How should I present a stroke case, summarizing the patient’s age, sex, relevant past medical history, onset time, presenting neurological deficits, initial examination and imaging findings, followed by the acute management plan, diagnostic work‑up, and secondary‑prevention strategy?

How to Present a Stroke Case

Begin your stroke case presentation by immediately stating the patient's age, sex, and the precise time of symptom onset (defined as when the patient was last at their baseline or symptom-free state), followed by the presenting neurological deficits quantified by a standardized stroke scale, then proceed systematically through initial vital signs, imaging findings, acute management decisions, and secondary prevention strategy. 1, 2, 3

Essential Opening Elements

Patient Demographics and Timing

• State age and sex first, as these influence differential diagnosis and prognosis 3, 4
• The single most important piece of information is time of symptom onset - defined as when the patient was last known to be at baseline or symptom-free 1, 3, 5
• For wake-up strokes, document when the patient was last awake and symptom-free 1, 5
• Use creative time anchors if needed: cell phone timestamps, TV programming times, or bathroom/kitchen ambulation times 1

Relevant Past Medical History

• Highlight stroke risk factors: prior TIA/stroke, atrial fibrillation, hypertension, diabetes, ischemic heart disease, hyperlipidemia 1
• Note history of drug abuse, migraine, seizures, infection, trauma, or pregnancy as these suggest alternative etiologies 1
• In younger patients, emphasize the broader differential including cardiac sources, hypercoagulable states, and substance use 3

Presenting Neurological Deficits

Quantified Assessment

• Use a standardized stroke scale score - NIHSS (preferred) or Canadian Neurological Scale 1, 3, 5
• Describe specific deficits to aid localization: contralateral hemiparesis, hemisensory loss, aphasia (anterior circulation) versus vertigo, ataxia, diplopia (posterior circulation) 5
• Document whether symptoms were sudden onset and stable versus fluctuating 1
• Note if preceded by similar symptoms that resolved (suggesting prior TIA) 1, 5

Initial Examination Findings

Vital Signs and Clinical Status

• Heart rate and rhythm (cardiac abnormalities commonly accompany stroke) 1, 5
• Blood pressure (critical for thrombolysis eligibility: must be <185/110 mmHg) 3
• Temperature (treat if >37.5°C as hyperthermia worsens outcomes) 2, 5
• Oxygen saturation (supplement only if <94%) 2
• GCS score and pupillary light reflexes 1
• Hydration status and presence of seizure activity 1

Neurological Examination

• Focal deficits consistent with vascular territory 1, 5
• Level of consciousness 1
• Cranial nerve findings 1

Imaging Findings

Initial Neuroimaging

• Non-contrast head CT performed immediately to exclude hemorrhage and assess early ischemic changes 2, 3, 5
• CT angiography from aortic arch to vertex to evaluate extracranial and intracranial circulation, including large vessel occlusion 2, 3, 5
• Extent of infarct territory, midline shift, brainstem compression if present 1
• Note: CT should be completed within 25 minutes of arrival 2, 5

Laboratory Results

• Present results but emphasize these should not have delayed imaging or treatment decisions 1, 2
• CBC, electrolytes, glucose, renal function (creatinine, eGFR), coagulation (INR, aPTT), troponin 1, 2
• For warfarin patients, INR is required before thrombolysis 1

Acute Management Plan

Time-Sensitive Interventions

• IV tissue plasminogen activator (tPA) 0.9 mg/kg (max 90 mg) if within 3-4.5 hours of onset and no contraindications 3
• State whether patient met inclusion/exclusion criteria for thrombolysis 1, 3
• Endovascular therapy consideration for large vessel occlusion on CTA 3
• Blood pressure management: for thrombolysis candidates, maintain <185/110 mmHg; for non-candidates, only treat if systolic >220 mmHg or diastolic >120 mmHg 1, 3

Supportive Care

• Swallowing screen completed within 24 hours using validated tool to prevent aspiration 1, 3
• Head of bed positioned at 25-30° 5
• Early mobilization and VTE prophylaxis (pharmacological with low-molecular-weight heparin for high-risk patients) 3
• Temperature monitoring every 4 hours for 48 hours 3

Seizure Management (if applicable)

• Treat new-onset seizures with short-acting medications (e.g., lorazepam IV) if not self-limiting 3
• Do not use prophylactic anticonvulsants for single, self-limited seizures 3

Diagnostic Work-Up

Etiologic Evaluation

• ECG to assess for atrial fibrillation and cardiac disease 1, 2, 3
• Echocardiogram to investigate cardioembolic source 2
• At least 24 hours of cardiac monitoring 1
• Complete brain and extracranial/intracranial vascular imaging 1
• In younger patients, more comprehensive evaluation including hypercoagulable workup, antiphospholipid antibodies, and consideration of conditions like Susac syndrome (hearing loss, CNS lesions, multiple BRAOs) 1

Stroke Mimics Excluded

• Document consideration and exclusion of: seizure, hypoglycemia, migraine with aura, hypertensive encephalopathy, psychogenic causes, CNS abscess/tumor, drug toxicity 1, 5

Secondary Prevention Strategy

Risk Factor Modification

• Blood pressure assessment and treatment targets 1
• LDL-cholesterol goal <1.8 mmol/L (70 mg/dL) 1
• HbA1c ≤7% for diabetic patients 1
• Smoking cessation counseling if applicable 1
• Alcohol intake reduction counseling if >2 drinks/day for men or >1 drink/day for women 1

Antiplatelet/Anticoagulation Therapy

• Aspirin within first 48 hours for ischemic stroke 1
• Dual antiplatelet therapy (clopidogrel or ticagrelor) for minor stroke (NIHSS ≤3-5) or high-risk TIA (ABCD2 ≥4) within 24 hours 1
• Oral anticoagulation for atrial fibrillation 1
• PFO closure consideration for cryptogenic stroke in patients aged 18-60 years after neurocardiology assessment 1

Surgical Interventions

• Carotid endarterectomy within 14 days for severe ipsilateral internal carotid artery stenosis 1
• Decompressive craniectomy consideration for large hemispheric infarction with malignant edema 1

Critical Pitfalls to Avoid

• Failure to establish accurate symptom onset time excludes patients from time-sensitive interventions 5
• Delaying neuroimaging while awaiting laboratory results - the therapeutic window for thrombolysis is only 3-4.5 hours 2
• Performing ECG or chest X-ray before imaging unless hemodynamically unstable 1
• Awaiting renal function results before CTA in most patients with disabling symptoms (neurons over nephrons) 1
• Missing posterior circulation strokes which may present with atypical symptoms 5
• Discharging TIA patients from ED without diagnostic evaluation and secondary prevention initiation 1