1 Stroke Emergencies
Learn how to recognize possible stroke, respond urgently, understand initial assessment and treatment decisions, and monitor for important complications.
Recognizing symptoms
is a time-critical emergency. Sudden neurologic changes need prompt emergency assessment, even if they improve or do not match the familiar face-arm-speech pattern.
The warning signs are Balance, Eyes, Face, Arms, Speech, and Time. Sudden facial or limb weakness and difficulty speaking are common warning signs; sudden balance or vision changes can also indicate .
A sudden combination of aphasia and weakness on the opposite side of the body is concerning for . In most people, language functions are primarily in the left hemisphere, so right arm and facial weakness with difficulty producing words suggests a left-hemisphere, dominant-hemisphere cortical syndrome involving language and motor function. Examination alone cannot determine whether the cause is ischemia or bleeding.
Recognizing posterior and hemorrhagic patterns
A affecting the back of the brain may cause severe vertigo, double vision or other visual changes, slurred speech, difficulty walking, balance or coordination problems, headache, or nausea. The absence of obvious facial droop does not rule out ; these symptoms require emergency evaluation.
A sudden, extremely severe headache that reaches peak intensity quickly, especially with vomiting and reduced alertness, raises concern for subarachnoid among other causes of acute neurologic deterioration. The symptom pattern alone does not confirm the diagnosis; immediate emergency assessment and brain imaging are needed.
Taking immediate action
For sudden facial droop, arm weakness, speech difficulty, or other possible symptoms, call 911 immediately. Note the time—the time the person was last at their usual neurologic baseline. Do not wait to see whether symptoms improve, and do not drive the person to the hospital yourself.
Emergency medical services can begin assessment and transport promptly. Symptoms that disappear after a brief period still need immediate medical assessment because a transient ischemic attack can warn of a future .
Initial assessment and imaging
The team assesses and stabilizes airway, breathing, and circulation; checks blood glucose; establishes the time; and performs a focused neurologic assessment while arranging urgent brain imaging. Relevant history includes medications such as anticoagulants.
The timing of symptom onset or helps determine treatment options. Glucose measurement can identify a mimic. Urgent CT or MRI helps distinguish from , and vascular imaging may be added when needed to identify a treatable large-vessel blockage.
Making urgent treatment decisions
A noncontrast head CT is important for detecting , but a normal early scan does not necessarily exclude . Imaging findings must be interpreted alongside the examination and timing. Advanced imaging should not delay standard-window when that treatment is otherwise appropriate.
For a disabling neurologic deficit with symptoms beginning 90 minutes earlier, the team should assess eligibility for and determine whether vascular imaging shows a large-vessel occlusion that may be treated with . In the standard 4.5-hour window, current AHA/ASA guidance endorses alteplase or tenecteplase for eligible patients with disabling deficits. Selected patients may qualify outside the standard window based on advanced imaging and clinical criteria.
Treatment decisions depend on symptom severity and disability, timing, imaging, medications, and bleeding risk. Thrombectomy eligibility has expanded for selected patients; a potentially eligible person should receive urgent specialist evaluation rather than be excluded solely because the appears severe or the time window is extended.
Avoiding preventable harm
Do not give aspirin as an unsupervised first-aid action before brain imaging has excluded . Activate emergency care; the treating team determines whether and when antiplatelet therapy is appropriate after assessment and imaging. Some strokes are caused by bleeding, and aspirin can worsen bleeding. After thrombolysis, antithrombotic timing is managed according to the treatment protocol.
Keep a person with acute NPO (nothing by mouth) until a trained clinician completes a swallow screen and determines that oral intake is safe. can impair swallowing even when the person is alert; screening helps reduce aspiration and related complications such as pneumonia.
Monitoring for complications
Continue monitoring for swallowing impairment, aspiration, and neurologic deterioration. After aneurysmal subarachnoid , monitor closely for associated with cerebral vasospasm. Early enteral nimodipine is recommended to reduce and improve functional outcomes.