A 67-year-old hypertensive woman is brought by her husband at 10:30am. He noticed at 10:15am that she suddenly couldn't speak and her right arm was hanging limply. She had been completely normal at 9:00am.
Examination: GCS 13 (E3V4M6). BP 188/106. Right facial droop, global aphasia, right arm power 1/5, right leg power 3/5. Right extensor plantar. NIHSS score 18.
Last known well: 9:00am. Time now: 10:30am. What is your immediate management?
What is Stroke?
Stroke is defined as a rapidly developing clinical syndrome of focal or global neurological deficit lasting more than 24 hours (or leading to death), with no apparent cause other than vascular origin. It is the second leading cause of death globally and the leading cause of adult disability.
There are two fundamental types — and distinguishing them is critical before any treatment:
| Type | Mechanism | Frequency | CT Appearance | Treatment |
|---|---|---|---|---|
| Ischaemic | Arterial occlusion — thrombotic or embolic | 85% | Normal early, then hypodensity in territory | Thrombolysis / thrombectomy |
| Haemorrhagic | Vessel rupture — intracerebral or subarachnoid | 15% | Hyperdense (bright) immediately | Blood pressure control, surgical if indicated |
Never give thrombolysis without CT head first. Thrombolysis in a haemorrhagic stroke is fatal. CT head takes minutes and is mandatory before any reperfusion therapy.
FAST — The Clinical Screen
The FAST acronym is the global standard for public recognition and clinical screening of stroke:
FAST + BE-FAST
- B — Balance: Sudden loss of balance or coordination
- E — Eyes: Sudden vision loss or double vision
- F — Face: Facial droop — ask patient to smile. Is it asymmetrical?
- A — Arms: Arm drift — ask to raise both arms. Does one drift down?
- S — Speech: Slurred, wrong words, or inability to speak/understand
- T — Time: Time of last known well is the most critical piece of information. Call for help immediately.
Vascular Territory Syndromes
| Territory | Artery | Clinical Features |
|---|---|---|
| Anterior circulation | MCA | Contralateral face+arm weakness > leg, aphasia (dominant) or neglect (non-dominant), gaze deviation toward lesion |
| Anterior circulation | ACA | Contralateral leg weakness > arm, abulia, personality change, urinary incontinence |
| Posterior circulation | PCA | Contralateral homonymous hemianopia, memory disturbance, alexia without agraphia (dominant) |
| Posterior circulation | PICA (lateral medullary) | Wallenberg syndrome: ipsilateral face + contralateral body sensory loss, dysphagia, vertigo, Horner's syndrome, ataxia |
| Lacunar | Small perforating vessels | Pure motor, pure sensory, ataxic hemiparesis, dysarthria-clumsy hand — no cortical features |
Time-Critical Management
Every minute of MCA occlusion destroys approximately 1.9 million neurons. The thrombolysis window is 4.5 hours from last known well. Thrombectomy window extends to 24 hours in selected patients. Speed of treatment is the single most modifiable determinant of outcome.
Acute Ischaemic Stroke — Management Checklist
- 0–10 min: Airway, BP, glucose, ECG, IV access, bloods (FBC, coag, glucose, lipids), CT head stat
- CT negative for haemorrhage + within 4.5 hours: IV alteplase (tPA) 0.9mg/kg (max 90mg) — 10% bolus, rest over 60 minutes. Contraindications: recent surgery, anticoagulation, BP >185/110 uncontrolled, blood glucose <2.7 or >22.2
- Large vessel occlusion (MCA/ICA/basilar): CT angiography → mechanical thrombectomy if eligible — up to 24 hours from onset in selected patients. NIHSS ≥6 and evidence of salvageable tissue
- Blood pressure: Do NOT aggressively lower BP in acute ischaemic stroke unless >185/110 and thrombolysis planned — autoregulation is impaired and hypotension worsens infarct
- Haemorrhagic stroke: Target SBP <140mmHg within 1 hour, reverse anticoagulation, neurosurgical review, supportive care
- All strokes: Aspirin 300mg after haemorrhage excluded, statin, monitoring on stroke unit, swallow assessment before oral intake, DVT prophylaxis
Secondary Prevention
The risk of recurrent stroke is highest in the first 48–72 hours. Secondary prevention must start immediately:
Secondary Prevention by Stroke Type
- Cardioembolic (AF): Anticoagulation — DOAC preferred over warfarin. Start within 2 weeks (earlier if small infarct).
- Large artery atherosclerosis: Dual antiplatelet (aspirin + clopidogrel) for 21 days then single agent. High-intensity statin. BP control. Carotid endarterectomy if ipsilateral stenosis >50% symptomatic.
- Small vessel/lacunar: Single antiplatelet, statin, aggressive BP and glucose control.
- All patients: BP target <130/80 long-term, statin (LDL <1.8 mmol/L), lifestyle — smoking cessation, exercise, diet.
NIHSS 18, last known well 90 minutes ago — large left MCA territory stroke. CT head: no haemorrhage. BP controlled to 180/100 with IV labetalol. IV alteplase given at 10:42am — 72 minutes from onset. CT angiography confirmed left MCA occlusion. Mechanical thrombectomy achieved TICI 2b reperfusion at 11:35am. At 24 hours: NIHSS improved from 18 to 6 — significant recovery. Discharged to stroke rehabilitation. Started apixaban for newly diagnosed AF. This outcome was possible because the time to treatment was under 90 minutes.
85% ischaemic, 15% haemorrhagic — CT before any treatment. Time of last known well is the most critical information. FAST+BE-FAST for recognition. Thrombolysis within 4.5 hours, thrombectomy up to 24 hours for LVO. Never lower BP aggressively in acute ischaemic stroke unless giving thrombolysis. Every minute = 1.9 million neurons lost.
References
- Powers WJ et al. Guidelines for the Early Management of Patients With Acute Ischemic Stroke. Stroke. 2019;50(12):e344–e418.
- Nogueira RG et al. Thrombectomy 6 to 24 Hours after Stroke with a Mismatch between Deficit and Infarct (DAWN). NEJM. 2018;378(1):11–21.
- Feigin VL et al. Global, regional, and national burden of stroke, 1990–2016. Lancet Neurology. 2019;18(5):439–458.
