• Definition:
o Sudden focal neurological deficit lasting <24 hours (usually <1 hour), no infarct seen on imaging.
• ABCD2 score:
o Age ≥60 (1 point)
o BP ≥140/90 (1 point)
o Clinical features: unilateral weakness (2), speech disturbance without weakness (1)
o Duration ≥60 min (2), 10–59 min (1)
o Diabetes (1)
• Secondary prevention:
o High-dose aspirin immediately.
o Specialist assessment within 24h if high-risk.
o Carotid Doppler if anterior circulation.
• Ischaemic (~85%) vs haemorrhagic (~15%).
• Acute management:
o CT head first to exclude bleed before thrombolysis.
o Thrombolysis window: <4.5 hours (alteplase).
o Thrombectomy: large vessel occlusion up to 6h (select cases to 24h).
• Blood pressure:
o Avoid aggressive lowering unless >185/110 mmHg pre-thrombolysis or very high.
• Secondary prevention:
o Antiplatelet (clopidogrel first-line).
o Statin (avoid starting within 48h of stroke).
o BP control.
• Lacunar stroke:
o Pure motor or pure sensory stroke, due to small vessel disease.
• Presentation:
o Sudden "thunderclap" headache ("worst ever"), neck stiffness, photophobia, reduced consciousness.
• Diagnosis:
o Non-contrast CT head (high sensitivity in first 6h).
o If negative: lumbar puncture ≥12h post-onset → xanthochromia (bilirubin breakdown).
• Causes:
o Berry aneurysm rupture (e.g., at circle of Willis).
o AVM (less common).
• Management:
o Nimodipine (reduces vasospasm risk).
o Neurosurgical coiling/clipping.
• Complications:
o Rebleed (first 24h), hydrocephalus, vasospasm (4–14 days).
Migraine
• Unilateral, pulsatile, photophobia, nausea.
• Aura (visual, sensory, speech disturbance) → resolves before headache.
Cluster headache
• Severe periorbital pain, lacrimation, nasal congestion.
• Male predominance, restless during attacks.
• Acute Rx: high-flow O₂, subcutaneous sumatriptan.
• Prophylaxis: verapamil.
Red flags ("SNOOP"):
• Systemic symptoms (fever, weight loss)
• Neurological signs
• Onset sudden ("thunderclap")
• Older age (>50)
• Progressive or positional
• Features:
o Young obese female.
o Headache, transient visual obscurations, pulsatile tinnitus.
o Papilloedema; risk of vision loss.
• Diagnosis:
o Normal MRI/CT (exclude mass).
o Elevated CSF opening pressure (>25 cm H₂O) on LP.
• Management:
o Weight loss, acetazolamide.
o Urgent ophthalmology if visual threat.
• Classic triad:
o Confusion.
o Ataxia (gait).
o Ophthalmoplegia (nystagmus, lateral rectus palsy).
• Cause:
o Thiamine (B1) deficiency → chronic alcohol use, hyperemesis.
• Management:
o IV thiamine before glucose.
• If untreated → Korsakoff’s syndrome (irreversible amnesia, confabulation).
• Presentation:
o Raised ICP: headache (worse AM), nausea, papilloedema.
o Focal deficits, new-onset seizures.
• Common tumours:
o Glioblastoma multiforme (most common primary adult).
o Meningioma (extra-axial, often benign).
o Mets: lung, breast, melanoma (most common overall cause).
• Management:
o Dexamethasone for oedema.
• Classic triad:
o Gait disturbance ("magnetic gait").
o Urinary incontinence.
o Cognitive impairment (dementia).
• Diagnosis:
o Ventricular enlargement on imaging; normal opening pressure on LP.
• Management:
o High-volume LP (tap test) for prognostication.
o Ventriculoperitoneal shunt.
• Presentation:
o Young woman (pregnancy, OCP).
o Headache, papilloedema ± seizures.
• Diagnosis:
o MR venography.
• Management:
o Anticoagulation (LMWH → warfarin/DOAC).
Extra Revision Pearls
• TIA → "FAST" resolves → carotid Doppler if anterior circulation; consider endarterectomy if >70% stenosis.
• SAH → watch for vasospasm; nimodipine reduces delayed ischaemia.
• IIH clue → "fat female with papilloedema, normal scan."
• Wernicke → always give thiamine before glucose to avoid precipitation.
• Red flags in headache → prompt imaging to exclude mass, SAH, infection.
• NPH triad clue → "wet, wobbly, wacky."
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Author & Educational Disclaimer
Author:
Dr Phillip Cockrell BM FRCP DipClinEd
Dr Phillip Cockrell is a UK Consultant Physician in Internal Medicine, currently working at Queen Alexandra Hospital, Portsmouth University Hospitals NHS Trust. He has previously worked as a registrar across Intensive Care Medicine, Gastroenterology, Cardiology, Stroke Medicine, Acute Medicine, and Respiratory Medicine.
He has held senior leadership roles including Associate Clinical Director of the Acute Medical Unit, Clinical Director of Internal Medicine, and Chief of Medicine. Dr Cockrell has over 15 years’ experience in postgraduate medical education, having lectured extensively across the MRCP syllabus and contributed to MRCP revision teaching and course development.
Dr Cockrell holds a Bachelor of Medicine (BM), Fellowship of the Royal College of Physicians (FRCP), and a Diploma in Clinical Education (DipClinEd). His teaching approach is based on structured consolidation of complex medical topics to support efficient and effective revision for postgraduate examinations.
Purpose of this content:
The material on this page is intended solely for educational purposes to support revision for the MRCP (UK) Part 1 examination. It reflects examination-relevant principles of internal medicine and is designed to aid learning and pattern recognition.
Medical disclaimer:
This content is designed for postgraduate medical examination revision and does not constitute medical advice, diagnosis, or treatment guidance and must not be used as a substitute for professional clinical judgement, local guidelines, or specialist consultation. Clinical decisions should always be made in the context of individual patient circumstances and current national guidance.
