New Neurological Deficit

at the bedside

airway, breathing, circulation; protect the airway if GCS ≤ 8; oxygen only if SpO₂ < 90%; cardiac monitor, IV access, ECG (AF?)
disability → GCS against baseline, pupils, the deficit; NIHSS · MDCalc ↗︎
last known well → the clock time the patient was last seen at baseline, from whoever saw them; woke up with it → the time they went to sleep. Every window counts from this, not from when the deficit was noticed
capillary glucose → low → glucose 10% 150–200 mL IV over 10–15 min, repeat the glucose → hypoglycemia; it mimics stroke exactly
NPO until a swallow screen

escalate now if

any new focal deficit → neurology on call now, before the workup is complete; CT is the first test → no bleed / bleed
GCS ≤ 8 or falling → ICU
bradycardia, hypertension and irregular breathing → raised ICP → neurosurgery
unequal or fixed pupils → bleed or herniation → hemorrhage

ischemic stroke → sudden focal deficit in a vascular territory; AF, hypertension, diabetes
intracerebral hemorrhage → same picture, more headache, vomiting, very high BP, anticoagulant; only CT tells them apart
TIA → resolved within minutes to an hour; still the same workup tonight
mimics → hypoglycemia, seizure with post-ictal weakness, migraine aura, Bell palsy, old deficit unmasked by infection, functional
not the brain → spinal cord (both legs, a level, bladder) → back pain; nerve or root (one limb, no upper motor neuron signs)
where is the lesion → fold in focused check

onset → sudden → stroke, bleed, seizure; progressive → tumour, metabolic
background → previous stroke or TIA, AF, hypertension, diabetes, cancer, epilepsy, migraine, recent fall or head injury
drug chart → anticoagulant (which one, last dose), antiepileptics, insulin
recent illness → fever → meningitis or encephalitis; any infection can unmask an old deficit
examine → face, arm and leg power; speech and language; neglect; gaze; visual fields; pupils; cerebellar signs; tongue bite or incontinence (seizure)
collateral history from relatives or staff

where is the lesion

face and arm more than leg, aphasia or neglect, gaze toward the lesion → cortical, middle cerebral artery
leg more than arm → anterior cerebral artery
vertigo, diplopia, dysarthria, ataxia, visual field loss, crossed face and body signs → posterior circulation; easily dismissed as “dizziness”
pure motor or pure sensory, no cortical signs → lacunar
both legs, a sensory level, bladder involvement → spinal cord → back pain
one limb in a nerve or root pattern, no upper motor neuron signs → peripheral
forehead weak on the same side → Bell palsy, not stroke
mimics → hypoglycemia, seizure with post-ictal weakness, migraine aura, old deficit unmasked by infection

CT head, non-contrast, now: bleed or no bleed decides everything below
CT angiography ± perfusion when a large vessel occlusion is possible or the patient is beyond 4.5 h; neurology decides
glucose, ECG, CBC, INR and aPTT, RFT, troponin

no bleed on CT: ischemic stroke until proven otherwise

neurology on call now; thrombolysis and thrombectomy are their decision, your job is the clock, the CT, the BP and the glucose
thrombolysis, within 4.5 h of last known well → tenecteplase 0.25 mg/kg IV single bolus, max 25 mg; or alteplase 0.9 mg/kg, max 90 mg, 10% as a bolus then the rest over 60 min
BP before lysis → must be < 185/110 → labetalol 10–20 mg IV over 2 min; after lysis keep < 180/105 for 24 h → hypertension
not lysed → leave the BP unless > 220/120 or another emergency indication
thrombectomy → large vessel occlusion up to 24 h from last known well (6–24 h needs mismatch imaging); basilar occlusion up to 24 h; a large established infarct is not an automatic exclusion, refer anyway
aspirin 300 mg once the CT excludes bleed; after lysis wait 24 h
minor stroke (NIHSS ≤ 5) or high-risk TIA (ABCD2 ≥ 4) → aspirin + clopidogrel (load 300 mg) for 21 days, then one agent; not with thrombolysis

thrombolysis: main exclusions

bleed on CT
active bleeding or known bleeding disorder
platelets < 100 ×10⁹/L if known
therapeutic anticoagulation → INR > 1.7, or a DOAC within 48 h without a normal specific assay or reversal
BP that cannot be brought below 185/110
glucose < 2.8 mmol/L with the deficit persisting after correction
deficit that is truly non-disabling
confusion or agitation from the stroke itself is not an exclusion
the list is not exhaustive; neurology weighs it

late windows

4.5–9 h from last known well, or 9 h from the sleep midpoint in wake-up stroke → thrombolysis only with perfusion or DWI-FLAIR mismatch on imaging
9–24 h → evidence split; depends on thrombectomy access
after successful reperfusion → do not drive systolic below 140 in the first 72 h
all neurology-led; the ward’s job is to call early

CT shows hemorrhage

neurosurgery and ICU now
stop all anticoagulants and antiplatelets
SBP 150–220 → lower to 140 and hold at 130–150, smoothly, never below 130; start within 2 h → hypertension
labetalol 10–20 mg IV over 2 min, repeat or double every 10 min (20–80 mg), max 300 mg; or nicardipine 5 mg/h IV, up by 2.5 mg/h every 5–15 min, max 15 mg/h; an infusion beats repeated boluses
reverse the anticoagulant → warfarin: 4F-PCC 25–50 IU/kg IV + vitamin K 10 mg IV; dabigatran: idarucizumab; apixaban, rivaroxaban, edoxaban: 4F-PCC per hematology
no prophylactic antiseizure drug; treat a clinical seizure → seizures
ICH score · MDCalc ↗︎ for severity; never alone to limit care

neurosurgery now if

cerebellar hemorrhage, especially > 15 mL, brainstem compression or hydrocephalus
intraventricular extension with reduced consciousness (may need a drain)
mass effect or any neurological deterioration

deficit that is not a stroke

hypoglycemia → glucose as above, repeat the glucose
seizure with post-ictal weakness → observe, reassess; antiepileptic loading with neurology → seizures
sodium, calcium or magnesium → correct → sodium
meningitis or encephalitis → antibiotics before imaging → headache, empiric antibiotics
old deficit unmasked by infection → treat the trigger

VTE prophylaxis

pneumatic compression from day one for every immobile stroke patient
pharmacological → ischemic stroke after 24–48 h if imaging is reassuring; hemorrhage only after a stable repeat scan, usually not before 24–48 h → VTE prophylaxis

stay and reassess → deficits evolve
hand over → last known well, NIHSS, CT result, thrombolysis decision, BP target, escalation trigger

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 Oct 2026file complaint/new-neurological-deficit