Neurology: Stroke Emergencies (Complete)

• Overview: At a Glance | Recognising Stroke and Its Mimics
• Ischaemic stroke: TIA | Acute Ischaemic Stroke | Acute Vertigo: Stroke or Not? | Cervical Artery Dissection | Central Retinal Artery Occlusion
• Haemorrhage and venous: Intracerebral Haemorrhage | Subarachnoid Haemorrhage | Cerebral Venous Sinus Thrombosis
• After the first hours: Early Complications After Stroke | Secondary Prevention After Stroke and TIA
• Revision: Drug Reference Table | Spot the Emergency | Exam-style Scenarios | Key Points | Guidelines and Further Reading

⏱️ Stroke emergencies are where "time is brain" matters most: about 2 million neurons die every minute an artery stays blocked, and every minute saved with thrombolysis or thrombectomy buys days of healthy life. This chapter covers TIA, ischaemic stroke, haemorrhage, venous thrombosis and the first days of stroke care.
Your four questions for every patient: When was the patient last known to be well? Is it a stroke or a mimic (check the glucose)? Is it ischaemic or haemorrhagic? Is there a target for thrombolysis, thrombectomy or surgery?

At a Glance

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Recognising Stroke and Its Mimics

Recognition:

• FAST (Face, Arm, Speech, Time) - used by the public and ambulance crews.
• ROSIER score in the emergency department - a score of 1 or more makes stroke likely.
• Sudden onset of a loss of function that fits a blood vessel territory - weakness, numbness, speech or language problems, visual field loss, ataxia, double vision.
• Time last known well decides treatment - record it precisely.

Stroke mimics (about 1 in 4 suspected strokes):

• Hypoglycaemia - always check glucose.
• Seizure with post-ictal (Todd's) weakness.
• Migraine with aura - spreading symptoms, positive features, headache.
• Functional neurological disorder.
• Sepsis or metabolic upset unmasking an old stroke.
• Brain tumour; subdural haematoma.
• Bell's palsy; peripheral nerve lesions.
• Syncope; MS; Wernicke's encephalopathy.

Stroke "chameleons" (strokes that look like something else):

• Isolated vertigo or unsteadiness (posterior circulation).
• Acute confusion or delirium.
• Isolated dysarthria or dysphasia mistaken for intoxication or confusion.
• Visual field loss mistaken for "eye trouble".

💡 Clinical Pearl: When in doubt, treat as a stroke and image urgently. Thrombolysing a stroke mimic carries a very low risk of harm; missing a treatable stroke costs brain.

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TIA

Definition: A transient episode of neurological dysfunction caused by focal brain, spinal cord or retinal ischaemia, without acute infarction. Symptoms usually last minutes. The stroke risk is highest in the first days, so it is a warning shot.

Typical features:

• Sudden loss of function - weakness, numbness, speech disturbance, visual loss in one eye (amaurosis fugax), or hemianopia.
• All at once, rather than spreading or marching.
• "Positive" features (tingling that spreads, flashing lights, jerking) suggest migraine aura or seizure instead.

Mimics: Migraine aura, focal seizures, hypoglycaemia, syncope, functional symptoms, peripheral nerve lesions.

Management (NICE NG128):

• Aspirin 300 mg immediately, unless contraindicated (bleeding risk, or already taking anticoagulation).
• Refer to be seen by a stroke specialist within 24 hours of symptom onset. Do not use risk scores (such as ABCD2) to decide urgency.
• If symptoms are still present, treat as an acute stroke - the patient may need thrombolysis.
• TIA clinic: Brain imaging (MRI with diffusion-weighted imaging if needed); carotid imaging; ECG and ambulatory monitoring for AF; bloods.
• Dual antiplatelet therapy (clopidogrel plus aspirin) for about 21 days, then clopidogrel alone, is used for high-risk TIA or minor stroke (RCP National Clinical Guideline for Stroke).
• Carotid stenosis of 50–99% on the symptomatic side: Carotid endarterectomy within 7 days.
• Secondary prevention: High-intensity statin, BP control, anticoagulation for AF, lifestyle.
• Driving: Must not drive for 1 month after a TIA or stroke (DVLA group 1).

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Acute Ischaemic Stroke

Mechanism: An artery to the brain is blocked by thrombus or embolus (from the heart in AF, or from carotid plaque). The core of the territory dies quickly; the surrounding "penumbra" can be saved if blood flow returns fast.

Recognition:

• FAST (Face, Arm, Speech, Time) pre-hospital. ROSIER in the emergency department.
• Check glucose - hypoglycaemia mimics stroke.
• Establish the time last known well - this decides treatment.
• NIHSS score for severity.

Imaging - immediately:

• Non-contrast CT head - excludes haemorrhage.
• CT angiography if thrombectomy may be indicated.
• CT perfusion (or MRI) if presenting more than 6 hours after onset, to look for salvageable brain.

Thrombolysis - within 4.5 hours of onset (NICE NG128 and technology appraisals):

• Alteplase 0.9 mg/kg (maximum 90 mg): 10% as a bolus, the rest over 60 minutes. Or
• Tenecteplase, a single weight-based bolus (0.25 mg/kg, maximum 25 mg) - now widely used.
• BP must be below 185/110 before treatment, and kept below 180/105 for the first 24 hours (e.g. IV labetalol).
• Main contraindications:
  • Haemorrhage on CT.
  • Recent major surgery, head injury or GI bleeding.
  • Active bleeding.
  • Therapeutic anticoagulation (unless reversed or levels known to be low).
  • Platelets below 100 × 10⁹/L.
  • Uncontrolled BP.
• Watch for: Intracranial haemorrhage - deterioration, headache, vomiting. Stop the infusion and get a CT. Also angioedema (especially on ACE inhibitors).

Thrombectomy (mechanical clot retrieval) for confirmed large vessel occlusion (NICE NG128):

• Anterior circulation (internal carotid or proximal middle cerebral artery): Offer up to 6 hours after onset (with thrombolysis if eligible). Offer at 6–24 hours if imaging shows salvageable brain.
• Posterior circulation (basilar artery): Consider up to 24 hours if there is potential to salvage brain.
• Generally for people with good pre-stroke function and a significant deficit.
• Transfer urgently to a thrombectomy centre - do not delay thrombolysis to arrange it.

Everyone - stroke unit care:

• Swallow screen before any food, drink or oral medication.
• Aspirin 300 mg daily for 2 weeks (from 24 hours after thrombolysis, once CT excludes bleeding), then long-term clopidogrel 75 mg.
• Oxygen only if SpO2 is below 95%; keep glucose between 4 and 11 mmol/L (NICE).
• VTE prevention: Intermittent pneumatic compression in immobile patients - not compression stockings.
• Early mobilisation; nutrition; continence care.
• Statin (e.g. atorvastatin 20–80 mg) after 48 hours.
• AF: Start anticoagulation - early DOAC start is now common practice, depending on stroke size.
• Malignant middle cerebral artery infarction (large swelling): Refer for decompressive hemicraniectomy within 48 hours in selected patients under about 60.

💡 Clinical Pearl: For a "wake-up" stroke, the onset time is when the patient was last seen well - usually the night before. Specialist imaging (MRI or CT perfusion) can still identify people who might benefit from treatment.

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Acute Vertigo: Stroke or Not?

The problem: Most acute vertigo is peripheral (vestibular neuritis, labyrinthitis, BPPV), but about 1 in 20 is a posterior circulation stroke. CT is poor at showing posterior fossa infarcts.

Clues to a central (stroke) cause:

• Inability to stand or walk unaided.
• Other brainstem or cerebellar signs: double vision, dysarthria, dysphagia, facial numbness, limb ataxia, Horner's syndrome.
• New severe headache or neck pain (vertebral artery dissection).
• Vascular risk factors, older age.

HINTS examination (in continuous vertigo with nystagmus, by trained examiners):

• Head impulse test: Normal (no catch-up saccade) is worrying in acute vertigo.
• Nystagmus: Direction-changing or vertical nystagmus suggests a central cause.
• Test of skew: Vertical eye misalignment on cover testing suggests a central cause.

Any central sign means admit, get an MRI (with diffusion-weighted imaging) and refer to the stroke team.

Basilar artery occlusion: Fluctuating or reduced consciousness, quadriparesis, eye movement abnormalities, "locked-in" syndrome - needs immediate CT angiography and consideration of thrombectomy.

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Cervical Artery Dissection

Mechanism: A tear in the wall of the carotid or vertebral artery lets blood track into the wall. This narrows the artery or forms clot that embolises to the brain. It is a common cause of stroke in younger adults.

Triggers and risk factors: Minor neck trauma (sport, coughing, neck manipulation), connective tissue disease, migraine, recent infection - often no trigger.

Clinical pattern:

• Neck pain or headache, often one-sided, before the stroke or TIA.
• Carotid dissection: Horner's syndrome (ptosis, small pupil), pulsatile tinnitus, lower cranial nerve palsies, anterior circulation stroke.
• Vertebral dissection: Occipital pain, posterior circulation stroke (vertigo, ataxia, lateral medullary syndrome).

Diagnosis: CT angiography or MR angiography (with fat-suppressed MRI of the neck).

Management:

• Thrombolysis and thrombectomy are used as for other ischaemic strokes.
• Antithrombotic treatment: Usually an antiplatelet; anticoagulation is an alternative in selected cases. Trials show similar outcomes.
• Advise avoiding neck manipulation; repeat imaging at 3–6 months.

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Central Retinal Artery Occlusion

What it is: Blockage of the central retinal artery - a stroke of the eye. It causes sudden, painless loss of vision in one eye. The causes and stroke risk are the same as for TIA and stroke.

Clinical pattern:

• Sudden painless monocular visual loss (often to counting fingers or worse).
• Relative afferent pupillary defect.
• Pale retina with a cherry-red spot at the macula; sometimes a visible embolus.
• Amaurosis fugax (transient monocular loss, like "a curtain coming down") is a retinal TIA.

Management:

• Treat as an acute stroke or TIA - same-day stroke and ophthalmology assessment.
• Exclude giant cell arteritis in anyone over 50 - check ESR and CRP and start steroids if suspected.
• Thrombolysis within 4.5 hours is offered in some specialist centres; older measures (ocular massage, lowering eye pressure) are of no proven benefit.
• Full stroke work-up: Carotid imaging, ECG and rhythm monitoring for AF, vascular risk factors.
• Secondary prevention as for ischaemic stroke.

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Intracerebral Haemorrhage

Causes:

• Hypertension - deep bleeds in the basal ganglia, thalamus, pons and cerebellum.
• Cerebral amyloid angiopathy - lobar bleeds in older people.
• Anticoagulants.
• Vascular malformations (AVM, cavernoma) - younger people.
• Tumours; cocaine and amphetamines; venous sinus thrombosis.

Clinical pattern: Often indistinguishable from ischaemic stroke without a scan. Headache, vomiting, high BP and falling consciousness are more common.

Management (NICE NG128):

• Reverse anticoagulation immediately:
  • Warfarin: Prothrombin complex concentrate plus IV vitamin K.
  • Dabigatran: Idarucizumab.
  • Factor Xa inhibitors (apixaban, rivaroxaban, edoxaban): Follow local protocols - usually PCC. Andexanet is not NICE-recommended for intracranial haemorrhage.
  • Stop antiplatelets.
• Rapid BP lowering if presenting within 6 hours with systolic BP 150–220 mmHg:
  • Aim for systolic 130–139 mmHg within 1 hour, and keep it there for at least 7 days.
  • Caution or exceptions: an underlying structural cause, GCS below 6, early neurosurgery planned, or a massive haematoma with poor prognosis.
• Neurosurgical referral for:
  • Hydrocephalus.
  • Cerebellar haemorrhage with brainstem compression.
  • Deteriorating consciousness in selected cases.
• Treat seizures; VTE prevention with intermittent pneumatic compression.
• Later: MRI or angiography to look for an underlying cause in younger people or lobar bleeds.

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Subarachnoid Haemorrhage

Mechanism: Bleeding into the space around the brain - about 85% from a ruptured berry aneurysm (circle of Willis). Mortality is about 1 in 3.

Risk factors:

• Smoking; hypertension; alcohol excess.
• Family history.
• Polycystic kidney disease.
• Connective tissue disorders (Ehlers–Danlos).
• Cocaine.

Clinical pattern:

• Thunderclap headache - sudden, severe, reaching maximum intensity within about a minute ("the worst headache of my life").
• Vomiting.
• Neck stiffness (may take hours to develop); photophobia.
• Reduced consciousness; seizures.
• Third nerve palsy (posterior communicating artery aneurysm).

Diagnosis (NICE NG228):

• CT head immediately. Within 6 hours of onset it detects nearly all SAH.
• CT done within 6 hours and normal: Do not routinely do an LP - consider other diagnoses.
• CT done more than 6 hours after onset and normal: Offer LP at least 12 hours after onset, to look for xanthochromia (yellow CSF from breakdown of blood).
• If SAH is confirmed: CT angiography to find the aneurysm.

Management:

• Urgent neurosurgical referral.
• Nimodipine 60 mg orally every 4 hours for 21 days - reduces delayed cerebral ischaemia from vasospasm.
• Aneurysm treatment: Endovascular coiling (preferred where suitable) or surgical clipping, as early as possible - rebleeding risk is highest in the first 24 hours.
• Analgesia, antiemetics; avoid hypotension and dehydration.
• Reverse anticoagulation.
• Watch for complications:
  • Rebleeding.
  • Hydrocephalus (falling GCS - needs CSF drainage).
  • Delayed cerebral ischaemia (days 4–14).
  • Hyponatraemia - do not fluid-restrict.
  • Seizures; neurogenic pulmonary oedema; stress cardiomyopathy.

⚠️ Safety Pearl: Any headache that reaches maximum intensity within about a minute is a SAH until proven otherwise - even if it has eased, and even if the patient looks well. A "sentinel" headache can precede a catastrophic bleed.

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Cerebral Venous Sinus Thrombosis

• Who: Mostly younger adults, especially women.
• Risk factors:
  • Combined oral contraceptive, pregnancy and the postpartum period.
  • Thrombophilia.
  • Dehydration.
  • Cancer.
  • Head and neck infection (mastoiditis, sinusitis).
  • Inflammatory disease (Behçet's, IBD).
• Clinical pattern:
  • Headache (often progressive over days, sometimes thunderclap).
  • Features of raised ICP - papilloedema, vomiting, visual blurring.
  • Seizures.
  • Focal deficits, often bilateral or not matching an arterial territory.
  • Reduced consciousness.
• Diagnosis: CT or MR venography - a plain CT may be normal. D-dimer can be normal.
• Management:
  • Anticoagulation with LMWH (or unfractionated heparin) - even if there is haemorrhage in the brain, because the bleeding is caused by venous congestion.
  • Then a DOAC or warfarin for 3–12 months.
  • Treat seizures and raised ICP; neurosurgery or endovascular treatment in severe deterioration.
  • Stop oestrogen-containing contraception.

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Early Complications After Stroke

Neurological deterioration - reassess and repeat the CT:

• Haemorrhagic transformation (especially after thrombolysis).
• Malignant middle cerebral artery oedema - large infarcts swell over days 2–5, causing drowsiness and herniation. Refer early for decompressive hemicraniectomy (within 48 hours, selected patients).
• Cerebellar infarct swelling - hydrocephalus and brainstem compression; neurosurgery.
• Recurrent stroke; seizures.
• Hypoglycaemia, hyponatraemia, sepsis or hypoxia making existing deficits worse.

Medical complications - preventable with good stroke unit care:

• Aspiration pneumonia - swallow screen within 4 hours, before any oral intake; specialist swallow assessment; NG feeding within 24 hours if unable to swallow safely.
• VTE - intermittent pneumatic compression for immobile patients (not stockings).
• Urinary retention and UTI; constipation.
• Hyperglycaemia and fever - both worsen outcome.
• Dehydration and malnutrition.
• Delirium, depression and anxiety.
• Pressure sores; shoulder pain and subluxation; falls.

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Secondary Prevention After Stroke and TIA

• Antiplatelet (ischaemic stroke without AF):
  • Aspirin 300 mg daily for 2 weeks, then clopidogrel 75 mg long-term.
  • If clopidogrel is unsuitable: aspirin plus modified-release dipyridamole.
  • Short-term dual antiplatelets after high-risk TIA or minor stroke (see TIA).
• Atrial fibrillation: Anticoagulation (usually a DOAC) instead of antiplatelets. Start earlier than the old "2-week rule" - the ELAN trial supports starting within about 48 hours after minor or moderate stroke, and around day 6–7 after major stroke.
• Lipids: High-intensity statin (atorvastatin 80 mg); NICE secondary prevention target LDL 2.0 mmol/L or less.
• Blood pressure: Start or adjust antihypertensives once stable - the RCP guideline aims for systolic below 130 mmHg in most people.
• Carotid stenosis (symptomatic, 50–99%): Carotid endarterectomy within 7 days.
• Young cryptogenic stroke with a PFO (under about 60): Consider PFO closure (specialist).
• Lifestyle: Stop smoking, limit alcohol, exercise, diet, weight, diabetes control.
• Driving: No driving for 1 month after a TIA or stroke (DVLA group 1); longer if there are lasting deficits or visual field loss.

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Drug Reference Table

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Spot the Emergency

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Exam-style Scenarios

1. A 72-year-old woman has sudden right-sided weakness and aphasia. She was last seen well 2 hours ago. Glucose is 6.2; CT shows no haemorrhage; CT angiography shows a left middle cerebral artery occlusion. BP 172/95.
Answer: Acute ischaemic stroke with large vessel occlusion.

• Thrombolysis (alteplase or tenecteplase) now - BP is below 185/110.
• Urgent transfer for thrombectomy without delaying thrombolysis.
• Keep BP below 180/105 for 24 hours; swallow screen; stroke unit.

2. A 68-year-old man on apixaban has sudden headache and left weakness. CT shows a right basal ganglia haemorrhage. BP 198/104, 2 hours after onset.
Answer: Intracerebral haemorrhage on a factor Xa inhibitor.

• Reverse anticoagulation per local protocol (e.g. PCC).
• Lower systolic BP to 130–139 within 1 hour (e.g. IV labetalol).
• Repeat CT if deteriorating; neurosurgical referral if hydrocephalus develops.

3. A 35-year-old woman has the sudden onset of a severe headache during sex. CT 8 hours later is normal.
Answer: Possible SAH - CT beyond 6 hours does not exclude it.

• LP at least 12 hours after onset, for xanthochromia.
• If positive: CT angiography, nimodipine, neurosurgical referral.

4. A 66-year-old man had 30 minutes of left-sided weakness this morning, now resolved. ECG shows AF; carotid ultrasound is normal.
Answer: TIA with AF as the likely cause.

• Aspirin 300 mg immediately, then specialist review within 24 hours.
• Brain imaging to exclude haemorrhage, then start anticoagulation (DOAC) rather than antiplatelets.
• Statin, BP control; no driving for 1 month.

5. A 74-year-old woman has sudden painless loss of vision in her right eye 2 hours ago. Fundoscopy shows a cherry-red spot.
Answer: Central retinal artery occlusion - a stroke equivalent.

• Same-day stroke and ophthalmology assessment; consider thrombolysis in a specialist centre.
• ESR and CRP - start steroids if GCA is suspected.
• Carotid imaging and AF screening; secondary prevention.

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Key Points

• Check glucose in every suspected stroke; record the time last known well.
• TIA: aspirin 300 mg and a stroke specialist within 24 hours - no ABCD2 scoring.
• Ischaemic stroke: thrombolysis within 4.5 hours (BP below 185/110); thrombectomy for large vessel occlusion up to 24 hours with salvageable brain.
• Intracerebral haemorrhage: reverse anticoagulation; systolic 130–139 within 1 hour.
• Thunderclap headache: CT immediately; LP at 12 hours or more if CT was after 6 hours and normal; nimodipine for SAH.
• CVST: anticoagulate, even when there is haemorrhage.
• Acute vertigo with an inability to walk or central HINTS signs needs MRI and the stroke team.
• Sudden painless monocular blindness is an eye stroke - same-day stroke assessment and exclude GCA.
• Swallow screen before anything by mouth; pneumatic compression for VTE prevention.
• Secondary prevention: clopidogrel (or DOAC if AF), high-intensity statin, BP control, carotid surgery within 7 days if indicated.

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Guidelines and Further Reading

• NICE NG128: Stroke and TIA in over 16s - diagnosis and initial management
• Royal College of Physicians: National Clinical Guideline for Stroke for the UK and Ireland (2023)
• NICE NG228: Subarachnoid haemorrhage caused by a ruptured aneurysm
• NICE NG238: Cardiovascular disease - risk assessment and reduction, including lipid modification
• European Stroke Organisation guidelines (thrombolysis, thrombectomy, cerebral venous thrombosis)
• DVLA: Assessing fitness to drive - neurological disorders
• BNF - for current doses

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