Stroke causes a vast amount of death and disability throughout the world, yet for many healthcare professionals it remains an area of therapeutic nihilism and thus uninteresting. This negative perception is shared by the general public, who often have a poor understanding of the early symptoms and significance of a stroke. Yet within the last few years there have been many important developments in the approach to caring for stroke patients, for both the acute management and secondary prevention.

Following the completion of numerous clinical trials, we now have robust evidence either to support or discredit various interventions. Even more exciting is the prospect of yet more data becoming available in the near future, testing a whole array of treatments, as clinical interest in stroke expands exponentially.

Management of acute stroke

• Acute stroke is hugely important worldwide as a cause of death and serious disability.

• Acute stroke represents a medical emergency, and should be managed as such.

• Management is crucially dependent upon an early and accurate diagnosis; investigations should be aimed to help to identify the type of stroke and its possible causes. They should be performed promptly and be cost effective.

• Patients should be managed within an organised stroke unit, which is the only intervention proven to reduce death and disability for most patients.

• Intravenous thrombolysis is currently only applicable to a small proportion of patients with proven ischaemic stroke presenting within three hours.

• There is no evidence to support the use of anticoagulants in any patient category. However we consider starting intravenous standard unfractionated heparin in evolving CT-proven ischaemic stroke which is likely to be due to progressive thromboembolism.

• We start all patients on aspirin 300 mg as soon as CT has confirmed an ischaemic stroke unless there is a contraindication.

• We would refer a patient with a large lobar intracerebral haemorrhage and falling conscious level for drainage of the haematoma.

• We would consider a patient in coma or deteriorating with a cerebellar haematoma for surgical intervention.

• It is likely that new, effective strategies to treat acute stroke will become available soon.

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