Neurology
Stroke and TIA for the physician
Written 30 September 2026.
Why this matters
A sudden focal deficit is a vascular emergency until hemorrhage is excluded. Time language changes between protocols, so this page does not print a minute cutoff.
Rapid clinical summary
- Sudden weakness, speech loss, or visual loss is stroke or TIA until proved otherwise.
- Glucose is part of the first look, because hypoglycemia mimics a stroke.
- Do not give a thrombolytic or an anticoagulant until imaging has excluded hemorrhage.
Mechanism
An artery to the brain blocks or breaks. Downstream tissue fails in a vascular pattern. A transient event that has fully resolved is still a warning, not a trivial turn.
Recognition
Face, arm, speech, and the time the person was last known to be well. Then exclude a mimic.
Typical
- One-sided weakness
- Aphasia
- Hemianopia
- Sudden onset
- Negative symptoms rather than a slow migraine march
Red flags
- Reduced consciousness
- A very sudden severe headache
- Anticoagulant use
- Fever and neck stiffness
- Hypoglycemia
Differential
| Condition | Clue | Trap |
|---|---|---|
| Hypoglycemia | A low glucose, may be focal | A stroke pathway that never checks glucose |
| Seizure with Todd paresis | A witnessed seizure first | Assuming every weakness is a seizure |
| Migraine | A positive spreading aura, history | Using migraine to explain a sudden negative deficit |
| Hemorrhage | Cannot be separated from ischemia at the bedside | A lytic drug before the scan |
Investigations
- Glucose immediately.
- Urgent brain imaging before any drug that could worsen bleeding.
- The exact window for reperfusion is the protocol in force, plus imaging selection. It is not a number memorized from this chapter.
Management
- Immediate
- Airway and glucose. Do not anticoagulate a possible hemorrhage. Do not lower blood pressure casually outside a protocol.
- Definitive
- Reperfusion only inside a stroke pathway after hemorrhage is excluded. Secondary prevention after a TIA is urgent even when the signs have gone. Drugs are not listed.
- Monitoring
- Conscious level, glucose, and swallowing before any oral drug. A resolved deficit still needs the urgent pathway.
Common pitfalls
- Waiting to see if it gets better before telling anyone.
- A lytic or anticoagulant before the scan.
- Calling a one-hour event ‘nothing’ because the examination is now normal.
Exam reasoning
The unsafe option is treatment that assumes ischemia before imaging, or discharge of a resolved but sudden deficit.
Practice this topicOpens original Mahazanaka questions in this subject. If this subject is thin on that track, the session uses what exists.
Visual summary
Imaging before a clot drug.
Recognize, reason, prioritize, act safely
- Recognize. Sudden, focal, vascular.
- Reason. Mimic, infarct, or bleed? You cannot see the difference without glucose and imaging.
- Prioritize. Airway, glucose, and the scan before a clot drug.
- Act safely. A stroke pathway. Not a clinic next month.
Knowledge check
Sudden aphasia. Someone suggests heparin before the CT. Why is that wrong?
No citation is attached to this chapter. Nothing here is personal medical advice.