Intended for healthcare professionals

Clinical Review

Diagnosis and management of transient ischaemic attack and ischaemic stroke in the acute phase

BMJ 2011; 342 doi: (Published 31 March 2011) Cite this as: BMJ 2011;342:d1938
  1. K S McArthur, clinical research fellow,
  2. T J Quinn, lecturer in geriatric medicine,
  3. J Dawson, lecturer in clinical pharmacology and stroke,
  4. M R Walters, professor of clinical pharmacology and stroke
  1. 1Institute of Cardiovascular and Medical Sciences, University of Glasgow, Western Infirmary, Glasgow G116NT, UK
  1. Correspondence to: K S McArthur kate.mcarthur{at}

Summary points

  • Education of patients and their relatives to recognise signs of stroke and transient ischaemic attack (TIA) is crucial to promote early presentation to medical services

  • TIA and stroke are medical emergencies; refer for urgent specialist opinion

  • The risk of further cerebrovascular event following TIA is substantial, immediate, quantifiable, and preventable; do not be reassured by resolution of symptoms

  • Effective treatments for selected stroke patients include: aspirin within first 48 hours; intravenous thrombolysis; surgical decompression of cerebral oedema

  • Admission to a dedicated stroke unit offers mortality and functional benefits to all patients with stroke

  • Deranged physiology is common in acute stroke and associated with poor prognosis

The care of people with acute ischaemic stroke has improved dramatically in recent years. Both stroke and transient ischaemic attack (TIA) are now recognised as medical emergencies that must be treated with the same urgency as myocardial infarction. Treatments such as thrombolysis are now widely adopted and underpinned by a robust evidence base. Rapid and accurate recognition of cerebral ischaemia, prompt treatment, and referral to specialist services can reduce the risk of further events.

Although cautious optimism has replaced therapeutic nihilism, stroke remains an important cause of death and disability and improvements in stroke services are still sorely needed. There are an estimated 900 000 stroke survivors in England, half of whom are dependent on others for care at an estimated cost of £8bn per year (about €9bn or $13bn).1 This burden will increase as population demographics change. We review the diagnosis and acute management of cerebral ischaemia drawing on evidence from original research (particularly multicentre randomised clinical trials), registry data, and systematic review and meta-analysis, and with particular attention to national and international clinical guidelines. Further discussion of the epidemiology and economical aspects of contemporary stroke care are available elsewhere1 2w1; …

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