AKT · Neurology/Stroke & vascular

Ischaemic stroke

Cerebral arterial occlusion (thrombotic/embolic) → infarction

Overview

Sudden focal neurological deficit from cerebral ischaemia (~85% of strokes). The acute task is to exclude haemorrhage on CT and reperfuse within the window; the localisation (territory) and Bamford class are the high-yield exam skills. See the Stroke localisation panel below the cards.

Recognise

Sudden focal deficit: unilateral weakness/sensory loss, facial droop, dysphasia (FAST), maximal at onset
Territory clues: MCA = face+arm>leg + dysphasia/neglect · ACA = leg>arm · PCA = homonymous hemianopia with macular sparing
Posterior circulation (Wallenberg/Weber): vertigo, ataxia, crossed signs, diplopia, reduced GCS

Red flags

Within the thrombolysis window (≤4.5h), large-vessel occlusion (thrombectomy), fluctuating deficit; exclude haemorrhage first

Differentials & how to tell them apart

Haemorrhagic strokeclinically indistinguishable — only CT separates them; thrombolysis is contraindicated until haemorrhage excluded

Hypoglycaemialow glucose mimics stroke — always check and correct first

Todd paresis (post-ictal)transient deficit after a seizure, resolves

Hemiplegic migraine / functionalgradual march, positive symptoms, normal imaging

Space-occupying lesionsubacute progressive deficit, imaging

Investigations

IMMEDIATE non-contrast CT head (exclude haemorrhage) + capillary glucose (mimic); CT angiography for large-vessel occlusion; ECG (AF); ROSIER/NIHSS; carotid Doppler + echo for source.

Management

Exclude haemorrhage on CT → thrombolysis ≤4.5h ± thrombectomy; then aspirin 300 mg 14d

1FAST + immediate CT + glucose. Ischaemic + ≤4.5h + no contraindication → thrombolysis; proximal large-vessel occlusion → mechanical thrombectomy (≤6h, up to 24h selected).Gate: Thrombolysis is contraindicated until intracerebral HAEMORRHAGE is excluded on CT (and with recent surgery/bleeding, anticoagulation, uncontrolled hypertension)
2Aspirin 300 mg for 2 weeks (delay 24h post-thrombolysis), then clopidogrel 75 mg + atorvastatin 80 mg long-term. AF → anticoagulate after ~2 weeks. Carotid endarterectomy if >50% symptomatic stenosis.
3Stroke-unit care, swallow screen, early rehab, address modifiable risk factors.

Alteplase/tenecteplase — thrombolysis ≤4.5h if haemorrhage excluded + no contraindication

Aspirin 300 mg — 14 days once haemorrhage excluded (delay 24h after thrombolysis), then clopidogrel 75 mg long-term

Clopidogrel 75 mg + atorvastatin 80 mg — secondary prevention; DOAC/warfarin if AF (start after ~2 weeks)

Key points

"Time is brain." Always check glucose. Anticoagulation for AF is delayed (haemorrhagic-transformation risk), not started acutely. Lacunar strokes (pure motor/sensory) come from small-vessel disease.

Monitor & prognosis

NIHSS/neuro obs, BP, swallow, post-thrombolysis bleeding; secondary-prevention adherence.

Better with faster reperfusion and stroke-unit care.

Source: NICE NG128 (stroke and TIA)