New Neurological Deficit
ABCs
- airway: assess obstruction; protect airway if GCS ≤ 8
- breathing: check SpO₂; supplemental O₂ if needed
- circulation: IV access, monitor vitals
- disability: GCS vs baseline; determine last seen normal; assess pupils + focal deficits
- exposure: trauma, infection, toxidrome; vitals + RBS
- if hypoglycemic → D50W 50 mL IV STAT
red flags
raised ICP / herniation
- HTN + bradycardia + irregular breathing → Cushing reflex / raised ICP
- unequal pupils → bleed / herniation
- GCS ≤ 8 → protect airway
HPI & examination
- onset: sudden → stroke, seizure, bleed; progressive → tumor, metabolic cause
- previous neuro history: CVA / TIA, seizures, migraine, MS
- medications: anticoagulants, antiepileptics, insulin
- recent illness: fever → meningitis / encephalitis; UTI / systemic infection → delirium
- comorbidities: AF, HTN, diabetes, cancer; substance use; recent fall / head injury
- collateral history from relatives / staff if possible
- examination
- focal weakness → stroke / mass
- unequal pupils → bleed / herniation
- dysphasia / neglect → cortical involvement
- tongue bite / post-ictal state → seizure
- fever → CNS infection; hypoxia / arrhythmia → possible cardioembolic stroke
- calculate NIHSS
workup
- keep NPO (aspiration risk); start IV fluids if needed
- send: serum glucose, CBC, INR / aPTT, electrolytes, troponin
- perform ECG
stroke pathway
- symptoms resolved → likely TIA → arrange MRI within 24 hr
- symptoms persist → non-contrast CT brain urgently to rule out hemorrhage; call neurology / neurosurgery early
CT shows no hemorrhage (likely ischemic stroke)
- allow BP up to < 220/110 before reperfusion decisions
- call neurology / stroke team first to decide on thrombolysis (tPA, alteplase 0.9 mg/kg, max 90 mg, per stroke team) if within 3–4.5 hr; if thrombolysing, lower BP to < 185/110 (labetalol 10–20 mg IV)
- large vessel occlusion suspected or not a thrombolysis candidate → consider mechanical thrombectomy (up to 24 h with perfusion mismatch)
- aspirin 300 mg once haemorrhage excluded and tPA not given (or 24 h after tPA)
hemorrhage present
- consult neurosurgery urgently
- stop anticoagulation; consider reversal
- control BP (SBP ~140)
calculator NIHSS · MDCalc ↗︎
reversible causes
- hypoglycemia → IV dextrose
- seizure / post-ictal state → observe, load AED if needed
- electrolyte abnormality → correct
- hypertensive emergency → controlled BP lowering
- meningitis / encephalitis → empiric antimicrobials
escalation
- always call the senior early; reassess frequently
- do not leave the patient until help arrives / patient is stabilized
studying for the IM exam? the IM Rapid Review covers stroke and the acute deficit in the same format. see the sample chapter.
Last reviewed · May 2026