Cerebrovascular Disease and Stroke
Stroke is the highest-yield domain in most neurology papers: time windows, vascular localisation, aetiological classification and secondary prevention all appear reliably.
Time-critical therapy
- Intravenous alteplase is licensed within 4.5 hours of last known well. Blood pressure must be below 185/110 before treatment and below 180/105 afterwards.
- Exclude haemorrhage on CT, check glucose, and record the NIHSS before deciding.
- Mechanical thrombectomy is offered up to 6 hours for internal carotid or M1 occlusion, and 6 to 24 hours in selected patients with salvageable penumbra on perfusion imaging.
- Aspirin starts within 24 to 48 hours, after 24 hours if thrombolysis was given.
Localisation
- Lacunar syndromes: pure motor, pure sensory, sensorimotor, ataxic hemiparesis, clumsy hand-dysarthria. Cortical signs are absent by definition.
- Cortical infarction: aphasia, neglect, hemianopia, and gaze deviation towards the hemispheric lesion.
Aetiology (TOAST)
Large artery atherosclerosis, cardioembolism, small vessel disease, other determined cause such as dissection or vasculitis, and undetermined.
Worked example
A 70-year-old with atrial fibrillation develops dense right hemiparesis and global aphasia two hours after onset. CT shows no blood and the NIHSS is 14. This is a left middle cerebral artery territory infarct, cardioembolic. Give alteplase if no contraindication, obtain CT angiography to look for large vessel occlusion, and plan anticoagulation after 4 to 14 days depending on infarct size and haemorrhagic transformation risk.
Traps
Missing hypoglycaemia as a stroke mimic; thrombolysing a Todd paresis after a seizure at onset; forgetting the blood pressure ceilings; attributing reduced consciousness to stroke without checking oxygenation and glucose.