Time-critical presentations

Stroke and TIA — emergency pathway

Overview and approach

Stroke causes sudden neurological deficit; TIA is transient focal dysfunction and still requires urgent evaluation.

  • Australian and New Zealand Living Clinical Guidelines for Stroke Management (Stroke Foundation) cover pre-hospital care, assessment, reperfusion, antithrombotics and secondary prevention, with an emergency department summary (1).
Assessment and clinical features

ABCDE, glucose, exact last-known-well time, anticoagulants, baseline function and focal assessment; include posterior circulation symptoms.

  • Vascular syndromes:
    • ACA infarct: dysarthria, aphasia, contralateral weakness (leg and shoulder worse than arm, hand and face), minimal sensory change, left limb apraxia, urinary incontinence.
    • MCA infarct: contralateral hemiparesis and hemisensory loss, hemianopia, aphasia if dominant hemisphere (expressive anterior, receptive posterior, global if extensive), neglect if non-dominant.
    • PCA infarct: contralateral homonymous hemianopia (occipital), hemisensory loss and burning hemi-body pain (thalamic); unilateral sensory loss plus hemianopia without paralysis suggests PCA territory; bilateral can reduce visual-motor coordination.
    • Cerebellar infarct: non-specific nausea, vomiting, dizziness, unsteadiness, headache; look for incoordination, ataxia, horizontal nystagmus; altered consciousness or coma may occur.
Differentials and investigations

Activate stroke pathway with urgent brain/vascular imaging, ECG and blood tests. Exclude haemorrhage before antithrombotic decisions.

Management and follow-up

Specialists assess reperfusion eligibility using current living guidelines. Manage swallowing safety, physiology, rehabilitation and cause-based secondary prevention.

  • Reperfusion: tenecteplase or alteplase within 4.5 hours after CT excludes haemorrhage; aspirin is not given in the first 24 hours after thrombolysis (2).
Red flags and clinical pearls

Do not give aspirin before haemorrhage is excluded or assume resolved symptoms are benign. Reperfusion selection is time- and imaging-dependent.

References
  1. Stroke Foundation: Living Clinical Guidelines for Stroke Management (InformMe)
  2. Living Guidelines Chapter 3: Acute medical and surgical management

Last updated from Sen’s notes on 9 October 2026.