How should I conduct a rapid neurological examination to assess a patient with suspected stroke?

Rapid Neurological Examination for Suspected Stroke

Use a validated stroke screening tool immediately upon patient contact—specifically the FAST (Face, Arm, Speech, Time) scale or Cincinnati Prehospital Stroke Scale (CPSS)—as these tools have demonstrated sensitivity of 81% and are strongly recommended by the American Heart Association for rapid stroke identification. 1

Initial Rapid Assessment (Within 10 Minutes)

Apply the FAST Scale Systematically

• Face: Ask the patient to smile or show teeth; observe for facial droop or asymmetry on one side 1
• Arm: Ask the patient to close their eyes and hold both arms extended forward for 10 seconds; observe for pronator drift or inability to maintain position 1
• Speech: Ask the patient to repeat a simple phrase (e.g., "You can't teach an old dog new tricks"); assess for slurred speech, inappropriate words, or inability to speak 1
• Time: Document the exact time symptoms began or when the patient was last seen normal—this is critical for treatment eligibility 1, 2

Complete the National Institutes of Health Stroke Scale (NIHSS)

• The NIHSS must be performed on arrival in the emergency department and before and after any thrombolytic treatment to quantify stroke severity and guide management decisions 1, 2
• The NIHSS assesses level of consciousness, visual fields, extraocular movements, facial palsy, motor function in arms and legs, limb ataxia, sensory loss, language, dysarthria, and extinction/inattention 2, 3

Critical Components of the Neurological Examination

Assess Airway, Breathing, Circulation, and Disability (ABCD)

• Evaluate airway patency and breathing adequacy; administer supplemental oxygen if oxygen saturation <94% 2, 4
• Check vital signs including blood pressure, heart rate, and temperature 2, 4
• Perform rapid disability assessment using the NIHSS or Glasgow Coma Scale for comatose patients 4, 3

Document Specific Neurological Deficits

• Motor weakness: Test strength in face, arms, and legs bilaterally; arm weakness shows the highest interrater agreement (98%) and may be the most reliable sign 5
• Speech disturbance: Assess for dysarthria (slurred speech) versus aphasia (language comprehension/production problems) 1, 6
• Visual deficits: Check for visual field cuts, diplopia, or gaze deviation 1, 3
• Sensory changes: Test for hemisensory loss 3
• Coordination: Assess for ataxia or balance problems, though adding these to FAST does not improve diagnostic accuracy 7

Essential Immediate Actions

Obtain Critical History Elements

• Time of symptom onset or last known normal is the single most important piece of information for treatment decisions 1, 8, 2
• Current medications, especially anticoagulants 1, 8
• Medical history pertinent to thrombolysis risks (recent surgery, bleeding disorders, prior stroke) 1, 8

Check Blood Glucose Immediately

• Hypoglycemia is a common stroke mimic that can present with focal neurological symptoms; checking glucose is essential before proceeding with stroke protocols 1, 8
• Stroke scales that include glucose measurement (LAPSS, ROSIER) have higher specificity (93%) compared to those without (47%) 1

Activate Code Stroke Protocol

• Notify the stroke team immediately upon positive stroke screen 1
• Arrange for brain imaging (non-contrast CT or MRI) to be completed within 25-30 minutes of arrival 1, 8
• Establish IV access and draw blood for complete blood count, coagulation studies, electrolytes, renal function, and cardiac troponin 8, 2, 4
• Obtain 12-lead ECG to identify atrial fibrillation or other arrhythmias 8, 2

Common Pitfalls to Avoid

• Do not delay stroke protocol activation based on suspicion of malingering—clinical judgment alone is insufficient to exclude cerebrovascular events, and objective assessment tools must be used 8
• Do not assume stroke type based on clinical presentation alone—only brain imaging can definitively differentiate ischemic from hemorrhagic stroke 8, 6
• Do not administer thrombolytic therapy until hemorrhagic stroke is excluded by imaging, regardless of how convincing the clinical presentation appears 8
• Do not overlook the temporal evolution of neurological deficits—symptoms may progress or improve between initial assessment and hospital arrival 5

Stroke Severity Assessment for Triage

• For patients screening positive for stroke, apply a stroke severity scale (Cincinnati Stroke Triage Assessment Tool, RACE, LAMS) to identify large vessel occlusion candidates who may benefit from endovascular thrombectomy 1
• Patients with suspected large vessel occlusion should be transported to comprehensive stroke centers capable of endovascular therapy, accepting up to 15 minutes additional transport time 1