Stroke, TIA and focal weakness

Recognising a vascular presentation

A sudden loss of neurological function suggests stroke until assessed otherwise. Ask the exact time last known well, including witnessed onset, waking symptoms and a fluctuating course. Facial asymmetry, arm weakness and speech change are useful recognition signs, but posterior circulation stroke may produce diplopia, dysphagia, ataxia or a visual-field defect without these features. Document a focused neurological examination and glucose promptly. Hypoglycaemia, migraine, seizure with postictal weakness and functional symptoms can resemble stroke; their possibility must not delay the stroke pathway when the presentation is concerning.

Call emergency stroke services, support airway and circulation, and arrange rapid imaging. Record anticoagulants, recent surgery, bleeding, baseline function and patient preferences. A low stroke scale can conceal a disabling deficit such as aphasia, hemianopia or loss of a skilled hand. Do not label a patient unsuitable for treatment solely because the symptoms are mild numerically. Conversely, reperfusion can cause bleeding, so treatment is a specialist eligibility decision, not an automatic response to every facial droop.

Imaging and reperfusion

Non-contrast CT rapidly identifies haemorrhage and major established injury; a normal early scan does not exclude ischaemic stroke. CT angiography identifies large-vessel occlusion. Perfusion CT or MRI may help select patients in extended or uncertain time windows. Renal and contrast considerations need assessment, but waiting for a routine creatinine result should not casually delay a time-critical pathway. Use telestroke support when on-site specialists are unavailable and arrange transfer in parallel with initial assessment.

Eligible patients with disabling ischaemic stroke may receive IV thrombolysis, with drug and dose selected by the current local stroke protocol. The usual early window is within 4.5 hours, but Australian living guidelines allow imaging-selected extended-window treatment in defined circumstances. Do not teach an absolute exclusion after 4.5 hours or give thrombolysis simply because the patient is inside that window. Large-vessel occlusion may warrant thrombectomy, including selected presentations up to 24 hours. Neither treatment should delay the other when both are indicated. Recent guideline updates include tenecteplase and require current specialist interpretation.

Haemorrhage and early ward care

Intracerebral haemorrhage needs urgent blood-pressure, anticoagulant-reversal and neurosurgical assessment. Do not give aspirin before excluding haemorrhage. Aneurysmal subarachnoid haemorrhage can present with sudden severe headache and little weakness; urgent imaging and neurovascular care are needed. During all stroke care, avoid hypoxia, hypoglycaemia, fever and hypotension, and use the relevant blood-pressure target rather than indiscriminately normalising a compensatory elevated pressure. Swallow screening precedes oral food, fluid and medicines. Assess mobility, VTE prevention, skin protection and communication needs early.

Stroke-unit care integrates nursing, rehabilitation, speech pathology, occupational therapy, physiotherapy and discharge planning. Explain the diagnosis using supported communication when aphasia limits expression; aphasia does not itself prove impaired decision-making capacity. Discuss achievable goals with the patient, then involve carers with permission. A patient who can walk may still have major visual, language or executive difficulties affecting medication safety and driving. Review the home environment and arrange follow-up rather than equating motor recovery with full independence.

TIA and secondary prevention

A resolved focal deficit can be TIA or a small stroke and still requires urgent assessment. Tissue imaging, vascular imaging, ECG and selected prolonged rhythm monitoring identify mechanisms. A risk score alone cannot safely determine discharge, particularly with recurrent attacks, AF or carotid disease. Antiplatelet treatment is used for suitable non-cardioembolic disease; selected minor stroke/high-risk TIA pathways use short-term dual antiplatelets before single therapy. AF generally calls for anticoagulation at a timing appropriate to infarct and bleeding risk. Combining these indefinitely without an indication adds harm.

Investigate symptomatic carotid stenosis promptly for specialist consideration of intervention. Manage smoking, blood pressure, diabetes, lipids, activity and adherence using shared decisions. Review driving against Austroads and the licensing authority requirements. Explain return precautions for recurrent deficits even if all symptoms have disappeared. The examination often asks the next action: urgent assessment beats a routine outpatient review or reassurance based on a normal examination after the attack.

For example, a right-handed patient suddenly cannot name familiar objects but has normal limb power. Record last known well, glucose and language findings, activate stroke assessment and obtain urgent CT/vascular imaging. The absence of weakness does not make the deficit non-disabling. A second patient with ten minutes of monocular blindness needs urgent vascular evaluation despite recovery; neither an eye drop nor a six-month appointment addresses the risk.

Australian stroke living guidelines and Stroke Clinical Care Standard.

Review checkpoints

• Activate the stroke pathway promptly for new focal neurological deficits.
• A normal early CT does not exclude ischaemic stroke.
• Selected patients may receive reperfusion beyond traditional time windows using specialist imaging criteria.