Stroke in the acute setting

Abstract

Acute stroke and transient ischaemic attack (TIA) are focal neurological syndromes of vascular origin and should be treated as medical emergencies. Brain imaging with computed tomography or magnetic resonance imaging is required to distinguish ischaemic stroke from intracerebral haemorrhage, recognize non-stroke pathologies that mimic stroke, and guide investigation into the underlying mechanism. Acute interventions of benefit in ischaemic stroke include intravenous thrombolysis with alteplase or tenecteplase and endovascular thrombectomy. Imaging additional to non-contrast computed tomography permits reperfusion treatment in a wider range of patients. Stroke unit care, aspirin and combination antiplatelet therapy benefit most patients. Decompressive hemicraniectomy reduces mortality in ischaemic stroke complicated by severe brain swelling. Intracerebral haemorrhage accounts for 10–15% of strokes, and outcome is improved by stroke unit care and active initial supportive management, which can include blood pressure lowering and anticoagulant reversal in some cases. TIA carries a high short-term risk of stroke, and immediate investigation and institution of secondary preventive treatment prevents a high proportion of this. Secondary prevention for ischaemic stroke and TIA should be tailored according to mechanism in individual patients.