3.2 Ischaemic stroke – Cerebral artery thrombosis

📄 Definition

Ischaemic stroke occurs when a cerebral artery is occluded by a thrombus or embolus, leading to focal brain infarction and neurological deficits lasting ≥24 hours.

🧠 Transient Ischaemic Attack (TIA): Neurological symptoms resolve within <24 hours and no infarction seen on imaging.

🧠 Causes – Mnemonic: THROMBO

  • Thromboembolism (from carotids or heart, e.g. AF)

  • Hypertension

  • Risk factors: smoking, diabetes, hyperlipidaemia

  • Oral contraceptives (young women)

  • Mural thrombus post-MI

  • Blood disorders (e.g. polycythaemia)

  • Other: carotid dissection, vasculitis

⚠️ Symptoms – FAST + others

  • Face drooping

  • Arm weakness

  • Speech disturbance

  • Time (act quickly)

  • Visual loss (amaurosis fugax, homonymous hemianopia)

  • Ataxia, vertigo (posterior circulation)

  • Dysphagia

  • Confusion or altered mental status

🧪 Investigations 

🥇 First-Line (Immediate)

  • ABCDE assessment

  • Blood glucose – rule out hypoglycaemia mimic

  • Urgent CT Head (within 1 hour) – exclude haemorrhage

  • ECG – AF or MI

  • FBC, U&Es, LFTs, Clotting, CRP, Lipids, HbA1c

🥈 Second-Line

  • CT Angiography (CTA) – assess large vessel occlusion

  • Carotid Doppler US – check for stenosis

  • MRI Brain – more sensitive for posterior strokes

🥉 Tertiary

  • Echocardiogram – embolic source

  • 24h Holter – paroxysmal AF

  • Thrombophilia screen – if <50 or unexplained stroke

Management – Mnemonic: ACT FAST

  • Antiplatelet – 300 mg aspirin STAT after haemorrhage excluded

  • CT Head – done urgently

  • Thrombolysis – alteplase IV within 4.5 hrs (if criteria met)

  • Fibrinolysis contraindicated? → consider thrombectomy (within 6 hours)

  • Antihypertensives – only if BP >185/110 mmHg

  • Statin – atorvastatin 80 mg after 48 hrs

  • TIA: refer to stroke clinic within 24 hours

Complications – Mnemonic: BE FAST

  • Brain oedema

  • Embolism recurrence

  • Falls

  • Aspiration pneumonia

  • Seizures

  • TIA or progression to haemorrhagic stroke

🔺 Last updated in line with NICE NG128 – Stroke and transient ischaemic attack in over 16s
Published: May 2019 • Last updated: October 2022
Last reviewed: July 2025
✅ PASSMAP ensures all content is NICE-aligned and reviewed for Physician Associate Registration Assessment (PARA) success.

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