Stroke is one of the most examinable emergencies in UK medicine because it demands fast recognition, an imaging-first pathway, and time-critical reperfusion decisions — and because the management changed with the 2023 national guideline. This guide covers acute stroke and transient ischaemic attack (TIA) as examiners frame them, drawing on the National Clinical Guideline for Stroke and NICE NG128. Follow current guidance and local protocols in practice; this reflects guidance as of mid-2026.
What a stroke is
A stroke is a sudden focal neurological deficit of vascular origin. Around 85% are ischaemic — a thrombus or embolus occluding a cerebral artery — and the remainder are haemorrhagic, from intracerebral or subarachnoid bleeding. A subarachnoid haemorrhage classically presents with a sudden, severe “thunderclap” headache rather than a focal deficit. A TIA is a transient episode of neurological dysfunction caused by focal ischaemia without infarction; the old definition based on symptoms lasting under 24 hours has been replaced by a tissue-based definition, since most true TIAs resolve within an hour and any lasting deficit implies infarction.
Recognition
Speed is everything, captured in the FAST message — Face, Arm, Speech, Time to call emergency services. In hospital, a validated tool such as ROSIER helps distinguish stroke from mimics (hypoglycaemia, seizures, migraine). The deficit reflects the territory: anterior circulation strokes cause hemiparesis, hemisensory loss, dysphasia and visual field defects, while posterior circulation strokes cause ataxia, vertigo, diplopia and bilateral signs. Always check the glucose — hypoglycaemia is a classic stroke mimic. Other mimics include seizures with a postictal deficit, migraine with aura, and functional presentations.
Diagnosis: imaging first
The immediate priority is an urgent non-contrast CT head, primarily to distinguish ischaemic from haemorrhagic stroke, because that determines everything that follows — you cannot give antithrombotic treatment until bleeding is excluded. CT is fast and sensitive for haemorrhage; early ischaemic changes may be subtle. Further imaging (CT angiography, CT perfusion or MRI) guides decisions about thrombectomy and extended-window thrombolysis.
Management of acute ischaemic stroke
Two reperfusion treatments dominate the answer:
Thrombolysis: offer intravenous thrombolysis with alteplase or tenecteplase to eligible patients within 4.5 hours of known onset, once haemorrhage is excluded and there is no contraindication. The 2023 guideline introduced tenecteplase, given as a single bolus, as an alternative to alteplase. Blood pressure must be below 185/110 before treatment, and only the glucose must be checked first — do not delay for a full laboratory work-up. A carefully selected extended window of 4.5 to 9 hours (or for wake-up stroke) is possible where perfusion imaging shows salvageable tissue.
Thrombectomy: for a proximal large-artery occlusion with a disabling deficit, offer mechanical thrombectomy if it can begin within 6 hours of onset, and up to 24 hours in selected anterior-circulation strokes meeting imaging criteria. Give thrombolysis as well if eligible — do not wait to assess its effect before proceeding to thrombectomy.
Antiplatelets: once haemorrhage is excluded, give aspirin 300 mg — but if the patient was thrombolysed, wait 24 hours and repeat imaging first, because early aspirin after thrombolysis increases the risk of bleeding. Admit to a hyperacute stroke unit.
Intracerebral haemorrhage
If CT shows a bleed, the priorities differ: reverse any anticoagulation urgently (a vitamin K antagonist with prothrombin complex concentrate and intravenous vitamin K; a DOAC with the appropriate reversal agent), and lower the blood pressure — for a systolic of 150 to 220, aim for 130 to 139 within an hour. Neurosurgical referral is considered for selected bleeds.
Transient ischaemic attack
A TIA is a warning of high stroke risk. Give aspirin 300 mg immediately unless contraindicated, and arrange specialist assessment within 24 hours. The ABCD2 score is no longer recommended for deciding urgency — all suspected TIAs need prompt specialist review. Patients must not drive, and should be told the relevant rules. Secondary prevention is then started.
Secondary prevention
After the acute phase, the package is familiar: long-term antiplatelet therapy (clopidogrel is the preferred choice after the initial aspirin), a high-intensity statin such as atorvastatin, blood pressure control, and anticoagulation where there is atrial fibrillation (usually started after a delay to avoid haemorrhagic transformation). Carotid endarterectomy is considered for symptomatic carotid stenosis, and lifestyle and risk-factor modification underpin everything. The choice of secondary prevention depends on the mechanism — an antiplatelet for most ischaemic strokes, but anticoagulation rather than an antiplatelet where atrial fibrillation is the cause.
High-yield exam points and traps
- Immediate CT head to exclude haemorrhage comes before any antithrombotic treatment.
- Thrombolysis is with alteplase or tenecteplase within 4.5 hours — tenecteplase is the 2023 addition.
- Give thrombolysis even if thrombectomy is planned, and do not assess the response first.
- Aspirin waits 24 hours after thrombolysis (with repeat imaging); otherwise give 300 mg once a bleed is excluded.
- ABCD2 is no longer used to triage TIA — all need specialist review within 24 hours.
- Always check the glucose: hypoglycaemia is a classic stroke mimic.
A few common questions
What is the time window for stroke thrombolysis? Within 4.5 hours of known onset for alteplase or tenecteplase, with a selected extended window of 4.5 to 9 hours (or for wake-up stroke) where perfusion imaging shows salvageable tissue.
Alteplase or tenecteplase? The 2023 guideline allows either within 4.5 hours; tenecteplase has the practical advantage of a single bolus rather than an hour-long infusion.
When is thrombectomy offered? For a proximal large-artery occlusion with a disabling deficit, within 6 hours of onset — and up to 24 hours in selected anterior-circulation strokes meeting imaging criteria.
How is a TIA managed? Aspirin 300 mg immediately and specialist assessment within 24 hours; the ABCD2 score is no longer used to decide urgency, and the patient must not drive.
What is the initial step in suspected stroke? An urgent non-contrast CT head to distinguish ischaemic from haemorrhagic stroke, after checking the glucose — no antithrombotic treatment until haemorrhage is excluded.
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