FFinalistSouthampton · 2027
Acute care
AKT · Acute care/Neurological

Acute ischaemic stroke

Cerebral arterial occlusion → infarction (time-critical)

Overview

Sudden focal neurological deficit from cerebral ischaemia. The emergency task is to confirm it is ischaemic (not haemorrhagic) on imaging and reperfuse within the window — thrombolysis (≤4.5 h) and/or thrombectomy for large-vessel occlusion.

Recognise

  • Sudden focal deficit: unilateral weakness, facial droop, dysphasia, visual/sensory loss (FAST)
  • Maximal at onset; time of onset is critical
  • Posterior circulation: vertigo, ataxia, diplopia, reduced consciousness

Red flags

  • Within the thrombolysis window, large-vessel occlusion, fluctuating/worsening deficit; exclude haemorrhage first

Differentials & how to tell them apart

Intracerebral haemorrhageimaging distinguishes — must exclude before thrombolysis
Hypoglycaemialow glucose can mimic stroke — always check and correct
Seizure (Todd’s paresis)post-ictal transient deficit
Migraine with aura / functionalgradual march, positive symptoms, normal imaging

Investigations

Immediate non-contrast CT head (exclude haemorrhage); capillary glucose (mimic); CT angiography for large-vessel occlusion; ECG (AF).

Management

Exclude haemorrhage on CT → thrombolysis ≤4.5 h ± thrombectomy for large-vessel occlusion

  1. 1FAST recognition, immediate CT, check glucose. Ischaemic + within 4.5 h + no contraindication → thrombolysis; large-vessel occlusion → mechanical thrombectomy (up to 24 h in selected patients).Gate: Thrombolysis is contraindicated until intracerebral HAEMORRHAGE is excluded on CT (and with recent surgery/bleeding, uncontrolled hypertension, etc.)
  2. 2Aspirin 300 mg once haemorrhage excluded (delay 24 h post-thrombolysis); admit to a stroke unit; secondary prevention (antiplatelet/anticoagulation for AF, statin, BP).
Alteplase/tenecteplase (thrombolysis) — within 4.5 h if no contraindication, haemorrhage excluded
Aspirin 300 mg — after haemorrhage excluded (and ≥24 h after thrombolysis)

Key points

"Time is brain." Always check glucose (mimic). Anticoagulation for AF starts later (haemorrhagic transformation risk), not acutely.

Monitor & prognosis

Neuro obs/NIHSS, BP, swallow screen, post-thrombolysis bleeding watch.

Better with faster reperfusion; stroke-unit care improves outcomes.

Source: NICE NG128 (stroke and TIA)