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Acute ischaemic stroke — MRCEM SBA MCQ

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EasyNeurological emergenciesAcute ischaemic strokeMRCEM SBA

A 72-year-old woman presents 100 minutes after the witnessed onset of left-sided weakness and neglect. Both deficits persist. Capillary glucose is 5.8 mmol/L. Her blood pressure is 194/114 mmHg on two measurements. She takes no anticoagulant and has no recent bleeding or surgery. Non-contrast CT shows no intracranial haemorrhage or extensive established infarction. CT angiography shows no proximal arterial occlusion. The acute stroke team is assessing her. What is the most appropriate immediate management plan?

Educational content. Not a substitute for clinical judgement or local policy.

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Correct answer: A — Lower blood pressure to 185/110 mmHg or below, then proceed with intravenous thrombolysis.

The persistent, disabling deficits, witnessed onset 100 minutes ago and exclusion of intracranial haemorrhage make intravenous thrombolysis a time-critical option. Her blood pressure remains above 185/110 mmHg on repeat measurement. NICE advises considering reduction to that level or below in candidates for intravenous thrombolysis. The stroke team should address this modifiable barrier promptly and give thrombolysis within an organised stroke service if she remains eligible. ([nice.org.uk](https://www.nice.org.uk/guidance/NG128/chapter/recommendations)) B gets the sequence wrong: the recorded pressure should be addressed before thrombolysis. C is an important reperfusion pathway when appropriate imaging confirms a proximal arterial occlusion, but her angiogram does not show one. D recognises the blood-pressure threshold, yet waiting for an unpredictable spontaneous fall could delay treatment; a prompt repeat reading already below threshold would change that decision. E offers established treatment after haemorrhage has been excluded, but substitutes aspirin and admission for an available assessment for time-critical reperfusion. Aspirin would become the relevant initial antithrombotic treatment if thrombolysis were unsuitable. Regardless of the reperfusion decision, she requires specialist acute stroke-unit care. ([nice.org.uk](https://www.nice.org.uk/guidance/NG128/chapter/recommendations))

Reference: NICE NG128: Stroke and transient ischaemic attack in over 16s — recommendations (Published 1 May 2019; thrombolysis section amended March 2025) — https://www.nice.org.uk/guidance/NG128/chapter/recommendations