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This is a clinician-written, evidence-based summary aligned to the 2026 MLA Content Map. It is intended for medical students and junior doctors preparing for the UKMLA. Always cross-reference with NICE guidance, local protocols, and clinical judgement.
The Bottom Line
- Stroke = sudden-onset focal neurological deficit lasting >24 h (or imaging-confirmed). TIA = symptoms resolve within 24 h with no infarct on imaging
- Ischaemic (85%): thrombolysis (alteplase) within 4.5 h of onset; thrombectomy for large vessel occlusion up to 24 h with salvageable tissue
- Haemorrhagic (15%): reverse anticoagulation, control BP, neurosurgical assessment
- Immediate CT head (non-contrast) to distinguish ischaemic from haemorrhagic — this determines treatment
- Secondary prevention (ischaemic): antiplatelet (clopidogrel 300 mg then 75 mg), statin, BP control, AF screening
Overview
Stroke is defined as an acute neurological deficit caused by focal cerebrovascular disease lasting >24 hours (or resulting in death) or confirmed by imaging. Ischaemic stroke (~85%) results from arterial occlusion — most commonly large artery atherosclerosis, cardioembolism (especially atrial fibrillation), or small vessel disease (lacunar infarcts). Haemorrhagic stroke (~15%) is caused by intracerebral haemorrhage (hypertensive, amyloid angiopathy) or subarachnoid haemorrhage. Stroke is the fourth leading cause of death in the UK and the single largest cause of adult disability.
Epidemiology
Approximately 100,000 strokes occur annually in the UK. Incidence rises steeply with age. Key modifiable risk factors: hypertension (single most important), atrial fibrillation, diabetes, smoking, hyperlipidaemia, obesity, excessive alcohol. Non-modifiable: age, male sex, ethnicity (higher in Black African/Caribbean populations), previous stroke/TIA, family history. AF accounts for approximately 20% of ischaemic strokes and carries the highest stroke risk among common arrhythmias.
Clinical Features
Symptoms
Sudden-onset unilateral weakness (face, arm, leg)
Sudden speech disturbance: dysphasia (expressive or receptive) or dysarthria
Sudden visual loss: homonymous hemianopia, monocular blindness (amaurosis fugax if TIA)
Sudden-onset severe headache (especially haemorrhagic stroke/SAH — "thunderclap")
Dizziness, ataxia, vertigo (posterior circulation)
Confusion, reduced consciousness (large territory infarct or haemorrhage)
Signs
Upper motor neurone signs: contralateral hemiparesis, hypertonia, hyperreflexia, upgoing plantar (Babinski)
Facial droop (UMN pattern: forehead spared)
Dysphasia: Broca (non-fluent, telegraphic) or Wernicke (fluent but nonsensical)
Visual field defect: homonymous hemianopia
Neglect (parietal lobe, typically right hemisphere)
Reduced consciousness, GCS drop (large infarct, haemorrhage, raised ICP)
Investigations
First-line
Non-contrast CT headIMMEDIATE — to distinguish ischaemic from haemorrhagic stroke. Ischaemic may be normal initially; haemorrhagic shows hyperdense blood. Must be done before thrombolysis
Blood glucoseExclude hypoglycaemia as a stroke mimic — check immediately
BloodsFBC, U&Es, coagulation screen, glucose, lipids
ECGScreen for atrial fibrillation
Second-line
CT angiography (CTA)If thrombolysis/thrombectomy being considered — identifies large vessel occlusion and guides intervention
MRI brain (DWI)More sensitive for acute ischaemia than CT — particularly useful for posterior circulation and small infarcts
Carotid Doppler USSAssess for internal carotid artery stenosis — if >50% symptomatic stenosis, consider carotid endarterectomy
24–72 h cardiac monitoringDetect paroxysmal AF not seen on 12-lead ECG
Specialist
EchocardiogramIf cardioembolic source suspected — transthoracic ± transoesophageal
Thrombophilia screen / vasculitis screenIn young stroke (<55 years) with no traditional risk factors
1
Hyperacute management — ischaemic stroke
- Admit to hyperacute stroke unit (HASU)
- IV thrombolysis (alteplase 0.9 mg/kg) if presenting within 4.5 h of symptom onset and no contraindications
- Mechanical thrombectomy for anterior large vessel occlusion within 6 h (up to 24 h if salvageable tissue on perfusion imaging)
- Aspirin 300 mg immediately (after haemorrhage excluded on CT) — continue for 2 weeks, then switch to clopidogrel 75 mg
- Do NOT give anticoagulants acutely (even if AF present) — wait ≥2 weeks for ischaemic stroke
2
Haemorrhagic stroke
- Stop and reverse anticoagulation: vitamin K + PCC for warfarin; idarucizumab for dabigatran; andexanet alfa for factor Xa inhibitors
- BP control: target systolic <140 mmHg (IV labetalol or nicardipine)
- Neurosurgical assessment if large haematoma, hydrocephalus, or cerebellar haemorrhage
- Anticoagulation for AF can generally restart after 4–8 weeks (MDT decision)
3
Supportive care
- Swallowing assessment before any oral intake (risk of aspiration)
- DVT prophylaxis with intermittent pneumatic compression (NOT LMWH in first 24 h for ischaemic, longer for haemorrhagic)
- Blood glucose management: target 4–11 mmol/L
- Multidisciplinary stroke rehabilitation: physio, OT, SALT, psychology
4
Secondary prevention (ischaemic stroke)
- Clopidogrel 75 mg OD lifelong (antiplatelet of choice per NICE)
- If AF confirmed: switch from antiplatelet to DOAC anticoagulation after ≥2 weeks
- High-dose statin: atorvastatin 20–80 mg
- BP target: <130/80 mmHg
- Carotid endarterectomy: if symptomatic ICA stenosis 50–99% (within 2 weeks of event)
- Lifestyle: smoking cessation, exercise, diet, alcohol reduction
Complications
- Cerebral oedema: Peaks at 3–5 days — risk of herniation in large infarcts. May require decompressive craniectomy
- Haemorrhagic transformation: Ischaemic infarct converts to haemorrhagic — risk increased by thrombolysis and anticoagulation
- Aspiration pneumonia: Dysphagia is common — must screen swallowing before oral intake
- DVT/PE: Immobility in paretic limb — pneumatic compression devices
- Depression: Affects ~30% post-stroke — screen and treat
- Spasticity: Develops over weeks-months — physiotherapy ± botulinum toxin
- Recurrence: Highest risk in first 90 days — aggressive secondary prevention is critical
UKMLA Exam Tips
- 1CT head is IMMEDIATE and before treatment — it distinguishes ischaemic (thrombolyse) from haemorrhagic (do NOT thrombolyse)
- 2Thrombolysis window: within 4.5 hours. Thrombectomy: up to 6 h (24 h if salvageable penumbra on perfusion imaging)
- 3Aspirin 300 mg AFTER CT excludes haemorrhage — give for 2 weeks then switch to clopidogrel 75 mg
- 4Do NOT anticoagulate acutely even if AF — wait ≥2 weeks for ischaemic stroke
- 5Clopidogrel (not aspirin) is the long-term antiplatelet of choice for secondary prevention per NICE
- 6Carotid endarterectomy: symptomatic ICA stenosis 50–99%, ideally within 2 weeks — this is time-critical
- 7Posterior circulation stroke: vertigo, ataxia, diplopia, dysarthria — do NOT dismiss as "just vertigo"
practicetest your knowledge on strokeApply what you've learnt with UKMLA-style questions from the iatroX Q-Bank — neurology and beyond.
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