Clinical Notes : Neurology

24. Acute stroke and TIA

Diagnosis of Acute Stroke or Transient Ischaemic Attack

  • Detailed history suggestive of TIA

  • Detailed history suggestive of stroke

  • Subtle signs of stroke

    • Unable to walk or stand unaided (stroke)

    • Sustained significant headache (cerebellar hemorrhage)

    • Sustained significant neck pain (vertebral artery dissection)

  • Obvious signs of stroke

    • FAST assessment (Face, Arms, Speech, Time)

      • 78% predictive in anterior stroke

      • 60% predictive in posterior circulation stroke

  • Exclude condition mimicking stroke (in presence of obvious signs of stroke)

    • Rosier stroke recognition score >/= 0

  • Assess stroke risk if TIA (in presence of obvious signs of stroke)

    • ABCD2 score

      • Exclude posterior circulation stroke presenting as Acute Vestibular Syndrome

        • HINTS testing (see AVS notes)


History suggestive of TIA

Patients often dismiss symptoms of TIA as a ‘funny turn’, but 10% go on to have a stroke in the next 7 days.


The most common symptoms of a TIA are:

  • vision changes

  • trouble speaking

  • confusion

  • balance issues

  • numbness

  • weakness

  • tingling

  • muscular weakness generally on one side of the body


A TIA may also cause:

  • an altered level of consciousness

  • dizziness

  • passing out

  • an abnormal sense of taste

  • an abnormal sense of smell

  • weakness or numbness on just one side of the body or face

Conditions that mimic stroke

  • Seizure (commonest mimic)

  • Sepsis

  • Space occupying lesion

  • Syncope

  • Delirium

  • Vestibular

  • Migraine


F.A.S.T. assessment


Rosier stroke recognition score


Stroke is likely if total scores are > 0.

Scores of </= 0 have a low possibility of stroke but not completely excluded.

If BM < 3.5 mmol/l treat urgently and reassess once blood glucose normal


ABCD2 score for stroke risk in TIA

Low risk < 4 (7 day CVA risk 1.2%)

Mod risk 4-5 ( 7 day CVA risk 6%)

High risk > 5

Immediate management of stroke and TIA

  • check for hypoglycaemia and treat

  • arrange emergency admission

  • DO NOT GIVE ASPIRIN (as hopefully will have thrombolysis in hospital)


Stroke and transient ischaemic attack in over 16s: diagnosis and initial management

NICE Clinical Guidance CG68

March 2017



2018 Guidelines for the Early Management of Patients With Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association

Stroke. Vol49 No.3

January 2018


Stroke Recommendations

JBS3 Joint British Societies for the Prevention of Cardiovascular Disease

Accessed online May 2015



Is it a stroke?

Graeme J Hankey, David J Blacker

BMJ 2015;350:h56.

November 2014.


Effects of aspirin on risk and severity of early recurrent stroke after transient ischaemic attack and ischaemic stroke: time-course analysis of randomised trials

Prof Peter M Rothwell, Prof Ale Algra, Prof Zhengming Chen, Prof Hans-Christoph Diener, ,

Prof Bo Norrving, Ziyah Mehta,

The Lancet. Volume 388, No. 10042, p365–375.

May 2016


Ireland notes.png

CPD Quiz and Certificate

This activity attracts 1,0 CPD point

24. Stroke.jpg

Scroll down the box above to view its entire content

All users who successfully complete the quiz are e-mailed a copy of their personalised CPD certificate.