Ischaemic stroke

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 computed tomographic (CT) scan. Early initiation of reperfusion strategies (intravenous thrombolysis or mechanical thrombectomy) 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 non-enhanced CT scan as soon as possible (at most within 1 hour of arrival at hospital). 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.

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.

Tenecteplase may be considered as a safe and effective alternative to alteplase within 4.5 hours of ischaemic stroke, but is off-label for this indication in the UK.

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”.[1]Aho K, Harmsen P, Hatano S, et al. Cerebrovascular disease in the community: results of a WHO collaborative study. Bull World Health Organ. 1980;58(1):113-30. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2395897 http://www.ncbi.nlm.nih.gov/pubmed/6966542?tool=bestpractice.com

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.