A lot has changed in the world of stroke over the four years since the last edition of the Royal College of Physicians National Clinical Guideline for Stroke was published. The quality of stroke care provided in the UK has continued to improve as judged by the Sentinel Stroke National Audit Programme, which started collecting data in 2013. National Guideline Centre (UK). Stroke and transient ischaemic attack in over 16s: diagnosis and initial management. London: National Institute for Health and Care Excellence (UK); 2019 May. (NICE Guideline, No. 128.) Endorsed NICE Clinical Guidelines 2019/2020. Date published: 20 February 2020. Topics: Safety and quality; NICE clinical guidelines; Endorsed NICE Clinical Guidelines 2019/2020. NICE Clinical Guideline NG 128 - Stroke and transient ischaemic attack in over 16s: diagnosis and initial management (updates and replaces CG68) - HSC (SQSD) (NICE This guideline covers interventions in the acute stage of a stroke or transient ischaemic attack (TIA). It offers the best clinical advice on the diagnosis and acute management of stroke and TIA in the 48 hours after onset of symptoms Recommendations In May 2019, we reviewed the evidence and made new recommendations on: Management of Patients With Acute Ischemic Stroke" (2018 AIS Guidelines) 2a and this 2019 update. The systematic reviews for the 2018 AIS Guidelines have been previously published.3,4 These guidelines use the American College of Cardiology (ACC)/AHA Class of Recommendations (COR) and Level of Evidence (LOE) format shown in Table 1. Management of Stroke Rehabilitation (2019) The guideline describes the critical decision points in the Management of Stroke Rehabilitation and provides clear and comprehensive evidence based recommendations incorporating current information and practices for practitioners throughout the DoD and VA Health Care systems. The guideline is intended New recommendations include the following: IV alteplase may be helpful when administered within 4.5 hours of stroke symptom recognition in patients with acute ischemic stroke (AIS) who awake with stroke symptoms or have onset time of uncertain timing but >4.5 hours from last known well, when the DW-MRI lesion is smaller than one third of the Individualized exercise programs (which may include muscle strengthening, balance, and coordination activities) for people with stroke should be prescribed, delivered, and monitored by the rehabilitation team. Advise smokers to stop smoking and non-smokers to avoid passive smoking: The Stroke Foundation's Clinical Guidelines for Stroke Management are evolving into living guidelines as a next generation solution for health evidence translation. This three-year pilot project will build and evaluate a world-first, online, dynamically updating summary of stroke evidence to guide clinical practice and policy development. In May 2019, NICE published NICE Guideline (NG) 128 on Stroke and transient ischaemic attack in over 16s: diagnosis and initial management, 1 which updates and replaces the previous NICE guideline on stroke and TIAs. 5 The update includes some radical changes, mostly related to inpatient and secondary care diagnosis and management. Administration of aspirin is recommended in acute stroke patients within 24 to 48 hours after stroke onset. For patients treated with IV tPA, aspirin administration is generally delayed for 24 hours. Urgent anticoagulation (e.g., heparin drip) for most stroke pa