**4. Investigations**

Risk factors for stroke have been classified as modifiable and non-modifiable. The non-modifiable factors include sex, age, race, family history, genetic and low birth weight while the modifiable risk factors include hypertension, diabetes mellitus, hyperlipidaemia, atrial fibrillation, smoking, obesity, carotid artery disease, hyperhomocysteinemia, hypercoagulable

Stroke increases sharply with age and the incidence of a first time stroke is about 200 per 100,000 annually with a prevalence of 5–12 per 1000 population. Stroke mortality rate is different among countries ranging from 20 to 250 per 100,000 populations annually [9]. In the UK about 90,000 females and 60,000 males die from stroke yearly with the approximate cost of stroke to NHS and social services being £2.3bn annually [10]. The risk of a recurrent stroke is very high among survivors. About 14% of patients who survive a stroke or TIA will have a recurrence in the first year; 22% of males and 25% of females will have mortality in the first year of an initial stroke and more than half of all stroke patients experience mortality within

Stroke is classified into two major types: Ischaemic and haemorrhagic. Ischaemic stroke is by far the commonest, accounting for 85% of all strokes while haemorrhagic stroke accounts for

Ischaemic stroke is the leading worldwide cause of morbidity and mortality in the developed world. About 8–12% of patients die within 30 days of their first stroke and those that survive the first attack are at increased risk of a recurrence [11]. Ischaemic stroke is caused by atherosclerotic vascular disease leading to occlusion and stenosis of major intracranial or extracranial arteries and constriction of small penetrating arteries of the brain. Cardioembolic stroke due to myocardial infarction is usually due to atherosclerosis of the coronary arteries. The resulting ischaemia leads to direct brain insult because of inadequacy of flow, hypoxia and metabolic substrate and institutes a cascade of neurochemical processes causing continuous damage within hours. Treatment of ischaemic stroke has been with the use of drugs such as fibrinolytic agents, anticoagulants and antiplatelets to improve blood supply to the brain. Prevention of stroke both at the primary and secondary levels is now possible because of availability of various safe and successful interventions

Patients present with abrupt onset of focal neurological deficit such as facial paresis, arm drift, leg weakness and abnormal speech [13]. Although patients with acute ischaemic stroke do present with headache, vomiting, seizures, depressed level of consciousness; these symptoms are commoner in patients with haemorrhagic stroke. It is difficult, on the basis of clinical presentation,

15% of strokes - intracerebral 10%, subarachnoid 5% [5].

directed at high risk individuals [5, 12].

**3. Clinical presentation**

states and select biomarkers [8].

230 Essentials of Accident and Emergency Medicine

8 years [5].

**2. Classification**

Besides doing basic investigations such as carotid Doppler, pregnancy test, full blood count, fasting lipid profile, blood sugar, serum homocysteine, serum electrolyte, urea and creatinine, coagulation studies (PT/INR/PTT), liver function tests, Haemoglobin AIc, electrocardiography (ECG), electroencephalopathy (EEG), toxicology screen, cardiac enzymes (CK,CK-MB, TROPONIN I and T) a brain Computed Tomography/Magnetic Resonance Imaging (CT/MRI) Scan is also required as this is the single most important investigation to help exclude a cerebral haemorrhage and stroke mimics. It confirms the diagnosis of ischaemic stroke allowing for prompt treatment of the condition. Increase in both cardiac Troponin T and Troponin I have been found to be associated with stroke severity and poor clinical outcomes [17, 18].
