Last known well, wake-up symptoms, exact deficit onset and progression
Anticoagulants, recent surgery/bleeding, prior stroke, seizure, headache/neck trauma
Baseline disability, pregnancy/postpartum status, vascular risk factors
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← All presentations
Focal Neurologic Deficit / Suspected Stroke
Time last known well, glucose, disability, imaging, reperfusion team.
Your objective: explain the approach, recognize important warning signs, then test your recall.
Abbreviations explained
- ACS
- Acute coronary syndrome
- OMI
- Occlusion myocardial infarction
- ECG
- Electrocardiogram
- PE
- Pulmonary embolism
- POCUS
- Point-of-care ultrasound
- QTc
- QT interval corrected for heart rate
- LBBB
- Left bundle branch block
- RBBB
- Right bundle branch block
- hs-cTn
- High-sensitivity cardiac troponin
- CTA
- Computed tomography angiography
- ICU
- Intensive care unit
Filter
The jobTime last known well, glucose, disability, imaging, reperfusion team.
- Record last-known-well, baseline function, anticoagulants, glucose, and deficit severity.
- Activate the local stroke pathway; noncontrast CT excludes hemorrhage and vascular imaging selects thrombectomy candidates.
- Do not let a low NIHSS dismiss a disabling deficit; reperfusion eligibility is protocol- and imaging-dependent.
A new focal deficit is stroke until proven otherwise, but hemorrhage, seizure, hypoglycemia, migraine, dissection, and toxic-metabolic causes may mimic it.
The clock starts at last known well, not arrival.
Acute ischemic stroke with disabling deficit Critical
Key: Rapid stroke-team assessment; IV thrombolysis and/or thrombectomy eligibility follows local protocol and imaging.
Intracranial hemorrhage Critical
Key: CT first; control physiology and reverse anticoagulation per local pathway.
Basilar artery occlusion Critical
Key: Vertigo, diplopia, dysarthria, weakness, coma, or fluctuating signs demand posterior-circulation vigilance.
Cervical artery dissection Emergent
Key: Neck pain/headache with partial Horner syndrome or focal deficit; CTA/MRA.
Hypoglycemia, seizure/Todd paralysis, migraine Common
Key: Treat mimics promptly, but do not delay stroke imaging when uncertainty remains.
Tick what your patient has — the banner updates as you go.
Glucose, NIHSS/local stroke scale, gaze/visual fields/language/neglect
Posterior signs
gait, dysarthria, diplopia, crossed findings
Blood pressure, airway, swallowing and aspiration risk
Immediate
- Bedside glucose, ECG, CBC/coagulation and type/screen without delaying imaging
- Noncontrast CT; CTA head/neck and perfusion/advanced imaging per local stroke protocol
Targeted
- Pregnancy test when relevant; troponin and rhythm monitoring
- MRI when diagnosis or wake-up/extended-window selection remains uncertain
Avoid delay
- Do not wait for every laboratory result before activating the reperfusion pathway unless locally required
Medication safety reminder
Use this as a first-pass prompt; verify all medications, doses, concentrations, contraindications, weight, pregnancy status, and local protocols before administration.
Check indication, allergy, route, renal/hepatic risk, interactions, monitoring, and local formulary.
Discharge
- Only after a confirmed low-risk mimic or specialist-directed TIA pathway with rapid follow-up.
Stroke unit
- Confirmed stroke/TIA, persistent deficit, or incomplete etiologic assessment.
Resuscitation / neuro-ICU / thrombectomy centre
- Reperfusion candidate, hemorrhage, large-vessel occlusion, declining consciousness, or airway risk.
Use objective reassessment and the local pathway.
Before the next decision · reassess and hand over
Use these learning prompts with the presentation’s pathway. They are not discharge criteria.
- Reassess: compare symptoms, observations and examination with the initial assessment and response to treatment.
- Warning signs for Focal Neurologic Deficit / Suspected Stroke:
- Disabling aphasia, neglect, hemiparesis, or visual loss
- Reduced consciousness or brainstem/posterior-circulation signs
- Thunderclap headache, vomiting, meningismus, or seizure
- Neck pain after minor trauma or new Horner syndrome
- Anticoagulation or severe hypertension with neurologic change
- Reconsider: check unresolved findings and alternative explanations, including the pitfalls below.
- Escalate: communicate deterioration, uncertainty or needs beyond the current setting.
- Plan the transition: identify outstanding results, responsibility for follow-up, patient understanding and specific return advice.
Clinical Pearls
- Glucose is immediate, but it is not a reason to postpone imaging once corrected.
- Posterior strokes can be subtle and still catastrophic.
Pitfalls
- Using arrival time rather than last-known-well.
- Calling a mild NIHSS “minor” when the deficit is disabling for the patient.
PRACTICE REFRESHER
Rapid recall
Test your first action and the dangerous diagnoses before revealing the answer.
01 · First move
Before you scroll, what needs to happen first?
Record last-known-well, baseline function, anticoagulants, glucose, and deficit severity.
02 · Immediate threats
Name at least two diagnoses that cannot wait.
Acute ischemic stroke with disabling deficit · Intracranial hemorrhage · Basilar artery occlusion
PRIVATE TO THIS DEVICE
Your learning note
Capture a weak point, a teaching pearl, or a question to take to your next shift.
Review schedule starts when marked reviewed
Selected guidance · source check 2026-09-07. These 1 source links support selected teaching points, not a complete review of this topic. Check population, setting and local protocol before applying a recommendation.
- Rosen’s Emergency Medicine, 10th ed. — acute stroke
- 2026 AHA/ASA Early Management of Acute Ischemic Stroke Guideline; local stroke pathway