🚨 Acute Stroke
Overview
Acute stroke is a sudden neurological deficit caused by ischaemia (85%) or haemorrhage (15%) in the brain. Rapid recognition and treatment are crucial to minimise brain damage and improve patient outcomes.
Recognition
Sudden onset of focal neurological deficits, often unilateral. Use the 'FAST' acronym (Face drooping, Arm weakness, Speech difficulty, Time to call emergency services). Other symptoms include sudden vision loss, severe headache, confusion, or balance problems.
Initial Assessment (ABCDE)
Immediate ABCDE assessment. Secure airway, ensure adequate oxygenation, and maintain blood pressure. Rapid neurological assessment using GCS and a stroke scale (e.g., NIHSS). Establish time of symptom onset, which is critical for treatment decisions.
Red Flags
Rapidly worsening neurological deficits, signs of raised ICP (e.g., headache, vomiting, GCS drop), pupillary asymmetry, or seizures. These may indicate a large stroke, haemorrhagic transformation, or intracranial haemorrhage.
Investigations
Bedside: Capillary blood glucose, vital signs, ECG. Bloods: FBC, U&Es, LFTs, coagulation screen, group and save. Imaging: Urgent non-contrast CT head to differentiate ischaemic from haemorrhagic stroke. CT angiography/perfusion may be used for ischaemic stroke assessment.
Immediate Management
For suspected ischaemic stroke, consider thrombolysis or thrombectomy if within the therapeutic window and no contraindications. Maintain normoglycaemia and normothermia. Manage blood pressure carefully. Administer oxygen if hypoxic. For haemorrhagic stroke, blood pressure control and neurosurgical consultation are key.
Escalation Triggers
Any suspected acute stroke requires immediate emergency department attendance and activation of the stroke pathway. Discuss all cases with the stroke team/neurologist. Patients requiring intubation, with large haemorrhages, or rapidly deteriorating need critical care and neurosurgical input.
MLA High-Yield Notes
Time is brain: early recognition and treatment are paramount. Ischaemic stroke is more common. CT head differentiates ischaemic from haemorrhagic stroke; thrombolysis is contraindicated in haemorrhagic stroke. The 'penumbra' is the salvageable brain tissue around an infarct. Secondary prevention is vital.
References
- NICE Guideline CG162: Stroke and TIA: diagnosis and initial management
- Resuscitation Council UK: Advanced Life Support (ALS) guidelines
- Royal College of Physicians: National Clinical Guideline for Stroke