Rapid Recognition: FAST
- Face — facial droop
- Arms — arm drift or weakness
- Speech — slurred or difficulty speaking
- Time — time of onset is critical; note the last time the patient was known to be normal
Some systems use BE-FAST, adding Balance and Eyes (vision changes) to catch posterior circulation strokes that FAST alone can miss.
Ischemic vs. Hemorrhagic
These cannot be reliably distinguished by clinical exam alone — a non-contrast CT head is needed urgently to differentiate them, since management differs significantly (thrombolysis is contraindicated in hemorrhagic stroke).
Quantifying Severity
The NIHSS quantifies deficit severity across 15 domains, and helps guide treatment eligibility and track change over time.
Key Time Windows
- IV thrombolysis: generally within 4.5 hours of last known well, in eligible ischemic stroke patients without contraindications
- Mechanical thrombectomy: traditionally within 6 hours for large-vessel occlusion, extended up to 24 hours in carefully selected patients based on advanced imaging
After a TIA
For transient symptoms that have resolved, use the ABCD2 score to help estimate short-term stroke risk, though urgent specialist assessment is now recommended regardless of score in many pathways.
Stroke Mimics
Hypoglycemia, seizure with post-ictal (Todd's) paralysis, complex migraine, and functional neurological disorders can all mimic stroke — a fingerstick glucose is a quick, essential check.