Key Facts

Acute stroke management requires an integrated system response from emergency services to specialist stroke units. The UK has developed a highly effective hyper-acute stroke pathway that has significantly improved outcomes over the past 15 years.

Epidemiology

Stroke affects approximately 100,000 people per year in the UK. It is the 4th leading cause of death (~34,000 deaths/year) and the leading cause of adult disability. Ischaemic stroke accounts for 85%, intracerebral haemorrhage 10%, and subarachnoid haemorrhage 5%. The UK stroke mortality rate has halved over the past 20 years.

Aetiology

Ischaemic stroke (85%):

• Large artery atherosclerosis (25%)
• Cardioembolism (25%) — AF, valvular disease
• Small vessel disease/lacunar (25%)
• Other/cryptogenic (25%) — dissection, PFO, thrombophilia

Haemorrhagic stroke (15%):

• Intracerebral haemorrhage: Hypertension (most common), amyloid angiopathy, anticoagulation, AVM
• Subarachnoid haemorrhage: Berry aneurysm rupture (85%), AVM, perimesencephalic

Pathophysiology

Ischaemic stroke: Acute vessel occlusion creates an ischaemic core (irreversible) and penumbra (salvageable). Reperfusion therapy targets the penumbra. Without intervention, the penumbra converts to infarct over hours. Cerebral oedema peaks at 3-5 days and may cause herniation in large infarcts.

Haemorrhagic stroke: Vessel rupture causes parenchymal haematoma with mass effect. Haematoma expansion in the first hours worsens outcome. Perihematomal oedema adds to mass effect. Blood products in CSF cause vasospasm (SAH) and hydrocephalus.

Ischaemic Stroke Syndromes

• Anterior circulation (MCA): Contralateral hemiparesis (face + arm > leg), hemisensory loss, homonymous hemianopia, aphasia (dominant) or neglect (non-dominant)
• Anterior circulation (ACA): Contralateral leg weakness > arm, personality change
• Posterior circulation: Vertigo, diplopia, visual field loss, ataxia, dysphagia, dysarthria, crossed signs
• Lacunar syndromes: Pure motor, pure sensory, ataxic hemiparesis, dysarthria-clumsy hand

Haemorrhagic Stroke

• Sudden severe headache (thunderclap in SAH)
• Rapid deterioration, vomiting, reduced consciousness
• Focal neurology depending on location
• SAH: Neck stiffness, photophobia, III/VI nerve palsy

Red Flags

• Thunderclap headache — SAH until proven otherwise (CT + LP if CT negative at <12h)
• Rapid neurological deterioration — haemorrhagic transformation, cerebral oedema, re-occlusion
• GCS deterioration — consider repeat CT, neurosurgical referral
• Posterior circulation stroke signs — frequently missed; requires high clinical suspicion

Bedside

• CT head (non-contrast): Immediately if thrombolysis candidate; within 1 hour for all strokes
• Blood glucose: Exclude hypoglycaemia
• NIHSS: Quantify severity
• ECG: AF detection
• Swallow screen: Before any oral intake

Bloods

• FBC, coagulation, U&Es, glucose, lipids: Baseline
• HbA1c: Diabetes screening
• Troponin: Co-existent MI

Imaging

• CT angiography: Identify LVO for thrombectomy; carotid stenosis assessment
• CT perfusion: Guide late thrombectomy decisions (penumbra assessment)
• MRI (DWI/FLAIR): Most sensitive for acute ischaemia; DWI-FLAIR mismatch for wake-up strokes
• Carotid USS: Non-invasive assessment of carotid stenosis

Special Tests

• Echocardiography (TTE ± TOE): Cardioembolic source — PFO, valve disease, LV thrombus
• Prolonged cardiac monitoring: 24-72h Holter or implantable loop recorder for paroxysmal AF
• Thrombophilia screen: Young stroke (<55) without obvious cause

Non-pharmacological

• Stroke unit care: All patients — reduces mortality and disability (Stroke Unit Trialists' Collaboration)
• Swallowing assessment: Within 4 hours of admission; SALT if concerns
• DVT prophylaxis: IPC/TEDS (NOT anticoagulants in first 14 days for large ischaemic or haemorrhagic stroke)
• Positioning: Avoid flat positioning in first 24h if aspiration risk
• Early rehabilitation: Within 24-48h — PT, OT, SALT, psychology
• Nutrition: Enteral feeding (NG tube) if unsafe swallow persists >24-48h

Pharmacological

Ischaemic stroke:

• Aspirin 300mg within 24 hours (after CT excludes haemorrhage); continue for 14 days then clopidogrel 75mg OD
• Thrombolysis: Alteplase 0.9mg/kg IV if within 4.5 hours
• Secondary prevention: Statin (atorvastatin 20-80mg), antihypertensive (target <130/80 after acute phase), anticoagulation for AF (DOAC)

Haemorrhagic stroke:

• BP control: SBP <140 mmHg within 1 hour (IV labetalol or GTN infusion) — INTERACT2 trial
• Reverse anticoagulation: Warfarin — IV vitamin K 10mg + prothrombin complex concentrate (Beriplex); DOAC — idarucizumab for dabigatran, andexanet alfa for factor Xa inhibitors
• Tranexamic acid 1g IV: Consider within 3 hours (TICH-2 trial — modest benefit)
• Avoid antiplatelet/anticoagulant for 1-2 weeks minimum

Surgical/Interventional

• Thrombectomy: LVO within 6h (or 24h with perfusion imaging)
• Decompressive craniectomy: Malignant MCA infarction (age ≤60, within 48h)
• Neurosurgical evacuation: Cerebellar haemorrhage >3cm or with hydrocephalus/deterioration
• EVD: For acute hydrocephalus (SAH, IVH)
• Carotid endarterectomy: Symptomatic stenosis >50% within 2 weeks

Referral Criteria

• All suspected strokes — emergency ambulance to HASU
• LVO — thrombectomy centre
• Cerebellar/large haemorrhage — neurosurgery
• Symptomatic carotid stenosis — vascular surgery within 2 weeks

• 30-day mortality: Ischaemic ~12%, ICH ~30-40%, SAH ~30-50%
• 1-year mortality: ~25% overall for all stroke types
• Stroke unit care: Reduces death AND disability — NNT 20 for one additional patient alive and independent
• Post-stroke disability: ~50% of survivors have some residual disability; 30% require help with ADLs
• Stroke recurrence: ~10% in first year without secondary prevention; anticoagulation for AF reduces stroke by ~65%
• Thrombectomy: NNT 2.6 for reduced disability in LVO

NIHSS Score Components

SSNAP Key Performance Indicators

Key Stroke Trials