Distinguishing Left Subdural Haematoma from Other Causes of Deteriorating Neurological Function in a Patient on Warfarin

Subdural haemorrhage (SDH) is a condition where blood accumulates in the subdural space around the brain, often as a result of trauma. It is more common in older patients and those on anticoagulants, such as warfarin. SDH typically presents with fluctuating conscious level, gradual progression of headaches, altered conscious level, and focal neurological deficits. It can be mistaken for dementia in older patients.

In a patient on warfarin with a supratherapeutic INR, a minor head injury can lead to slowly progressive deterioration in neurological function over days or weeks, which is classic for SDH. Recurrent seizures are unlikely without another insult to the brain, and the clinical picture described does not fit with seizures. Further cardioembolic stroke is also unlikely, as warfarin at a therapeutic INR greatly reduces the risk of stroke. Concurrent lobar pneumonia could cause drowsiness and worsening of residual weakness, but focal neurology would be unusual. Left hemisphere intracerebral haemorrhage is a possibility, but symptoms would develop rapidly rather than gradually.

Therefore, in a patient on warfarin with a history of head injury and slowly progressive deterioration in neurological function over days, left subdural haematoma is the most likely cause. Intercurrent infection could also cause deterioration, but not specifically of the right hemiparesis, unless the patient had made a less than complete recovery. Recurrent seizures are uncommon, but could cause deterioration if the patient was in partial status epilepticus.

When dealing with an older patient, it is important to rule out glaucoma if they are experiencing severe unilateral eye pain. However, for a 23-year-old patient, this is not a top concern. Migraine and cluster headaches are common causes of unilateral eye pain, as well as sinusitis which can cause pain behind the eye.

Red Flags for Headaches

Headaches are a common complaint in clinical practice, but some symptoms may indicate a more serious underlying condition. The National Institute for Health and Care Excellence (NICE) has identified several red flags that should prompt further investigation. These include compromised immunity, a history of malignancy, sudden-onset headache, new-onset neurological deficit, impaired level of consciousness, recent head trauma, and symptoms suggestive of giant cell arteritis or acute narrow-angle glaucoma. Other red flags include vomiting without an obvious cause, worsening headache with fever, new-onset cognitive dysfunction, change in personality, orthostatic headache, and a substantial change in the characteristics of the headache. If any of these symptoms are present, it is important to seek medical attention promptly. By identifying these red flags, healthcare providers can ensure that patients receive appropriate care and treatment for their headaches.

When to Investigate Transient Loss of Consciousness: A Guide for Clinicians

Transient loss of consciousness (LOC) can be a concerning symptom for patients and clinicians alike. However, not all cases require extensive investigation. According to the National Institute for Health and Care Excellence (NICE) guidelines, patients presenting with a transient LOC should undergo a thorough history, examination, and electrocardiogram (ECG). If these are normal and the patient meets certain criteria, further work-up may not be necessary.

For example, uncomplicated vasovagal syncope can be diagnosed if there are no features suggesting an alternative diagnosis and if the patient experiences the 3 Ps of posture-prolonged standing, provoking factors, and prodromal symptoms. Doppler ultrasonography of the carotids would only be indicated if there was suspicion of carotid artery stenosis, while a single syncopal episode is not an indication for a computed tomography (CT) scan of the brain.

Electroencephalogram (EEG) may be considered if the history is suggestive of epilepsy, but it should not be routinely used in the work-up for transient LOC. Features strongly suggestive of epilepsy include a bitten tongue, head turning to one side during transient LOC, no memory of abnormal behavior witnessed by someone else, unusual posturing, prolonged limb jerking, confusion following the event, and prodromal déjà vu or jamais vu. If any of these are present, the patient should be reviewed by a specialist within 2 weeks, who would then make a decision regarding EEG.

In summary, a thorough evaluation is necessary for all patients presenting with a transient LOC. However, if the patient meets certain criteria and there are no features suggesting an alternative diagnosis, further investigation may not be required.

Immediate admission for imaging to rule out a hemorrhage is necessary if a patient with suspected TIA is on warfarin, a DOAC, or has a bleeding disorder.

A transient ischaemic attack (TIA) is a brief period of neurological deficit caused by a vascular issue, lasting less than an hour. The original definition of a TIA was based on time, but it is now recognized that even short periods of ischaemia can result in pathological changes to the brain. Therefore, a new ’tissue-based’ definition is now used. The clinical features of a TIA are similar to those of a stroke, but the symptoms resolve within an hour. Possible features include unilateral weakness or sensory loss, aphasia or dysarthria, ataxia, vertigo, or loss of balance, visual problems, and sudden transient loss of vision in one eye (amaurosis fugax).

NICE recommends immediate antithrombotic therapy with aspirin 300 mg unless the patient has a bleeding disorder or is taking an anticoagulant. If the patient has had more than one TIA or has a suspected cardioembolic source or severe carotid stenosis, specialist review is necessary. Urgent assessment is required within 24 hours for patients who have had a suspected TIA in the last 7 days. Referral for specialist assessment is necessary as soon as possible within 7 days for patients who have had a suspected TIA more than a week previously. Neuroimaging and carotid imaging are recommended, and antithrombotic therapy is necessary. Carotid artery endarterectomy should only be considered if the carotid stenosis is greater than 70% according to ECST criteria or greater than 50% according to NASCET criteria.

The patient’s symptoms suggest Brown-Séquard syndrome, which is caused by a hemisection of the spinal cord. This results in ipsilateral pyramidal weakness and loss of joint position/vibration sense, along with contralateral loss of pain/temperature sensation. The patient’s lesion is located in the left mid-thoracic cord. A lesion in the left lumbosacral plexus would only affect the left lower limb. A cervical cord lesion would affect the upper limbs. A central lesion would produce bilateral symmetrical defects, which is not the case here. A right mid-thoracic cord lesion would produce similar symptoms, but on the right side instead. Other spinal cord syndromes include complete cord transection, anterior cord syndrome, subacute combined degeneration of the cord, syringomyelia, and cauda equina syndrome. Each of these has a distinct set of symptoms and affected areas.

The GCS score for this man is 6. His response to a painful stimulus (supraorbital pressure) is opening his eyes, which scores 2. His verbal response is groaning, which also scores 2. His motor response to pain is extension, which scores 2. Therefore, his overall GCS score is 6.

Understanding the Glasgow Coma Scale for Adults

The Glasgow Coma Scale (GCS) is a tool used to assess the level of consciousness in adults who have suffered a brain injury or other neurological condition. It is based on three components: motor response, verbal response, and eye opening. Each component is scored on a scale from 1 to 6, with a higher score indicating a better level of consciousness.

The motor response component assesses the patient’s ability to move in response to stimuli. A score of 6 indicates that the patient is able to obey commands, while a score of 1 indicates no movement at all.

The verbal response component assesses the patient’s ability to communicate. A score of 5 indicates that the patient is fully oriented, while a score of 1 indicates no verbal response at all.

The eye opening component assesses the patient’s ability to open their eyes. A score of 4 indicates that the patient is able to open their eyes spontaneously, while a score of 1 indicates no eye opening at all.

The GCS score is expressed as a combination of the scores from each component, with the motor response score listed first, followed by the verbal response score, and then the eye opening score. For example, a GCS score of 13, M5 V4 E4 at 21:30 would indicate that the patient had a motor response score of 5, a verbal response score of 4, and an eye opening score of 4 at 9:30 PM.

Overall, the Glasgow Coma Scale is a useful tool for healthcare professionals to assess the level of consciousness in adults with neurological conditions.

Depression is a prevalent psychiatric issue in patients with Parkinson’s disease, with approximately 40% of individuals experiencing it, despite dementia being a common comorbidity.

Parkinson’s disease is a progressive neurodegenerative condition that occurs when dopaminergic neurons in the substantia nigra degenerate. This leads to a classic triad of symptoms, including bradykinesia, tremor, and rigidity, which are typically asymmetrical. The disease is more common in men and is usually diagnosed around the age of 65. Bradykinesia is characterized by a poverty of movement, shuffling steps, and difficulty initiating movement. Tremors are most noticeable at rest and typically occur in the thumb and index finger. Rigidity can be either lead pipe or cogwheel, and other characteristic features include mask-like facies, flexed posture, and micrographia. Psychiatric features such as depression, dementia, and sleep disturbances may also occur. Diagnosis is usually clinical, but if there is difficulty differentiating between essential tremor and Parkinson’s disease, 123I‑FP‑CIT single photon emission computed tomography (SPECT) may be considered.

Understanding Optic Neuritis: Symptoms, Causes, and Differential Diagnosis

Optic neuritis is a condition characterized by inflammation, degeneration, or demyelination of the optic nerve. It typically presents with sudden-onset unilateral visual loss, retro-orbital pain, and altered color vision, and is more common in women aged 20-40. Patients with optic neuritis have up to a 50% risk of developing multiple sclerosis (MS) after an episode.

There are three types of optic neuritis: papillitis or anterior optic neuritis, retrobulbar neuritis, and neuroretinitis. Papillitis affects the intraocular portion of the nerve and causes optic disc swelling, while retrobulbar neuritis does not involve the disc and is often associated with MS. Neuroretinitis affects the optic disc and adjacent temporal retina.

The most common cause of retrobulbar neuritis is MS, but it can also be caused by toxic exposure, vitamin deficiency (especially B12), ischaemia (diabetes, giant cell arteritis), or infection. Symptoms include variable loss of central vision, dull aching pain in the eye, and a central scotoma on examination.

Cerebral infarction is an unlikely diagnosis in a young patient without significant risk factors. Optic nerve glioma typically presents with gradual reduction in visual acuity, while migraine aura presents with positive visual phenomena and is associated with unilateral headache. Temporal arteritis, which causes sudden loss of vision associated with ischaemic optic neuropathy, is rare in people under 50 and is associated with polymyalgia rheumatica.

Diagnosis of temporal arteritis requires three of five criteria: >50 years at disease onset, new headache, raised erythrocyte sedimentation rate (ESR), temporal artery abnormality, and abnormal temporal artery biopsy. Understanding the symptoms, causes, and differential diagnosis of optic neuritis is crucial for accurate diagnosis and appropriate treatment.

A POCI (posterior circulation infarct) typically affects the vertebrobasilar arteries. In contrast, a TACI involves the middle and anterior cerebral arteries, a PACI affects the smaller arteries of anterior circulation, and a LACI involves the perforating arteries around the internal capsule, thalamus, and basal ganglia.

Stroke can be classified based on the initial symptoms using the Oxford Stroke Classification, also known as the Bamford Classification. The criteria assessed include unilateral hemiparesis and/or hemisensory loss of the face, arm, and leg, homonymous hemianopia, and higher cognitive dysfunction such as dysphasia.

Total anterior circulation infarcts (TACI) involve the middle and anterior cerebral arteries and present with all three criteria mentioned above. Partial anterior circulation infarcts (PACI) involve smaller arteries of the anterior circulation and present with two of the criteria. Lacunar infarcts (LACI) involve perforating arteries around the internal capsule, thalamus, and basal ganglia and present with one of three symptoms: unilateral weakness (and/or sensory deficit) of face and arm, arm and leg, or all three; pure sensory stroke; or ataxic hemiparesis.

Posterior circulation infarcts (POCI) involve vertebrobasilar arteries and present with one of three symptoms: cerebellar or brainstem syndromes, loss of consciousness, or isolated homonymous hemianopia. Other recognized patterns of stroke include lateral medullary syndrome (posterior inferior cerebellar artery), also known as Wallenberg’s syndrome, which presents with ipsilateral ataxia, nystagmus, dysphagia, facial numbness, cranial nerve palsy (e.g., Horner’s), and contralateral limb sensory loss. Weber’s syndrome presents with ipsilateral III palsy and contralateral weakness.

The patient experienced a fall caused by a mechanical issue, with a potentially harmful mechanism of injury.

NICE Guidelines for Investigating Head Injuries in Adults

Head injuries can be serious and require prompt medical attention. The National Institute for Health and Care Excellence (NICE) has provided clear guidelines for healthcare professionals to determine which adult patients need further investigation with a CT head scan. Patients who require immediate CT head scans include those with a Glasgow Coma Scale (GCS) score of less than 13 on initial assessment, suspected open or depressed skull fractures, signs of basal skull fractures, post-traumatic seizures, focal neurological deficits, and more than one episode of vomiting.

For patients with any loss of consciousness or amnesia since the injury, a CT head scan within 8 hours is recommended for those who are 65 years or older, have a history of bleeding or clotting disorders, experienced a dangerous mechanism of injury, or have more than 30 minutes of retrograde amnesia of events immediately before the head injury. Additionally, patients on warfarin who have sustained a head injury with no other indications for a CT head scan should also receive a scan within 8 hours of the injury.

It is important for healthcare professionals to follow these guidelines to ensure that patients receive appropriate and timely care for their head injuries. By identifying those who require further investigation, healthcare professionals can provide the necessary treatment and support to prevent further complications and improve patient outcomes.

Patients with Bell’s palsy should receive oral prednisolone within 72 hours of onset, regardless of the severity of their symptoms or any improvement since onset. This is important to differentiate Bell’s palsy from other conditions such as cerebral events and Ramsay-Hunt syndrome. Eye protection with lid taping or lubricating eye drops should also be considered. Therefore, the correct answer is oral prednisolone and artificial tears. Oral aciclovir alone is not sufficient as it does not provide steroids or eye protection. Reassurance only and advice to return if symptoms persist after 2 weeks is not appropriate as treatment should be offered within the 72-hour window. Urgent referral to ENT is not necessary as the diagnosis can be made and managed in primary care, but non-urgent referral may be necessary in severe or prolonged cases or where the diagnosis is unclear.

Understanding Bell’s Palsy

Bell’s palsy is a sudden, one-sided facial nerve paralysis of unknown cause. It is more common in individuals aged 20-40 years and pregnant women. The condition is characterized by lower motor neuron facial nerve palsy, which affects the forehead. Unlike upper motor neuron lesions, the upper face is spared. Patients may also experience post-auricular pain, altered taste, dry eyes, and hyperacusis.

The management of Bell’s palsy has been a subject of debate. However, it is now widely accepted that all patients should receive oral prednisolone within 72 hours of onset. The addition of antiviral medications is still a matter of discussion, but it may be beneficial for severe facial palsy. Eye care is also crucial to prevent exposure keratopathy, and patients should be prescribed artificial tears and eye lubricants. If they are unable to close their eyes at bedtime, they should tape them closed using microporous tape.

If the paralysis shows no sign of improvement after three weeks, an urgent referral to ENT is necessary. Patients with long-standing weakness may require a referral to plastic surgery. The prognosis for Bell’s palsy is generally good, with most patients making a full recovery within 3-4 months. However, untreated patients may experience permanent moderate to severe weakness in around 15% of cases.

Understanding Carpal Tunnel Syndrome: Symptoms and Examination Findings

Carpal tunnel syndrome (CTS) is a condition caused by compression of the median nerve in the carpal tunnel. One of the symptoms of CTS is the wasting of the thenar eminence, which is innervated by the median nerve. It is important to note that the hypothenar eminence, which is innervated by the ulnar nerve, is not affected by CTS.

During examination, weakness of thumb abduction (abductor pollicis brevis) is a common finding in CTS. Tapping along the problematic nerve causes paraesthesia, which is known as Tinel’s sign. Flexion of the wrist also causes symptoms, which is known as Phalen’s sign.

Treatment for CTS may include a corticosteroid injection, wrist splints at night, and surgical decompression through flexor retinaculum division.

Overall, understanding the symptoms and examination findings of CTS can help with early diagnosis and appropriate treatment.

For the prophylactic management of migraines in a patient with a history of asthma, the recommended medication is topiramate. Propranolol is an alternative first-line option, but should be avoided in patients with asthma. Amitriptyline is a second-line drug for those who are not responsive to initial prophylactic treatment. Diclofenac is an NSAID used for acute management of migraines, while triptans like sumatriptan are used for acute treatment but not prophylaxis. It should be noted that topiramate is teratogenic and should be avoided in women of childbearing age.

Managing Migraines: Guidelines and Treatment Options

Migraines can be debilitating and affect a significant portion of the population. To manage migraines, it is important to understand the different treatment options available. According to the National Institute for Health and Care Excellence (NICE) guidelines, acute treatment for migraines involves a combination of an oral triptan and an NSAID or paracetamol. For young people aged 12-17 years, a nasal triptan may be preferred. If these measures are not effective, non-oral preparations of metoclopramide or prochlorperazine may be considered, along with a non-oral NSAID or triptan.

Prophylaxis should be given if patients are experiencing two or more attacks per month. NICE recommends topiramate or propranolol, depending on the patient’s preference, comorbidities, and risk of adverse events. Propranolol is preferred in women of childbearing age as topiramate may be teratogenic and reduce the effectiveness of hormonal contraceptives. Acupuncture and riboflavin may also be effective in reducing migraine frequency and intensity for some people. For women with predictable menstrual migraines, frovatriptan or zolmitriptan may be recommended as a type of mini-prophylaxis.

Specialists may consider other treatment options, such as candesartan or monoclonal antibodies directed against the calcitonin gene-related peptide (CGRP) receptor, like erenumab. However, pizotifen is no longer recommended due to common adverse effects like weight gain and drowsiness. It is important to exercise caution with young patients as acute dystonic reactions may develop. By following these guidelines and considering various treatment options, migraines can be effectively managed.

Extradural (epidural) hematoma – Head injury with a lucid interval

Types of Traumatic Brain Injury

Traumatic brain injury can result in primary and secondary brain injury. Primary brain injury can be focal or diffuse. Diffuse axonal injury occurs due to mechanical shearing, which causes disruption and tearing of axons. Intra-cranial haematomas can be extradural, subdural, or intracerebral, while contusions may occur adjacent to or contralateral to the side of impact. Secondary brain injury occurs when cerebral oedema, ischaemia, infection, tonsillar or tentorial herniation exacerbates the original injury. The normal cerebral auto regulatory processes are disrupted following trauma rendering the brain more susceptible to blood flow changes and hypoxia. The Cushings reflex often occurs late and is usually a pre-terminal event.

Extradural haematoma is bleeding into the space between the dura mater and the skull. It often results from acceleration-deceleration trauma or a blow to the side of the head. The majority of epidural haematomas occur in the temporal region where skull fractures cause a rupture of the middle meningeal artery. Subdural haematoma is bleeding into the outermost meningeal layer. It most commonly occurs around the frontal and parietal lobes. Risk factors include old age, alcoholism, and anticoagulation. Subarachnoid haemorrhage classically causes a sudden occipital headache. It usually occurs spontaneously in the context of a ruptured cerebral aneurysm but may be seen in association with other injuries when a patient has sustained a traumatic brain injury. Intracerebral haematoma is a collection of blood within the substance of the brain. Causes/risk factors include hypertension, vascular lesion, cerebral amyloid angiopathy, trauma, brain tumour, or infarct. Patients will present similarly to an ischaemic stroke or with a decrease in consciousness. CT imaging will show a hyperdensity within the substance of the brain. Treatment is often conservative under the care of stroke physicians, but large clots in patients with impaired consciousness may warrant surgical evacuation.

Understanding Cataplexy

Cataplexy is a condition characterized by a sudden and temporary loss of muscle control triggered by intense emotions such as laughter or fear. It is commonly associated with narcolepsy, with around two-thirds of patients experiencing cataplexy. The symptoms of cataplexy can vary from mild buckling of the knees to complete collapse.

This condition can be debilitating and can significantly impact a person’s quality of life. It can also be challenging to diagnose, as the symptoms can be mistaken for other conditions such as seizures or fainting spells. Treatment options for cataplexy include medication and lifestyle changes, such as avoiding triggers that can cause emotional responses.

To differentiate between the possible answers, it is crucial to analyze the patient’s symptoms. Considering his age and the duration of one year, the decline in cognitive function indicates a potential dementia condition. Additionally, the presence of visual hallucinations involving an animal strongly suggests Lewy-body dementia. Furthermore, the decrease in mobility and higher frequency of falls may indicate parkinsonism, further supporting the correct answer of Lewy-body dementia.

Understanding Lewy Body Dementia

Lewy body dementia is a type of dementia that is becoming more recognized as a cause of cognitive impairment, accounting for up to 20% of cases. It is characterized by the presence of alpha-synuclein cytoplasmic inclusions, known as Lewy bodies, in certain areas of the brain. While there is a complicated relationship between Parkinson’s disease and Lewy body dementia, with dementia often seen in Parkinson’s disease, the two conditions are distinct. Additionally, up to 40% of patients with Alzheimer’s disease have Lewy bodies.

The features of Lewy body dementia include progressive cognitive impairment, which typically occurs before parkinsonism, but both features usually occur within a year of each other. Unlike other forms of dementia, cognition may fluctuate, and early impairments in attention and executive function are more common than memory loss. Other features include parkinsonism, visual hallucinations, and sometimes delusions and non-visual hallucinations.

Diagnosis of Lewy body dementia is usually clinical, but single-photon emission computed tomography (SPECT) can be used to confirm the diagnosis. Management of Lewy body dementia involves the use of acetylcholinesterase inhibitors and memantine, similar to Alzheimer’s disease. However, neuroleptics should be avoided as patients with Lewy body dementia are extremely sensitive and may develop irreversible parkinsonism. It is important to carefully consider the use of medication in these patients to avoid worsening their condition.

Diagnostic Tests for Acoustic Tumours: Importance of MRI with Contrast

Acoustic tumours require accurate diagnosis for effective treatment. The most definitive diagnostic test is gadolinium-enhanced magnetic resonance imaging (MRI) of the cerebellopontine angle. This test can detect tumours as small as 1-2 mm in diameter, while fine-cut computed tomography (CT) scanning may miss tumours as large as 1.5 cm even with intravenous contrast enhancement.

Audiometry is also important, but only 5% of patients with acoustic tumours will have a normal audiogram. If MRI is contraindicated, air-contrast cisternography can detect relatively small intracanalicular tumours with high sensitivity.

Fine-cut CT scanning of the internal auditory canal with contrast can rule out medium to large tumours, but cannot reliably detect tumours smaller than 1-1.5 cm. CT scanning without contrast can rule out medium-sized tumours, but is not reliable for detecting smaller tumours.

It is critical to use gadolinium contrast in MRI of the cerebellopontine angle, as non-enhanced MRI may miss small tumours. Therefore, MRI with contrast is the most important diagnostic test for acoustic tumours.

NICE Guidelines for Investigating Head Injuries in Adults

Head injuries can be serious and require prompt medical attention. The National Institute for Health and Care Excellence (NICE) has provided clear guidelines for healthcare professionals to determine which adult patients need further investigation with a CT head scan. Patients who require immediate CT head scans include those with a Glasgow Coma Scale (GCS) score of less than 13 on initial assessment, suspected open or depressed skull fractures, signs of basal skull fractures, post-traumatic seizures, focal neurological deficits, and more than one episode of vomiting.

For patients with any loss of consciousness or amnesia since the injury, a CT head scan within 8 hours is recommended for those who are 65 years or older, have a history of bleeding or clotting disorders, experienced a dangerous mechanism of injury, or have more than 30 minutes of retrograde amnesia of events immediately before the head injury. Additionally, patients on warfarin who have sustained a head injury with no other indications for a CT head scan should also receive a scan within 8 hours of the injury.

It is important for healthcare professionals to follow these guidelines to ensure that patients receive appropriate and timely care for their head injuries. By identifying those who require further investigation, healthcare professionals can provide the necessary treatment and support to prevent further complications and improve patient outcomes.

Lifelong use of aspirin and dipyridamole. Age: 55.

The Royal College of Physicians (RCP) and NICE have published guidelines on the diagnosis and management of patients following a stroke. The management of acute stroke includes maintaining normal levels of blood glucose, hydration, oxygen saturation, and temperature. Blood pressure should not be lowered in the acute phase unless there are complications. Aspirin should be given as soon as possible if a haemorrhagic stroke has been excluded. Anticoagulants should not be started until brain imaging has excluded haemorrhage. Thrombolysis with alteplase should only be given if administered within 4.5 hours of onset of stroke symptoms and haemorrhage has been definitively excluded. Mechanical thrombectomy is a new treatment option for patients with an acute ischaemic stroke. NICE recommends thrombectomy for people who have acute ischaemic stroke and confirmed occlusion of the proximal anterior circulation demonstrated by computed tomographic angiography or magnetic resonance angiography. Secondary prevention includes the use of clopidogrel and dipyridamole. Carotid artery endarterectomy should only be considered if carotid stenosis is greater than 70% according to ECST criteria or greater than 50% according to NASCET criteria.

For patients with an acute ischaemic stroke who present within 4.5 hours, the recommended treatment is a combination of thrombolysis and thrombectomy. Thrombolysis involves the use of alteplase, a tissue plasminogen activator that breaks down the clot, while thrombectomy physically removes the clot using a specialized device inserted through the femoral artery. In this case, as the patient has confirmed occlusion of the proximal anterior circulation, both thrombolysis and thrombectomy should be performed together for the best possible outcome. While alteplase alone can be considered if thrombectomy is not available, a better prognosis is more likely with the combination treatment. It would not be appropriate to perform thrombectomy alone without considering thrombolysis, as the patient is presenting within the window for thrombolysis and should be considered for both in combination according to the guidelines.

The Royal College of Physicians (RCP) and NICE have published guidelines on the diagnosis and management of patients following a stroke. The management of acute stroke includes maintaining normal levels of blood glucose, hydration, oxygen saturation, and temperature. Blood pressure should not be lowered in the acute phase unless there are complications. Aspirin should be given as soon as possible if a haemorrhagic stroke has been excluded. Anticoagulants should not be started until brain imaging has excluded haemorrhage. Thrombolysis with alteplase should only be given if administered within 4.5 hours of onset of stroke symptoms and haemorrhage has been definitively excluded. Mechanical thrombectomy is a new treatment option for patients with an acute ischaemic stroke. NICE recommends thrombectomy for people who have acute ischaemic stroke and confirmed occlusion of the proximal anterior circulation demonstrated by computed tomographic angiography or magnetic resonance angiography. Secondary prevention includes the use of clopidogrel and dipyridamole. Carotid artery endarterectomy should only be considered if carotid stenosis is greater than 70% according to ECST criteria or greater than 50% according to NASCET criteria.