performed at the same time as the initial brain imaging to avoid delays.

RCP Guideline

• Imaging: Echoes the need for immediate imaging. Provides more detailed discussion on the potential role of MRI with diffusion-weighted imaging (DWI) in cases of diagnostic uncertainty, particularly for posterior circulation strokes.
• Hyperacute Assessment: Also recommends the NIHSS but provides more comprehensive guidance on the systematic assessment of other factors, including swallow screen, hydration, and glucose control, from the moment of arrival.
• Key Difference: The RCP guideline offers more extensive, system-wide operational detail on the setup and function of hyperacute stroke units (HASUs), including staffing models and monitoring requirements.

Practical Takeaway: The key difference is operational. NICE provides a clear, direct pathway for the individual patient (image + angiogram simultaneously). RCP expands on the infrastructure needed to deliver this efficiently (the HASU model).

Acute Treatment: Thrombolysis and Thrombectomy

Both guidelines strongly advocate for reperfusion therapy in eligible patients.

Thrombolysis (Alteplase)

• NICE & RCP (Aligned): Both recommend intravenous thrombolysis with alteplase for eligible patients within 4.5 hours of symptom onset. The guidelines detail contraindications and the need for careful benefit-risk discussion, especially in milder strokes.
• Key Nuance: NICE has a specific technology appraisal (TA264) that recommends alteplase within its licensed indication (0-4.5 hours). The RCP guideline discusses the evidence base more broadly, including off-label discussions for wake-up strokes where advanced imaging is used (a rapidly evolving area).

Thrombectomy

• NICE & RCP (Aligned): Both strongly recommend mechanical thrombectomy for patients with confirmed large vessel occlusion (LVO) in the anterior circulation, presenting within 6 hours of onset.
• Extended Time Windows: Both guidelines also support thrombectomy in selected patients in an extended time window (up to 24 hours) based on advanced imaging (CT perfusion or MRI-DWI) confirming a favourable penumbra.
• Key Difference: The RCP guideline provides more explicit and assertive guidance on service configuration, stating that thrombectomy services should be available 24/7 and that patients should be transferred directly to a thrombectomy centre if suspected of having an LVO, bypassing the nearest non-thrombectomy hospital ("drip-and-ship" vs "mothership" models).

Practical Takeaway: For the clinician at the receiving end, the treatment indications are identical. The major difference lies in pre-hospital and inter-hospital logistics, where the RCP guideline is more prescriptive about bypass protocols to maximise access to thrombectomy.

Management in Special Situations

Transient Ischaemic Attack (TIA)

• NICE (NG236): Recommends using the ABCD² score to assess the risk of subsequent stroke. Patients with an ABCD² score of 4 or above should have specialist assessment and investigation within 24 hours.
• RCP Guideline: Moves away from the ABCD² score, arguing it is not a reliable triage tool. Instead, it recommends that all suspected TIAs should be assessed within 24 hours by a specialist. This is a significant practical divergence.

Blood Pressure Management in Acute Stroke

• NICE: Advises not to lower blood pressure in the acute phase of an ischaemic stroke unless there is a comorbid hypertensive emergency. For haemorrhagic stroke, it recommends cautious lowering to a target of 140/90 mmHg.
• RCP: Provides more nuanced guidance, discussing specific thresholds and agents. For ischaemic stroke, it recommends starting antihypertensives only if BP is persistently >220/120 mmHg. For intracerebral haemorrhage (ICH), the target is more specific: SBP 130-140 mmHg within 1 hour of diagnosis.

Anticoagulation-Associated Intracerebral Haemorrhage

• NICE: Recommends prompt reversal of anticoagulation. For patients on DOACs, suggests using a specific reversal agent (e.g., Idarucizumab for dabigatran) if available.
• RCP: Provides a more detailed and urgent protocol, strongly emphasising the immediate reversal of anticoagulation. It gives clear pathways for vitamin K antagonists (PCC) and DOACs (specific reversal agents as first-line) and stresses this should not be delayed for imaging.

Practical Clinical Flow: Acute Ischaemic Stroke

This flow chart synthesises both guidelines into a practical pathway for front-line clinicians.

1. Suspicion of Stroke (Pre-hospital): FAST positive. Emergency services alert hospital. Paramedics consider LVO screening tools for potential thrombectomy centre transfer.
2. Arrival at Hospital (Door): Immediate clinical assessment (NIHSS), swallow screen, bloods (including glucose).
3. Imaging (Within 15 mins): Non-contrast CT + CT Angiography simultaneously. Confirm ischaemic stroke vs ICH. Identify LVO.
4. Thrombolysis Decision (Within 30-45 mins): If ischaemic stroke <4.5 hours and eligible, administer alteplase.
5. Thrombectomy Decision: If LVO is confirmed and patient is eligible (within 6 hours, or selected patients 6-24 hours), arrange immediate thrombectomy. This may involve inter-hospital transfer.
6. Admission to HASU: Admit to a hyperacute stroke unit for frequent monitoring, multidisciplinary assessment, and secondary prevention initiation.

Frequently Asked Questions (FAQs)

1. Which guideline should I follow if they conflict?

In practice, major clinical conflicts are rare. NICE guidelines are often considered the national standard for England and Wales. The RCP guideline provides more granular, operational, and specialist detail. Trusts typically develop their own local protocols that integrate both. For specific dilemmas (e.g., TIA triage), the local protocol is definitive.

2. What is the single biggest difference between the guidelines?

The most significant practical difference is in TIA triage. NICE supports the use of the ABCD² score to prioritise assessments within 24 hours for high-risk patients. The RCP recommends a 24-hour specialist assessment for all suspected TIAs, irrespective of the ABCD² score.

3. Do the guidelines differ on secondary prevention?

No, they are highly aligned. Both recommend dual antiplatelet therapy (aspirin + clopidogrel) for short-term use after non-cardioembolic ischaemic stroke/TIA, followed by single antiplatelet therapy long-term. Both advise high-intensity statins and rigorous management of vascular risk factors.

4. How do they address stroke mimics?

Both acknowledge the high rate of mimics (e.g., seizures, migraine). NICE highlights the importance of rapid imaging to aid differentiation. The RCP provides more detailed clinical descriptions and a stronger emphasis on the role of specialist clinical assessment to identify mimics without delaying treatment for true strokes.

5. Where is rehabilitation covered?

This is a major difference in scope. The NICE guideline (NG236) focuses primarily on acute care and early secondary prevention. The RCP guideline is vastly more comprehensive, with extensive chapters on all aspects of rehabilitation, long-term care, and community reintegration, making it the primary resource for post-acute management.

Source Links

• NICE Guideline NG236 (May 2023, last updated Feb 2024): Stroke and transient ischaemic attack in over 16s: diagnosis and initial management
• RCP National Clinical Guideline for Stroke (2023): National Clinical Guideline for Stroke for the United Kingdom and Ireland