Stroke and TIA: Recognition, Thrombolysis and Prevention

A stroke is a sudden loss of brain function caused by interruption of the blood supply to part of the brain. It is a leading cause of death and long-term disability. Modern treatments such as thrombolysis and thrombectomy can reverse damage, but only if given quickly. "Time is brain."

Types

• Ischaemic stroke (about 85%) — a blocked artery from thrombosis, embolism (often from the heart in atrial fibrillation, or from the carotid arteries) or small vessel disease.
• Haemorrhagic stroke — intracerebral haemorrhage (often from hypertension) or subarachnoid haemorrhage.
• Transient ischaemic attack (TIA) — temporary symptoms with full recovery, usually within minutes to an hour, and no infarction on imaging. A TIA is a warning: the risk of stroke is highest in the following days.

Risk factors

• Hypertension (the most important).
• Atrial fibrillation.
• Diabetes.
• Smoking.
• High cholesterol.
• Previous stroke or TIA.
• Carotid artery disease.
• Obesity and inactivity.
• Excess alcohol.
• Increasing age.

Recognising stroke: BE FAST

• Balance — sudden loss of balance or coordination.
• Eyes — sudden loss of vision.
• Face — drooping on one side.
• Arm — weakness on one side.
• Speech — slurred or difficult speech.
• Time — call emergency services immediately and note when symptoms started.

Check blood glucose in every suspected stroke, because hypoglycaemia can mimic it.

Investigations

• Urgent non-contrast CT head to exclude haemorrhage. CT angiography identifies large vessel occlusion; perfusion imaging is used in selected patients.
• MRI (diffusion-weighted) is more sensitive for small and posterior circulation infarcts.
• Blood tests: glucose, full blood count, clotting, kidney function and lipids.
• ECG and cardiac monitoring for atrial fibrillation.
• Carotid Doppler ultrasound for anterior circulation events.
• Echocardiography when a cardiac source is suspected.

Acute treatment of ischaemic stroke

• Intravenous thrombolysis (alteplase or tenecteplase) within 4.5 hours of symptom onset in eligible patients, after haemorrhage is excluded.
• Mechanical thrombectomy for large vessel occlusion in the anterior circulation, ideally within 6 hours. Selected patients can be treated up to 24 hours based on advanced imaging.
• Aspirin (300 mg in UK guidance) as soon as possible once haemorrhage is excluded — 24 hours after thrombolysis.
• General care:
  • swallow screen before giving anything by mouth
  • oxygen if hypoxic
  • glucose control
  • careful blood pressure management according to protocol
  • early mobilisation
  • care on a stroke unit

Haemorrhagic stroke

• Reverse anticoagulation.
• Lower very high blood pressure, following current protocols.
• Consult neurosurgery when appropriate.

Secondary prevention

• Long-term antiplatelet therapy after ischaemic stroke, for example clopidogrel.
• Anticoagulation for atrial fibrillation, with timing according to stroke severity.
• A high-intensity statin.
• Blood pressure control.
• Carotid endarterectomy for significant symptomatic carotid stenosis.
• Stopping smoking, diabetes control and lifestyle changes.
• Rehabilitation:
  • physiotherapy
  • speech and language therapy
  • occupational therapy

Exam pearls

• Always check glucose and do a CT before thrombolysis.
• A TIA needs urgent specialist assessment, because early stroke risk is high.
• "Worst headache of my life," sudden in onset: think subarachnoid haemorrhage.

See also Atrial Fibrillation, Hypertension, our Exam Night Notes 1.0: Neurology and CT Scan Interpretation Simplified.

Test yourself

5 exam-style single-best-answer questions. Choose your answer, then tap “Show answer”.

1. Before thrombolysis for suspected stroke, which investigation is essential?

   1. Lumbar puncture
   2. Non-contrast CT head to exclude haemorrhage
   3. EEG
   4. Echocardiogram
   5. MRI spine
   Show answer

   Answer: B. Non-contrast CT head to exclude haemorrhage
   Haemorrhage must be excluded; also check glucose.

2. Usual time window for IV thrombolysis in ischaemic stroke:

   1. Any time
   2. Within 4.5 hours of onset
   3. Within 24 hours for all
   4. Within 3 days
   5. Within 1 hour
   Show answer

   Answer: B. Within 4.5 hours of onset
   IV thrombolysis is given within 4.5 hours in eligible patients.

3. Which treatment can be offered up to 24 hours in selected patients with large vessel occlusion?

   1. Mechanical thrombectomy
   2. Mannitol
   3. Steroids
   4. Warfarin
   5. IV thrombolysis
   Show answer

   Answer: A. Mechanical thrombectomy
   Thrombectomy can be used up to 24 hours based on advanced imaging selection.

4. What must be checked in every suspected stroke because it can mimic one?

   1. Thyroid function
   2. Cholesterol
   3. Vitamin D
   4. Amylase
   5. Blood glucose
   Show answer

   Answer: E. Blood glucose
   Hypoglycaemia can cause focal neurological deficits.

5. Ischaemic stroke in a patient with atrial fibrillation. Long-term prevention?

   1. Clopidogrel only
   2. No treatment
   3. Aspirin alone
   4. Beta-blocker only
   5. Anticoagulation (timing depends on stroke severity)
   Show answer

   Answer: E. Anticoagulation (timing depends on stroke severity)
   AF-related stroke prevention requires anticoagulation, started at an appropriate time.

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Disclaimer

For education and exam preparation only. This is not medical advice and must not be used to diagnose or treat patients. Always follow current clinical guidelines and the advice of qualified senior colleagues.