Acute stroke: ischaemic and haemorrhagic

Also known as Acute ischaemic stroke (AIS) · Intracerebral haemorrhage (ICH) · Thrombolysis (alteplase/tenecteplase) · Mechanical thrombectomy · Large vessel occlusion (LVO) · Cerebral venous sinus thrombosis

Acute stroke is a neurological emergency. Time is brain — 1.9 million neurons lost per minute without reperfusion. Ischaemic stroke: thrombolysis (alteplase 0.9 mg/kg up to 4.5 h, or tenecteplase 0.25 mg/kg) plus mechanical thrombectomy for large vessel occlusion (up to 24 h with favourable imaging). Intracerebral haemorrhage (10-15% of strokes): BP control (SBP <140 within 1 h), reverse anticoagulation, urgent neurosurgical evaluation of the cerebellar haematoma with brainstem compression or hydrocephalus. ICU management: airway, BP control (permissive hypertension for ischaemic — SBP <185/110 for thrombolysis; reduce for haemorrhagic — SBP <140), glucose and temperature control, DVT prophylaxis, swallowing assessment.

high28 referencesUpdated 19 Aug 202626 min readSource-verified · Sept 2026

Checked against its sources on 13 Sept 2026

Practise this topic

8 MCQs

The one-line answer

Acute stroke splits on a single non-contrast CT into ischaemic (roughly 85 per cent) and haemorrhagic stroke (10 to 15 per cent of all strokes), and the split reverses the blood-pressure strategy entirely.^[17] Ischaemic stroke gets reperfusion — alteplase 0.9 mg/kg within 4.5 h of last-known-well (or tenecteplase 0.25 mg/kg as a single bolus) plus mechanical thrombectomy for a large-vessel occlusion from 6 up to 24 h when the imaging shows a salvageable penumbra — with the blood pressure held at 185/110 or under to give the lytic, and under 180/105 afterwards to keep the penumbra perfused without bleeding.^[2]^[4]^[9]^[14] Intracerebral haemorrhage gets the opposite: lower SBP to under 140 within 1 h (INTERACT2), reverse anticoagulation urgently with prothrombin complex concentrate-based regimens, and urgent neurosurgical evaluation of the cerebellar clot with brainstem compression or hydrocephalus.^[15]^[19] Both share the same ICU bundle — airway, glucose, temperature, swallow before feed, DVT prophylaxis.

Meet the patient

A 72-year-old woman on warfarin for atrial fibrillation is found on the floor at 06:30, last seen well and talking at 22:30 the night before. She has a right hemiparesis, eyes deviated to the left, and mutters only the odd syllable; NIHSS 16, BP 168/92, capillary glucose 7.3 mmol/L, GCS 13. The stroke alarm is sounding before the CT scanner is even warm.^[12]^[2]

Two questions will decide her next hour, and they are the two that decide every stroke: is there blood on the CT? (the scan answers in minutes and reverses the whole plan) and is the artery openable in time? (the clock answers over the next few hours). Hold those two questions and every section below falls into place.^[28]

References28Show

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