Cerebrovascular diseases and neurointensive care
This domain tests time-critical decision-making: reperfusion eligibility, blood pressure targets, haemorrhage management and neurocritical care. Questions are usually vignette-based with a clock running.
Acute ischaemic stroke
- Intravenous thrombolysis (alteplase 0.9 mg/kg, max 90 mg; or tenecteplase 0.25 mg/kg) within 4.5 hours of a disabling deficit, after excluding haemorrhage on CT, with blood pressure below 185/110 mmHg, glucose corrected, platelets adequate and INR ≤1.7.
- Mechanical thrombectomy within 6 hours for anterior circulation large-vessel occlusion (ICA or M1) with ASPECTS ≥6 and significant deficit; between 6 and 24 hours when perfusion or clinical–imaging mismatch criteria are met (DAWN, DEFUSE-3).
- Blood pressure: lower to below 185/110 before lysis and keep below 180/105 afterwards; in non-reperfused patients permissive hypertension is usual unless extremely high.
- Aspirin after 24 hours post-lysis; dual antiplatelet therapy for 21 days in minor stroke or high-risk TIA.
- Malignant MCA infarction: decompressive hemicraniectomy within 48 hours in younger patients with deteriorating consciousness.
Intracerebral haemorrhage
Systolic target about 140 mmHg, urgent reversal of anticoagulation (vitamin K plus prothrombin complex concentrate; idarucizumab for dabigatran), no routine steroids or platelet transfusion, neurosurgical referral for cerebellar haemorrhage with deterioration or hydrocephalus. The ICH score uses GCS, volume, intraventricular extension, infratentorial location and age.
Subarachnoid haemorrhage
Thunderclap headache; CT is highly sensitive within 6 hours, otherwise lumbar puncture for xanthochromia after 12 hours. Secure the aneurysm by coiling or clipping, give nimodipine for 21 days, and grade with Hunt–Hess, WFNS and modified Fisher.
Cerebral venous thrombosis
Headache, papilloedema, seizures and fluctuating deficits; the empty delta sign on contrast CT. Anticoagulate with low-molecular-weight heparin even when a haemorrhagic infarct is present.
Secondary prevention
Carotid endarterectomy for symptomatic 50–99% stenosis, ideally within 14 days; statin, antithrombotic, risk-factor control, and consideration of embolic stroke of undetermined source.
Worked example
A 68-year-old arrives 3 hours after onset with NIHSS 14, M1 occlusion and ASPECTS 8, blood pressure 176/96. Give alteplase and proceed to thrombectomy (bridging therapy); do not wait for thrombectomy alone, and do not lower pressure below the threshold unnecessarily.
Traps
Giving thrombolysis with untreated blood pressure of 190/110; dismissing posterior circulation stroke because the NIHSS is low; starting prophylactic antiepileptics after stroke; forgetting hypoglycaemia and seizure as mimics.