New Neurological Deficit
at the bedside
- airway: assess obstruction; protect if GCS ≤ 8
- breathing: SpO₂, supplemental O₂ only if hypoxic
- circulation: IV access, monitor, ECG
- disability: GCS vs baseline, pupils, focal deficit, last known well (document clearly)
- exposure: trauma, infection, toxidrome; vitals + RBS
- hypoglycemia → IV glucose 150–200 mL of 10% or 75–100 mL of 20% rapidly; D50W 50 mL if 10/20% not stocked; it mimics stroke exactly
why “last known well”, not “symptom onset”
Reperfusion windows count from when the patient was last seen at baseline, not when the deficit was noticed. Wake-up stroke: the time they went to sleep. Get the clock time from whoever saw them last, not “this morning”.
call for help now
- GCS ≤ 8 or losing the airway
- HTN + bradycardia + irregular breathing: Cushing reflex, raised ICP
- unequal or fixed pupils: bleed or herniation
- any deficit that could be a stroke → call the stroke team before you finish the workup: time is the treatment
focused check
- onset: sudden → stroke, seizure, bleed; progressive → tumor, metabolic
- neuro history: CVA / TIA, seizures, migraine, MS
- medications: anticoagulants (which one, last dose), antiepileptics, insulin
- recent illness: fever → meningitis / encephalitis; systemic infection → delirium or unmasked old deficit
- background: AF, HTN, diabetes, cancer, substance use, recent fall or head injury
- collateral history from relatives or staff
- examination
- focal weakness → stroke or mass
- dysphasia or neglect → cortical involvement
- unequal pupils → bleed or herniation
- tongue bite, incontinence, post-ictal state → seizure
- fever → CNS infection; arrhythmia → cardioembolic source
- posterior circulation: vertigo, diplopia, dysarthria, ataxia, visual field loss (easily missed: do not dismiss as “just dizziness”)
- calculate NIHSS
calculator NIHSS · MDCalc ↗︎
send now
- first: non-contrast CT brain urgently, to separate ischemic from hemorrhagic
- bedside: glucose, ECG
- bloods: CBC, INR / aPTT, electrolytes, renal function, troponin
- if indicated: CT angiography ± perfusion when a large vessel occlusion or a late presentation is possible (stroke team decides)
- keep NPO until swallow assessed
treat
CT shows no hemorrhage: likely ischemic stroke
- call the stroke team first. Thrombolysis and thrombectomy are their decision, not a ward decision
- thrombolysis, within 4.5 hr of last known well: tenecteplase 0.25 mg/kg, max 25 mg single IV bolus, or alteplase 0.9 mg/kg, max 90 mg
- BP before lysis: must be < 185/110 → labetalol 10–20 mg IV; keep < 180/105 for the next 24 hr
- not lysing, no thrombectomy: leave the BP alone unless > 220/120 or another indication (dissection, ACS, heart failure)
- thrombectomy: large vessel occlusion → refer, up to 24 hr from last known well
- antiplatelet: aspirin 300 mg once hemorrhage excluded, and only if not thrombolysed (otherwise wait 24 hr)
- minor stroke or high-risk TIA: dual antiplatelet (aspirin + clopidogrel) for 21 days, then single agent, started within 24 hr
thrombolysis: major exclusions
not exhaustive; the stroke team weighs bleeding risk against benefit per current guidance
- intracranial hemorrhage on CT
- active internal bleeding or known bleeding diathesis
- platelet count < 100,000/µL if known
- therapeutic anticoagulation: INR > 1.7, or therapeutic-dose DOAC within 48 hr without a normal specific coagulation assay or reversal
- BP that cannot be brought < 185/110
- glucose < 50 mg/dL not corrected with persistent deficit
- symptoms that are truly non-disabling
- confusion or agitation from the stroke itself is not a contraindication
- stroke-team call, not a ward decision either way
thrombolysis: dose detail and the late windows
- tenecteplase: single bolus, now preferred in many services. Stroke dose 0.25 mg/kg; 0.4 mg/kg is specifically not recommended.
- alteplase: 10% as a bolus over about a minute, remaining 90% infused over 60 minutes.
- beyond 4.5 hr: possible out to 9 hr from last known well, or 9 hr from the sleep midpoint for a wake-up stroke, only when perfusion or DWI-FLAIR imaging shows salvageable brain; imaging-selected, stroke-team-led.
- 9 to 24 hr: evidence split (TRACE-III positive, TIMELESS negative), depends on thrombectomy availability; never a ward-initiated decision.
- After reperfusion, do not drive systolic below 140: intensive lowering is harmful in the first 72 hr after successful thrombectomy.
2026 AHA/ASA acute ischemic stroke guideline.
thrombectomy: how late, and which strokes
- Anterior circulation large vessel occlusion: within 6 hr, and 6–24 hr when perfusion or clinical mismatch criteria are met.
- A large established infarct is no longer an automatic exclusion (SELECT2, ANGEL-ASPECT, RESCUE-Japan LIMIT, TENSION): image and refer, do not rule out at the bedside.
- Basilar occlusion: up to 24 hr.
- Practical consequence: call the stroke team even at hour 20.
dual antiplatelet: who qualifies
- Non-cardioembolic minor stroke (NIHSS ≤ 3, extended to ≤ 5 in current guidance) or high-risk TIA (ABCD2 ≥ 4).
- Start within 24 hr, 21 days only, then a single agent: beyond 21 days bleeding risk rises without added benefit (pooled CHANCE and POINT).
- Loading dose per local protocol (CHANCE used clopidogrel 300 mg, POINT 600 mg).
- Not to be given alongside thrombolysis.
CT shows hemorrhage
- call neurosurgery and the senior now
- stop all anticoagulants and antiplatelets
- BP: if systolic 150–220, lower to about 140 (range 130–150), starting within 2 hr. Do not go below 130: intensive lowering below this has shown harm, not benefit
- nicardipine 5 mg/h IV, increase by 2.5 mg/h every 5–15 min (max 15 mg/h)
- labetalol 10–20 mg IV over 1–2 min, repeat or double every 10 min (max 300 mg), or infusion 0.5–2 mg/min
- aim for smooth, sustained control: an infusion is preferred over repeated boluses where available
- reverse the anticoagulant: warfarin → 4F-PCC 25–50 IU/kg + vitamin K IV
- DOAC-associated bleed → discuss the reversal agent with hematology / stroke, per local protocol
- seizures: no routine prophylactic antiseizure medication, even in lobar hemorrhage. Treat clinical or electrographic seizures per senior. Consider continuous EEG (≥ 24 hr) if consciousness is depressed out of proportion to the bleed, fluctuating, or there is concern for non-convulsive status
calculator ICH score · MDCalc ↗︎
reversal by drug, and why the DOAC answer changed
- warfarin: 4F-PCC 25–50 IU/kg (INR > 2) plus IV vitamin K. PCC is preferred over FFP.
- dabigatran: idarucizumab. Check your formulary for the stocked presentation before you promise it.
- apixaban / rivaroxaban / edoxaban: andexanet alfa withdrawn from the US market December 2025 (ANNEXA-I: better hemostasis, roughly double the thrombotic events, no functional benefit); availability varies by country. 4F-PCC is the usual alternative. Confirm locally.
- Intracerebral hemorrhage still runs on the 2022 AHA/ASA guideline, which predates both of those findings.
ICH score: severity, not a treatment-limiting decision
- five components, 0–6 points: GCS (3–4 / 5–12 / 13–15), ICH volume ≥ 30 mL, intraventricular extension present, infratentorial origin, age ≥ 80
- higher scores track higher 30-day mortality in the original cohort; a population-level prognostic tool, not a bedside cutoff
- do not use it alone to limit treatment or withdraw care: early care-limitation based on a predicted poor outcome biases the mortality data the score was built from (a well-documented self-fulfilling prophecy in ICH)
VTE prophylaxis
- mechanical (intermittent pneumatic compression) from admission for every immobile stroke patient, ischemic or hemorrhagic
- ischemic stroke: pharmacologic prophylaxis can generally start once any hemorrhagic transformation risk has been considered, typically within the first 24–48 hr if imaging is reassuring
- ICH: pharmacologic prophylaxis only once hematoma stability is confirmed on repeat imaging, typically not before 24–48 hr, and later for large or expanding bleeds: hold if any doubt and ask the stroke/neurosurgery team
- dosing and the general risk/bleeding-contraindication framework: VTE prophylaxis
deficit that is not a stroke
- hypoglycemia → IV glucose rapidly (see ABCs above), recheck
- seizure or post-ictal Todd’s paresis → observe and reassess; antiepileptic loading per senior
- electrolyte derangement (Na, Ca, Mg) → correct
- meningitis / encephalitis → do not wait for imaging to start empiric treatment; see empiric antibiotics and headache for meningitis regimen
- old deficit unmasked by infection or fever → treat the trigger
if not improving / further escalation
- stroke team: any acute focal deficit, whatever the hour
- neurosurgery / neurocritical care
- cerebellar hemorrhage, especially > 15 mL, brainstem compression, hydrocephalus, or any neurological deterioration (surgical emergency)
- hydrocephalus or intraventricular extension with reduced consciousness (may need EVD)
- mass effect or ongoing deterioration
- selected large lobar / supratentorial hemorrhage (minimally invasive evacuation may be considered)
- any other bleed the stroke / neurosurgery team wants to see urgently
- ICU: GCS ≤ 8, unprotected airway, refractory seizures
- stay with the patient and reassess: deficits evolve
evidence
| source | type |
|---|---|
| 2026 AHA/ASA acute ischemic stroke guideline | international guideline |
| 2022 AHA/ASA ICH guideline (INTERACT2 / ATACH-2 BP evidence, ENRICH lobar-evacuation data) | international guideline |
| Neurocritical Care Society seizure-prophylaxis guideline, nontraumatic ICH | specialty-society guidance |
| Hemphill et al, ICH score | validated prognostic tool |
Verify indication, dose, allergies, interactions, renal/hepatic function and local protocols before prescribing.
free the on-call checklist covers the whole shift on one printable page.
studying for the IM exam? the IM Rapid Review covers stroke and the acute deficit in the same format. see the sample chapter.
reviewed Jul 2026updated Sep 2026file complaint/new-neurological-deficit