Ischaemic stroke is a leading cause of morbidity and mortality. If you suspect stroke, work rapidly through the initial assessment and aim for quick access to CT scan. Early initiation of thrombolysis (i.e., within 4.5 hours from onset of symptoms, if not contraindicated) is associated with improved functional outcomes.
Use a validated tool to aid recognition: use ROSIER (Recognition of Stroke in the Emergency Room) in the emergency department; use FAST (Face Arm Speech Test) in the community.
Manage any airway, breathing, and circulatory insufficiencies requiring urgent treatment.
Admit everyone with suspected stroke directly to a hyperacute or acute stroke unit within 4 hours of presentation.
Request an immediate (i.e., ideally in the next available time slot and definitely within 1 hour of arrival at hospital) non-enhanced CT scan if indicated. Ischaemic stroke is a clinical diagnosis based on signs and symptoms. A normal CT scan does not rule out a stroke but will rule out intracranial haemorrhage, which must be excluded before starting thrombolysis.
Admit the patient directly to a hyperacute or acute stroke unit as soon as possible; UK guidelines recommend doing this within 4 hours of presentation to hospital.
Intravenous alteplase should be given (if not contraindicated) if treatment is started as soon as possible within 4.5 hours of onset of symptoms AND intracranial haemorrhage has been excluded by imaging.
Mechanical thrombectomy can be performed in selected patients within 6 to 24 hours of symptoms onset.
The World Health Organization defines stroke as “a clinical syndrome consisting of rapidly developing clinical signs of focal (or global) disturbance of cerebral function, lasting more than 24 hours or leading to death, with no apparent cause other than that of vascular origin”.
Stroke can be further subdivided into ischaemic stroke (caused by vascular occlusion or stenosis) and haemorrhagic stroke (caused by vascular rupture, resulting in intraparenchymal and/or subarachnoid haemorrhage). Central venous sinus thrombosis is a rare form of stroke that occurs due to thrombosis of the dural venous sinuses. This topic focuses on the first 24 hours of acute care of patients with ischaemic stroke.
For information on other types of stroke, see Stroke due to spontaneous intracerebral haemorrhage, Subarachnoid haemorrhage, and Cavernous sinus thrombosis.
History and exam
Key diagnostic factors
- unilateral weakness or paralysis in the face, arm or leg
- visual disturbance
- risk factors
Other diagnostic factors
- sensory loss (numbness)
- gaze paresis
- arrhythmias, murmurs, or pulmonary oedema
- nausea and/or vomiting
- neck or facial pain
- miosis, ptosis, and facial anhidrosis (hemilateral)
- decreased level of consciousness or coma
- older age
- family history of stroke
- history of ischaemic stroke or TIA
- diabetes mellitus
- atrial fibrillation
- comorbid cardiac conditions
- carotid artery stenosis
- sickle cell disease
- lower levels of education
- African-American or Hispanic ancestry
- poor diet and nutrition
- physical inactivity
- alcohol abuse
- oestrogen-containing therapy
- obstructive sleep apnoea
- illicit drug use
- elevated lipoprotein(a)
- hypercoagulable states
- elevated C-reactive protein
- aortic arch plaques
1st investigations to order
- non-contrast CT head
- serum glucose
- serum electrolytes
- serum urea and creatinine
- cardiac enzymes
- prothrombin time and PTT (with INR)
Investigations to consider
- serum toxicology screen
- diffusion-weighted MRI head
- CT angiography or MR angiography ± contrast
- CT or MRI perfusion-weighted imaging
- carotid ultrasound
suspected ischaemic stroke
confirmed ischaemic stroke
Matthew Jones, MD, FRCP
Greater Manchester Neurosciences Centre
Salford Royal Foundation Trust
Honorary Senior Lecturer
University of Manchester
MJ is the chair of the Association of British Neurologists Education Committee (unpaid position). MJ is a faculty member of an MRCP revision course.
Rachael Power, MBChB, MRCP
Manchester Centre for Clinical Neurosciences
RP has been sponsored by Novartis to attend the International Headache Conference.
BMJ Best Practice would like to gratefully acknowledge the previous expert contributor for this topic, whose work has been retained in parts of the content:
George Ntaios, MD, MSc (ESO Stroke Medicine), PhD, FESO
Assistant Professor of Internal Medicine
University of Thessaly
GN is on the advisory boards for, and has received honoraria, speaker fees, and research support from: Amgen, Bayer, Boehringer-Ingelheim, BMS/Pfizer, Elpen, Galenica, Medtronic, Sanofi, and Winmedica.
BMJ Best Practice would like to gratefully acknowledge Dr Hamish McAuley for his previous involvement in the creation of comorbidity content relevant to asthma and COPD.
Kayvan Khadjooi, MD, FRCP, PGCertMedEd
Consultant in Stroke Medicine
School of Clinical Medicine
University of Cambridge
KK has received travel grants for conferences/speaker honoraria from Bayer, Boehringer, Daiichi-Sankyo, Pfizer, and Shire.
Section Editor, BMJ Best Practice
HDC declares that she has no competing interests.
Lead Section Editor, BMJ Best Practice
TAO declares that she has no competing interests.
Comorbidities Editor, BMJ Best Practice
JC declares that she has no competing interests.
Drug Editor, BMJ Best Practice
AM declares that he has no competing interests.
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