The first hour
- Airway, breathing, circulation — recovery position if the consciousness is depressed, oxygen only if saturation is below 94%
- Capillary glucose — hypoglycaemia mimics stroke exactly and is reversible in two minutes
- Time last seen well, not time found. A patient who wakes with a deficit is timed from when they went to bed
- Focused neurological examination and an NIHSS score
- Urgent non-contrast CT of the brain — the single decision that everything else depends on
- Nil by mouth until a swallow screen is done
- ECG, full blood count, urea and electrolytes, creatinine, clotting screen, lipids, HIV test in a young patient
Ischaemic or haemorrhagic?
| Feature | Favours infarction | Favours haemorrhage |
|---|---|---|
| Onset | Deficit maximal at onset or stuttering; often on waking | Sudden, during exertion or emotion |
| Headache and vomiting | Uncommon | Common and early |
| Consciousness | Usually preserved initially | Often depressed, deteriorating |
| Blood pressure | Raised | Very high, often above 200 systolic |
| Neck stiffness | Absent | May be present |
| CT in the first hours | May be normal; loss of grey–white differentiation, a hyperdense artery | Hyperdense blood visible immediately |
Oxford (Bamford) classification
| Syndrome | Criteria | Prognosis |
|---|---|---|
| TACS — total anterior circulation | All three: higher cortical dysfunction, homonymous hemianopia, and motor or sensory deficit of at least two of face, arm and leg | Worst; high mortality |
| PACS — partial anterior circulation | Two of the three, or higher cortical dysfunction alone | High early recurrence |
| LACS — lacunar | Pure motor, pure sensory, sensorimotor or ataxic hemiparesis; no cortical signs, no hemianopia | Best outcome |
| POCS — posterior circulation | Cranial nerve palsy with contralateral deficit, bilateral signs, cerebellar signs, isolated hemianopia | Variable; basilar occlusion is devastating |
Reperfusion
Intravenous thrombolysis
Alteplase 0.9 mg/kg (maximum 90 mg) — 10% as a bolus, the remainder infused over one hour — within 4.5 hours of onset, or tenecteplase 0.25 mg/kg (maximum 25 mg) as a single bolus over 5 seconds, which is easier to give and does not tie up an infusion pump during transfer.
| Include | Exclude |
|---|---|
| Clinical diagnosis of stroke, age 18 or over | Sustained blood pressure above 185/110 mmHg despite treatment |
| Onset to needle 4.5 hours or less | Bleeding diathesis or anticoagulation |
| CT showing no haemorrhage and no oedema affecting more than one-third of the middle cerebral artery territory | Recent head injury or previous intracerebral haemorrhage |
| Major surgery in the last 14 days; gastrointestinal bleeding in the last 21 days; recent myocardial infarction |
After the infusion: frequent blood pressure monitoring, no other antithrombotic for 24 hours, avoid urethral catheterisation for at least 2 hours, and repeat the CT if the patient deteriorates or the blood pressure becomes uncontrolled — stopping the infusion and giving cryoprecipitate if haemorrhage is found.
Mechanical thrombectomy
- For proven large-vessel occlusion — internal carotid, middle cerebral or basilar artery — on CT angiography, within 6 hours
- Beyond 6 hours and up to 16–24 hours in selected patients with favourable perfusion imaging, on the DAWN and DEFUSE-3 criteria
- Given in addition to thrombolysis where both are possible, or alone where thrombolysis is contraindicated
Blood pressure — the rule candidates get wrong
| Situation | Action |
|---|---|
| Ischaemic stroke, not for thrombolysis | Leave it alone unless it exceeds 220/120 mmHg, or there is malignant hypertension, myocardial ischaemia, aortic dissection or heart failure. Permissive hypertension maintains collateral flow to the penumbra |
| Ischaemic stroke, for thrombolysis | Must be at or below 185/110 mmHg before treatment, and kept below 180/105 for 24 hours afterwards |
| Intracerebral haemorrhage | Lower carefully towards a systolic of 140 mmHg where the presenting systolic is 150–220 mmHg |
| Long term, after the acute phase | Treat everyone, aiming low — well below 140/90 mmHg — starting a few days to weeks after the event |
Use a controllable intravenous agent — labetalol or nicardipine infusion — not sublingual nifedipine, which causes an uncontrolled fall and extends the infarct. See Hypertensive emergencies and secondary hypertension.
Antiplatelet treatment
- Aspirin 300 mg (160–300 mg) as soon as haemorrhage is excluded, then 75 mg daily; give it rectally or by nasogastric tube if swallowing is unsafe
- After thrombolysis, wait 24 hours and repeat imaging before starting it
- Minor stroke (NIHSS 5 or less) or high-risk TIA: dual antiplatelet therapy for 21–30 days — aspirin plus clopidogrel (300–600 mg loading dose, then 75 mg daily) or ticagrelor — then a single agent for life. Longer dual therapy only increases bleeding
- Atrial fibrillation: anticoagulate, but not immediately — the usual practice is to start after 1 day in a TIA, 3 days in a small stroke, 6 days in a moderate stroke and about 12 days in a large one, to avoid haemorrhagic transformation. See Atrial fibrillation with ischaemic heart disease
Stroke unit care — what works everywhere
Organised stroke unit care reduces death and dependency more than any single drug, and it costs nothing but discipline.
| Measure | Detail |
|---|---|
| Swallow screen before any oral intake | Nasogastric feeding within 24 hours if unsafe; aspiration pneumonia is a leading cause of death |
| Glucose | Keep between 7.8 and 10 mmol/L; treat hypoglycaemia at once. Tight control does not improve outcome |
| Fever | Treat above 37.5 °C with paracetamol and look for the source — pneumonia, urinary infection, malaria |
| Hydration | Normal saline; avoid dextrose-containing fluids, which worsen cerebral oedema |
| Venous thromboembolism | Intermittent pneumatic compression; low-molecular-weight heparin once haemorrhage is excluded and the patient is stable. Not graduated stockings, which do not work and cause skin damage |
| Pressure areas, bladder and bowels | Two-hourly turning; avoid an indwelling catheter where possible |
| Early mobilisation and physiotherapy, occupational and speech therapy | Start within 24–48 hours, but avoid very early high-intensity mobilisation in the first 24 hours |
| Mood and cognition | Screen for post-stroke depression, which is common and treatable |
Surgical referral
- Decompressive hemicraniectomy for malignant middle cerebral artery infarction with deteriorating consciousness — it halves mortality, and improves outcome in survivors; benefit is smaller but real above 60 years. Best done within 48 hours
- Suboccipital decompression for cerebellar infarction with deterioration, before brainstem compression develops — a cerebellar stroke can look like labyrinthitis, and head or neck pain suggests vertebral dissection
- Neurosurgical referral for cerebellar haemorrhage over 3 cm, hydrocephalus, or a superficial lobar haematoma with deterioration
Secondary prevention — start before discharge
Antiplatelet or anticoagulant as above · high-intensity statin regardless of the cholesterol level · blood pressure control · diabetes control · smoking and alcohol cessation · weight, diet and exercise advice · carotid imaging, with endarterectomy for symptomatic stenosis of 50–99% within two weeks · screen for atrial fibrillation with prolonged monitoring where the cause is otherwise unexplained · sickle cell disease, HIV, syphilis and vasculitis screening in a young patient with no vascular risk factors.
Examiner questions
References
- Longo DL, Fauci AS, Kasper DL, Hauser SL, Jameson JL, Loscalzo J, et al., eds. Harrison's Principles of Internal Medicine. 22nd ed. New York: McGraw Hill; 2025.
- Powers WJ, Rabinstein AA, Ackerson T, et al. Guidelines for the early management of patients with acute ischemic stroke: 2019 update. Stroke. 2019;50:e344–418.
- National Institute for Health and Care Excellence. Stroke and transient ischaemic attack in over 16s: diagnosis and initial management (NG128). London: NICE; 2019, updated 2022.