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Stroke & TIA

Time is brain — know the onset time, check the glucose, scan immediately. Recognise the stroke, establish when the patient was last known well, exclude hypoglycaemia, get an immediate CT (and CT angiography for thrombectomy candidates), and activate the stroke team. For TIA: aspirin and a specialist review within 24 hours. Built for revision, not live patient decisions.

NBNeed for BleepClinical revision for junior doctorsUpdated 6 min read
1

Settle them, and check the basics

time is brain

Red flags — what each should make you think

Onset within 4.5 hthrombolysis candidate Large vessel occlusion signs (gaze deviation, aphasia, neglect)thrombectomy candidate On anticoagulantsurgent CT — haemorrhage risk Thunderclap headacheSAH Vertigo, ataxia, diplopia, dysarthriaposterior circulation stroke Neck pain + neuro deficitarterial dissection Glucose lowhypoglycaemia mimic
🩺
Pearl

Pin down the exact time the patient was last known to be well. If they woke up with symptoms, that is when they went to bed, not when they woke. Every decision about thrombolysis and thrombectomy depends on that time.

First actions

  • 🧪Glucose
  • ⏱Time last known well
  • ☎Stroke team
  • CTCT head immediately
  • BPBlood pressure
  • 🚫NBM
2

Understand the patient

ischaemic or haemorrhagic? which window?

Recognition

  • FAST (face, arm, speech, time) pre-hospital; ROSIER in ED
  • NIHSS to quantify severity
  • Posterior circulation strokes are easily missed: vertigo, ataxia, diplopia, dysarthria, dysphagia, visual field loss, reduced consciousness

Reperfusion (NICE NG128 / National Clinical Guideline for Stroke)

  • Thrombolysis (alteplase or tenecteplase) — within 4.5 h of onset, once haemorrhage excluded, no contraindications
  • Thrombectomy — proximal anterior circulation large vessel occlusion: as soon as possible within 6 h; up to 24 h if imaging shows salvageable brain; posterior (basilar) occlusion within 24 h in selected patients
  • Aspirin 300 mg — once haemorrhage excluded (24 h after thrombolysis), continue for 2 weeks
  • ICH — reverse anticoagulation; if SBP 150–220 within 6 h, lower to 130–140 within 1 h

TIA

  • Aspirin 300 mg immediately (unless contraindicated or bleeding risk)
  • Specialist assessment within 24 h of onset (suspected TIA in the last 7 days)
  • Don't use ABCD2 scores to decide urgency
  • Advise no driving (DVLA); dual antiplatelet therapy for high-risk TIA/minor stroke is a specialist decision

Work A–E — assess and act as you go

AAirway. Reduced GCS, poor swallow → aspiration risk.position, NBM
BBreathing. SpO₂ — oxygen only if below 95%.—
CCirculation. BP, rhythm (AF), murmurs.ECG
DDisability. GCS, NIHSS, pupils, glucose.CT now
EExposure. Temperature, signs of trauma, anticoagulant history.—
3

The diagnoses you must not miss

tap to open each

What points toward it, what would rule it in, and how to manage it.

4

Investigate — what to order, when, and what it tells you

test with a question in mind

Glucose

First
Before anything else.

CT head

When
Immediately for possible thrombolysis/thrombectomy, anticoagulated, GCS below 13, progressive symptoms, severe headache, papilloedema, neck stiffness or fever.

CT angiography

When
Possible large vessel occlusion (thrombectomy).

Others

Bloods
FBC, U&E, clotting, glucose, lipids.
ECG
AF.
Later
Carotid imaging (anterior TIA/stroke), echo, prolonged ECG monitoring.
5

How the plan comes together

disposition · handover

hyperacute stroke unit

All acute strokes; swallow screen within 4 h, VTE prevention (intermittent pneumatic compression), early rehab.

TIA clinic

TIA: aspirin 300 mg, specialist review within 24 h, driving advice.

Hand over: onset time, NIHSS, imaging, thrombolysis decision and time.

🩺
Pearl

Glucose first, onset time second, CT immediately. Remember the posterior circulation, and don't let a mimic or a slow scan cost the patient their window. Nicely done getting here.

✎

Clerking template

copy or download

Stroke & TIA — documentation structure

A structure and prompt list to help you document and think systematically. It is not a completeness check and cannot guarantee nothing is missed — use your trust's own proforma, your seniors, and your clinical judgement.

STROKE / TIA — CLERKING TEMPLATE PRESENTING COMPLAINT: HISTORY OF PRESENTING COMPLAINT Symptoms — weakness / speech / vision / balance / sensation: Time last known well (exact): Witness: Headache / seizure / trauma: Anticoagulants / antiplatelets: Previous stroke / TIA / AF: RED FLAGS ASKED (record present or absent) [ ] Onset within 4.5 h -> thrombolysis candidate [ ] Large vessel occlusion signs (gaze deviation, aphasia, neglect) -> thrombectomy candidate [ ] On anticoagulants -> urgent CT — haemorrhage risk [ ] Thunderclap headache -> SAH [ ] Vertigo, ataxia, diplopia, dysarthria -> posterior circulation stroke [ ] Neck pain + neuro deficit -> arterial dissection [ ] Glucose low -> hypoglycaemia mimic SCORES / KEY CHECKS Glucose: NIHSS: ROSIER: CT / CTA (time / result): Thrombolysis: Y / N (time) Thrombectomy referral: Y / N Swallow screen: PAST MEDICAL HISTORY: DRUG HISTORY: ALLERGIES: SOCIAL HISTORY (smoking / alcohol / function / who's at home): FAMILY HISTORY: OBSERVATIONS: RR SpO2 ( % O2) HR BP Temp GCS NEWS2 EXAMINATION A - B - C - D - (GCS pupils glucose ) E - INVESTIGATIONS ORDERED: IMPRESSION: DIFFERENTIALS CONSIDERED: [ ] Large vessel occlusion [ ] Intracerebral haemorrhage [ ] Subarachnoid haemorrhage [ ] Posterior circulation / basilar occlusion [ ] Mimics [ ] Hypoglycaemia [ ] Todd's paresis [ ] Migraine with aura [ ] Functional neurological disorder [ ] Space-occupying lesion PLAN: 1. 2. 3. ESCALATION / SENIOR DISCUSSION: Discussed with: Time: Advice: SAFETY NET / IF DETERIORATES: Documented by: Grade: Date/Time:
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Test yourself

active recall

Cover the answer, say it out loud, then reveal. Retrieval beats re-reading.

0 / 12 known
Red flag
Onset within 4.5 h — what should it make you think?
thrombolysis candidate
Red flag
Large vessel occlusion signs (gaze deviation, aphasia, neglect) — what should it make you think?
thrombectomy candidate
Red flag
On anticoagulants — what should it make you think?
urgent CT — haemorrhage risk
Red flag
Thunderclap headache — what should it make you think?
SAH
Red flag
Vertigo, ataxia, diplopia, dysarthria — what should it make you think?
posterior circulation stroke
Red flag
Neck pain + neuro deficit — what should it make you think?
arterial dissection
Red flag
Glucose low — what should it make you think?
hypoglycaemia mimic
Must not miss
How do you rule in large vessel occlusion?
CT angiography.
Must not miss
How do you rule in intracerebral haemorrhage?
CT head.
Must not miss
How do you rule in subarachnoid haemorrhage?
CT (± LP if CT after 6 h and negative).
Must not miss
How do you rule in posterior circulation / basilar occlusion?
CT angiography / MRI.
Must not miss
How do you rule in mimics?
Glucose, history, imaging.
Q

Frequently asked questions

quick answers
What are the red flags for acute stroke and TIA?
  • Onset within 4.5 h — think thrombolysis candidate
  • Large vessel occlusion signs (gaze deviation, aphasia, neglect) — think thrombectomy candidate
  • On anticoagulants — think urgent CT — haemorrhage risk
  • Thunderclap headache — think SAH
  • Vertigo, ataxia, diplopia, dysarthria — think posterior circulation stroke
  • Neck pain + neuro deficit — think arterial dissection
  • Glucose low — think hypoglycaemia mimic
What is the initial management of acute stroke and TIA?
  • Glucose — exclude hypoglycaemia immediately
  • Time last known well — from witnesses/family
  • Stroke team — pre-alert / activate
  • CT head immediately — + CT angiography if thrombectomy may be indicated
  • Blood pressure — below 185/110 if thrombolysis planned
  • NBM — swallow screen before oral intake

Always alongside senior support and your local guideline.

What diagnoses must you not miss in acute stroke and TIA?
  • Large vessel occlusion — thrombectomy
  • Intracerebral haemorrhage — CT shows blood
  • Subarachnoid haemorrhage — thunderclap
  • Posterior circulation / basilar occlusion — vertigo · ataxia · low GCS
  • Mimics — glucose · seizure · sepsis

Open each one in the must-not-miss section for what points toward it, how to rule it in, and how to manage it.

What investigations should a junior doctor order for acute stroke and TIA?
  • Glucose — Before anything else.
  • CT head — Immediately for possible thrombolysis/thrombectomy, anticoagulated, GCS below 13, progressive symptoms, severe headache, papilloedema, neck stiffness or fever.
  • CT angiography — Possible large vessel occlusion (thrombectomy).
  • Others — FBC, U&E, clotting, glucose, lipids.
Admit or discharge: how is the plan decided for acute stroke and TIA?
  • Hyperacute stroke unit — All acute strokes; swallow screen within 4 h, VTE prevention (intermittent pneumatic compression), early rehab.
  • Tia clinic — TIA: aspirin 300 mg, specialist review within 24 h, driving advice.
Is there a clerking template for acute stroke and TIA?

Yes — there is a free clerking template for acute stroke and TIA on this page, structured as presenting complaint, red flags asked, history, examination (A–E), investigations, differentials, plan and escalation. You can copy it or download it as a Word document. Jump to the template.

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