Stroke in the acute setting

Acute stroke and transient ischaemic attack (TIA) are focal neurological syndromes of vascular origin and should be treated as medical emergencies. Brain imaging with computed tomography or magnetic resonance imaging is required to distinguish ischaemic stroke from intracerebral haemorrhage, recognize non-stroke pathologies that mimic stroke and guide investigation into the underlying mechanism. Acute interventions of benefit in ischaemic stroke include intravenous thrombolysis with alteplase given within 4.5 hours of onset, endovascular thrombectomy within 6 hours of onset in selected patients, stroke unit care and aspirin. Decompressive hemicraniectomy reduces mortality in ischaemic stroke complicated by severe brain swelling. Intracerebral haemorrhage accounts for 10-15% of strokes, and while specific treatments are lacking at present, patients benefit from general measures, notably stroke unit care. TIA carries a high short-term risk of stroke, and immediate investigation and institution of secondary preventive treatment prevents a high proportion of this. Secondary prevention for ischaemic stroke and TIA should be tailored according to mechanism in individual patients.