Examqo › Examqo library › Internal medicine › Neurology for the internist · IMLE
Ischaemic stroke and TIA
In suspected stroke, glucose is checked and a non-contrast CT is done at once to exclude bleeding; intravenous thrombolysis is given up to 4.5 hours from symptom onset (or from when last seen well), and catheter clot removal for large-vessel occlusion up to 24 hours with suitable selection.
Why it matters in the exam
The question presents sudden one-sided weakness, facial droop or speech disturbance, and asks for the next step. Time is measured from when the patient was last seen well — so someone who woke up with symptoms "started" when they fell asleep. Before thrombolysis blood pressure must be below 185/110 mmHg, and afterwards it is kept below 180/105 for 24 hours. In a patient not receiving thrombolysis blood pressure is not lowered unless it is above 220/120 — "permissive hypertension" preserves flow to the injured area. Hypoglycaemia can mimic stroke, so glucose is checked before anything else.
After the acute phase the source is sought: echocardiography, Holter for atrial fibrillation, and carotid Doppler. Symptomatic 70–99% stenosis of the carotid artery is treated by endarterectomy within two weeks. Atrial fibrillation — anticoagulation (a DOAC). In minor stroke (NIHSS up to 3) or high-risk TIA, aspirin with clopidogrel is given for 21 days and then a single drug. High-intensity statin with an LDL target below 70 mg/dL. A TIA is a warning: stroke risk is highest in the first days, so work-up is urgent rather than "clinic follow-up".
Key points
- Glucose and non-contrast CT at once.
- Thrombolysis up to 4.5 hours; blood pressure below 185/110 before.
- Catheter for large-vessel occlusion up to 24 hours.
- Without thrombolysis — do not lower blood pressure unless above 220/120.
- Prevention: aspirin + clopidogrel for 21 days in minor stroke, endarterectomy for 70–99%, DOAC in fibrillation.
Summary table
| Phase | Finding | Action | Exam note |
|---|---|---|---|
| Arrival | Sudden neurological deficit | Glucose and non-contrast CT at once | Exclude bleeding |
| Thrombolysis | Up to 4.5 hours, no bleeding | Alteplase or tenecteplase | Blood pressure below 185/110 before |
| Catheter | Large-vessel occlusion on CTA | Clot removal up to 24 hours with suitable selection | Also after thrombolysis |
| Blood pressure without thrombolysis | High blood pressure | Do not lower unless above 220/120 | Permissive hypertension |
| Minor stroke or high-risk TIA | NIHSS up to 3 | Aspirin + clopidogrel for 21 days | Then one drug |
| Secondary prevention | Carotid stenosis 70–99%; atrial fibrillation | Endarterectomy within two weeks; DOAC | Statin, LDL below 70 |
In the full version for subscribers
- A simple algorithm
- Memory aid
- Exam traps
- 5 review cards
- Enough for IMLE
The full version is open to subscribers of: Medical licensing exam (IMLE), Internal medicine, Emergency medicine, Neurology, Family medicine, Forensic medicine, Neurosurgery, Physical medicine and rehabilitation, Cardiothoracic surgery, Urology, Vascular surgery, Geriatrics.
Subscriber? Read the full topic Plans and prices 25 free questions
Sources
- AHA/ASA Guidelines for the Early Management of Patients With Acute Ischemic Stroke, 2019 update — Imaging, thrombolysis, thrombectomy, blood pressure
- AHA/ASA Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack, 2021 — Antiplatelets, carotid disease, atrial fibrillation
- Harrison's Principles of Internal Medicine, 21st edition (2022) — Ischemic Stroke
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-02. The text may contain errors; when in doubt, check the source.