Clinical Education Module

Stroke: Rapid Assessment

An evidence-based training module aligned with AHA/ASA 2024-2025 guidelines. Master stroke recognition, acute assessment, and treatment pathways to improve patient outcomes in time-critical scenarios.

Duration40 - 60 min
Sections7 Lessons
StandardAHA/ASA 2024-2025
CreditCertificate
Section 1 of 7 Pathophysiology

Stroke Pathophysiology & Classification

A stroke occurs when blood flow to a region of the brain is interrupted, causing neuronal injury within minutes. Rapid classification guides treatment decisions and directly affects patient outcomes.

I

Ischemic Stroke

Accounts for approximately 87% of all strokes. Caused by arterial occlusion from thrombosis or embolism. The ischemic penumbra — tissue at risk but not yet infarcted — is the target of acute intervention.

H

Hemorrhagic Stroke

Accounts for approximately 13% of strokes but carries higher mortality. Includes intracerebral hemorrhage (ICH) and subarachnoid hemorrhage (SAH). Often related to hypertension or vascular malformations.

Key Subtypes

Transient Ischemic Attack (TIA)

Transient neurological deficit without infarction on imaging. A TIA is a medical emergency and a warning sign: 10-15% of TIA patients will have a stroke within 90 days, with highest risk in the first 48 hours.

Large Vessel Occlusion (LVO)

Occlusion of a major cerebral artery (ICA, M1/M2 MCA, basilar). Causes severe deficits and is amenable to mechanical thrombectomy. LVO identification drives transfer and treatment decisions.

Posterior Circulation Stroke

Involves the vertebrobasilar system. Presents with vertigo, diplopia, ataxia, dysarthria, and visual field deficits. Commonly misdiagnosed as peripheral vertigo or migraine, leading to delayed treatment.

Key takeaway: Time is brain. Each minute of untreated large vessel occlusion destroys approximately 1.9 million neurons. Rapid classification of stroke type determines the treatment pathway.

Section 2 of 7 Recognition

BE-FAST Recognition & Prehospital Assessment

The BE-FAST mnemonic expands on the traditional FAST assessment to capture posterior circulation strokes that are frequently missed. Use BE-FAST for systematic screening of all suspected stroke patients.

B

Balance

Sudden loss of balance or coordination, difficulty walking, or new-onset gait instability. Key indicator of posterior circulation involvement.

E

Eyes

Sudden visual changes: blurred or double vision (diplopia), visual field cuts, or loss of vision in one or both eyes. Screen by testing each eye independently.

F

Face

Facial droop or asymmetry. Ask the patient to smile and show teeth. One side that does not move or droops indicates facial nerve involvement.

A

Arms

Arm weakness or drift. Ask the patient to raise both arms and hold for 10 seconds. Unilateral drift or inability to raise indicates motor deficit.

S

Speech

Slurred speech (dysarthria) or inability to speak or understand language (aphasia). Ask the patient to repeat a simple phrase.

T

Time

Establish last known well (LKW) time immediately. This is the single most critical piece of information for treatment eligibility. Call emergency services without delay.

Prehospital Priorities

  • Establish and document last known well time precisely
  • Perform blood glucose check to rule out hypoglycemia as a stroke mimic
  • Activate stroke alert and notify the receiving facility
  • Transport to the nearest stroke-capable facility (PSC or CSC)
  • Do not lower blood pressure in the field unless greater than 220/120 mmHg
  • Position the patient with the head of bed elevated to 30 degrees

Why BE-FAST matters: The traditional FAST mnemonic misses up to 14% of strokes, particularly posterior circulation events. Adding Balance and Eyes improves detection sensitivity to greater than 95%.

Section 3 of 7 NIHSS Assessment

NIHSS Rapid Assessment

The National Institutes of Health Stroke Scale (NIHSS) is the standardized clinical assessment tool for quantifying stroke severity. It guides treatment decisions, predicts outcomes, and is required for thrombolytic and thrombectomy eligibility documentation.

The 11 NIHSS Domains

DomainAssessment
1a. Level of consciousnessAlert, drowsy, stuporous, comatose
1b. LOC questionsMonth and age
1c. LOC commandsOpen/close eyes, grip/release hand
2. Best gazeHorizontal eye movements
3. Visual fieldsVisual field testing by confrontation
4. Facial palsySymmetry of facial movements
5. Motor arm (L and R)Arm drift at 90 degrees (sitting) or 45 degrees (supine)
6. Motor leg (L and R)Leg drift at 30 degrees supine
7. Limb ataxiaFinger-nose and heel-shin testing
8. SensoryPin prick to face, arm, trunk, and leg
9. Best languageNaming, reading, describing a picture
10. DysarthriaClarity of speech reading a word list
11. Extinction/inattentionDouble simultaneous stimulation

Score Interpretation

0: No stroke symptoms

Normal examination. Does not rule out TIA or minor stroke — imaging still indicated if clinical suspicion exists.

1-4: Minor stroke

Mild deficits. IV thrombolysis may still be indicated depending on disabling nature of symptoms.

5-15: Moderate stroke

Significant deficits. Strong indication for thrombolysis. Consider LVO screening for thrombectomy eligibility.

16-42: Severe stroke

Major deficits. High probability of LVO. Urgent CTA and thrombectomy evaluation required.

Clinical pearl: An NIHSS score of 6 or greater has high sensitivity for large vessel occlusion. However, posterior circulation LVO can present with a deceptively low NIHSS. Always obtain CTA when LVO is suspected regardless of score.

Section 4 of 7 Imaging

Imaging & Time Windows

Neuroimaging is the gatekeeper of acute stroke treatment. The primary goals are to exclude hemorrhage, identify ischemia, and evaluate for large vessel occlusion — all within strict time constraints.

Imaging Protocol

CT

Non-contrast CT Head

First-line imaging. Must be obtained and interpreted within 20 minutes of arrival. Primary purpose: exclude hemorrhage. Early ischemic changes may be subtle or absent.

CTA

CT Angiography

Evaluates for large vessel occlusion. Should be obtained simultaneously with or immediately after non-contrast CT. Critical for thrombectomy triage.

CTP

CT Perfusion

Maps ischemic core versus salvageable penumbra. Required for extended-window thrombectomy (6-24 hours). RAPID software automates mismatch analysis.

Critical Time Windows

MetricTarget
Door to CT interpretation< 20 minutes
Door to needle (IV thrombolysis)< 60 minutes
Door to groin puncture (thrombectomy)< 90 minutes
IV alteplase window0 - 4.5 hours from LKW
Thrombectomy (standard window)0 - 6 hours from LKW
Thrombectomy (extended window)6 - 24 hours with favorable perfusion imaging

Extended Window Thrombectomy

The DAWN and DEFUSE 3 trials demonstrated that select patients benefit from thrombectomy up to 24 hours from last known well when perfusion imaging shows a favorable mismatch: a small ischemic core relative to a large area of salvageable penumbra. RAPID software provides automated volumetric analysis to identify eligible patients.

Key takeaway: Never let a perfusion scan delay treatment in the standard window. In extended-window patients, perfusion imaging is the key to identifying who can still benefit from intervention.

Section 5 of 7 Acute Management

Acute Ischemic Stroke Management

IV thrombolysis remains the first-line pharmacologic treatment for acute ischemic stroke. Understanding eligibility criteria, dosing, and concurrent management is essential for every member of the stroke team.

IV Alteplase (tPA)

  • Dose: 0.9 mg/kg (max 90 mg), 10% as bolus over 1 minute, remainder infused over 60 minutes
  • Window: 0 to 4.5 hours from last known well
  • Key exclusion (0-3h): Active internal bleeding, recent intracranial surgery or serious head trauma (3 months), platelet count less than 100,000, INR greater than 1.7
  • Additional exclusions (3-4.5h): Age greater than 80, NIHSS greater than 25, history of both diabetes and prior stroke, oral anticoagulant use regardless of INR

IV Tenecteplase

Tenecteplase (0.25 mg/kg, max 25 mg, single IV bolus) is emerging as an alternative to alteplase. Advantages include single-bolus administration, ease of use, and growing evidence of non-inferiority. It is increasingly used as a bridging agent before thrombectomy.

Blood Pressure Management

ScenarioBP Target
Pre-thrombolysis eligibility< 185/110 mmHg
During and 24h post-thrombolysis< 180/105 mmHg
No thrombolysis plannedPermissive hypertension unless > 220/120

Concurrent Acute Care

  • Glucose: Treat hypoglycemia immediately. Target glucose 140-180 mg/dL. Avoid hyperglycemia, which worsens outcomes.
  • Temperature: Treat fever aggressively. Target normothermia. Hyperthermia increases infarct volume.
  • Airway: Monitor for aspiration risk. Formal dysphagia screen before any oral intake. Intubation if GCS less than 8 or airway compromise.
  • Positioning: Head of bed flat for first 24 hours to optimize cerebral perfusion, unless aspiration risk or elevated ICP.

Critical reminder: Do not delay IV thrombolysis to obtain laboratory results unless there is clinical suspicion of bleeding diathesis or anticoagulant use. Blood glucose is the only lab required before treatment initiation.

Section 6 of 7 Thrombectomy

Large Vessel Occlusion & Mechanical Thrombectomy

Mechanical thrombectomy has revolutionized treatment of large vessel occlusion stroke. Identifying LVO early and expediting transfer to a thrombectomy-capable center is a critical competency for all stroke clinicians.

LVO Screening Scales

RACE Scale

Rapid Arterial oCclusion Evaluation. Scores 0-9, evaluating facial palsy, arm motor, leg motor, head/gaze deviation, and aphasia/agnosia. Score of 5 or greater suggests LVO.

LAMS Scale

Los Angeles Motor Scale. Scores 0-5, assessing facial droop, arm drift, and grip strength. Score of 4 or greater suggests LVO. Quick to perform in the field.

NIHSS-based Screening

NIHSS of 6 or greater raises suspicion for LVO. Gaze deviation, aphasia, and neglect in combination are particularly predictive. CTA is the definitive diagnostic tool.

Thrombectomy Eligibility

  • Confirmed LVO on CTA (ICA, M1 MCA, and in select cases M2 MCA or basilar artery)
  • NIHSS of 6 or greater (though lower thresholds may apply with disabling deficits)
  • Pre-stroke modified Rankin Scale (mRS) of 0-1
  • Standard window: 0-6 hours from last known well
  • Extended window (6-24 hours): favorable perfusion imaging mismatch required
  • ASPECTS score of 6 or greater on non-contrast CT (for anterior circulation)

Transfer Decision: Drip-and-Ship vs. Mothership

ModelDescription
Drip-and-shipAdminister IV thrombolysis at nearest PSC, then transfer to CSC for thrombectomy. Faster treatment initiation, but adds transfer time.
MothershipBypass local PSC and transport directly to CSC. Optimal when CSC is within 30-minute additional transport time. Avoids inter-facility transfer delays.

Key takeaway: IV thrombolysis should never be delayed for thrombectomy. Administer tPA at the earliest opportunity, then arrange transfer for thrombectomy. The two treatments are complementary, not competitive.

Section 7 of 7 Hemorrhagic Stroke

Hemorrhagic Stroke & Post-acute Care

Hemorrhagic stroke requires a distinct management approach focused on hemostasis, blood pressure control, and preventing hematoma expansion. Secondary prevention strategies are essential to reduce recurrence risk for all stroke types.

ICH Score

The ICH Score predicts 30-day mortality using five variables:

  • GCS score (3-4 = 2 pts, 5-12 = 1 pt, 13-15 = 0 pts)
  • ICH volume (greater than or equal to 30 mL = 1 pt)
  • Intraventricular hemorrhage present (1 pt)
  • Infratentorial origin (1 pt)
  • Age 80 years or older (1 pt)

Blood Pressure Management in ICH

Acute intensive blood pressure lowering to a target systolic BP of 140 mmHg within the first hour is recommended for ICH patients presenting with systolic BP between 150-220 mmHg. Use IV labetalol or nicardipine infusion for rapid, titratable control.

Reversal Agents

Warfarin-related ICH

Administer IV vitamin K plus 4-factor prothrombin complex concentrate (4F-PCC). Target INR less than 1.3 within 60 minutes. Do not rely on FFP alone.

DOAC-related ICH

Idarucizumab for dabigatran. Andexanet alfa for factor Xa inhibitors (rivaroxaban, apixaban). Administer immediately without waiting for drug levels.

Surgical Criteria

  • Cerebellar hemorrhage greater than 3 cm with neurological deterioration or brainstem compression: emergent surgical evacuation
  • Lobar ICH greater than 30 mL within 1 cm of cortical surface: may benefit from minimally invasive evacuation
  • Obstructive hydrocephalus: external ventricular drain (EVD) placement

Secondary Prevention

  • Antiplatelet therapy for non-cardioembolic ischemic stroke (aspirin, clopidogrel, or dual therapy for 21 days after minor stroke or TIA)
  • Anticoagulation for atrial fibrillation-related stroke (typically initiated 4-14 days post-event)
  • Statin therapy for atherosclerotic stroke (high-intensity: atorvastatin 80 mg or rosuvastatin 20 mg)
  • Blood pressure control targeting less than 130/80 mmHg long-term
  • Carotid revascularization (endarterectomy or stenting) for symptomatic carotid stenosis of 50% or greater

Critical distinction: Hemorrhagic stroke management is the opposite of ischemic management in several key areas — aggressively lower blood pressure, reverse anticoagulation, and avoid antithrombotics in the acute setting.

You have completed all 7 learning sections.

E
Patient Scenario 1 of 4

Elena, 67F

Elena is brought to the ED by EMS with sudden-onset right-sided weakness and difficulty speaking. Symptom onset was witnessed 45 minutes ago. She is alert but unable to produce fluent speech. Right arm drift is present. BP 178/96, HR 88, SpO2 97% on room air, glucose 142 mg/dL. No history of recent surgery or bleeding.

Step 1: What is your assessment priority?

R
Patient Scenario 2 of 4

Robert, 78M

Robert's wife found him on the floor at 6:30 AM with left-sided weakness and slurred speech. He was last seen normal at 10:00 PM the night before (8.5 hours ago). He is drowsy but arousable. Left facial droop, left arm and leg plegia. BP 192/104, HR 76, SpO2 95% on 2L nasal cannula, glucose 188 mg/dL. History of hypertension and atrial fibrillation (on apixaban).

Step 1: Robert is outside the standard IV alteplase window and is on a DOAC. What is the next best step?

A
Patient Scenario 3 of 4

Ana, 52F

Ana presents to the ED with sudden-onset severe vertigo, double vision, and difficulty walking that began 2 hours ago. She has been vomiting. The triage nurse initially categorizes this as an inner ear problem. On your exam: rightward gaze nystagmus, diplopia on lateral gaze, right-sided limb ataxia, dysarthria. BP 168/92, HR 82, glucose 110 mg/dL.

Step 1: What is your primary concern?

D
Patient Scenario 4 of 4

David, 60M

David presents with sudden-onset worst headache of his life followed by vomiting and rapid decline in consciousness. On arrival his GCS is 9 (E2V3M4). He has left pupil dilation and right hemiplegia. BP 228/118, HR 62, SpO2 94% on room air. History of uncontrolled hypertension. He is not on anticoagulants.

Step 1: CT shows a large left basal ganglia hemorrhage (45 mL) with intraventricular extension. What is the immediate management priority?

Knowledge Assessment

Comprehension Quiz

Answer 5 questions based on the module content. You need at least 4 out of 5 correct (70% adjusted to 4/5 threshold) to pass and earn your certificate.

Question 1 of 5

What is the maximum time window for IV alteplase administration, and which of the following is a key contraindication?

Question 2 of 5

Which NIHSS score threshold has high sensitivity for predicting large vessel occlusion?

Question 3 of 5

What imaging criteria must be met for extended-window mechanical thrombectomy (6-24 hours)?

Question 4 of 5

What is the target systolic blood pressure for acute intracerebral hemorrhage management when the patient presents with systolic BP between 150-220 mmHg?

Question 5 of 5

Which type of stroke presentation is most commonly missed in the emergency department?

of 5

Module Complete

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