Acute Aphasia and Speech DisturbanceAPPROACH

NEUROLOGIC · 19 SECTIONS

⚲

437 items

☷ Legend

⚲

Resuscitation and Universal Approaches9▾

Chest and Cardiovascular12▾

Respiratory11▾

Abdominal and Gastrointestinal24▾

Renal and Urinary7▾

Neurologic11▾

Transient Neurologic Deficits Acute Aphasia And Speech Disturbance Acute Confusion And Delirium Postictal State And Seizure Recurrence Concern Seizure Acute Vision Loss New Tremor And Involuntary Movements Headache Vertigo Acute Weakness Or Numbness Gait Instability And Ataxia

Back and Neck8▾

Women's Health, Pregnancy, and GU11▾

Infectious Disease and Fever Syndromes11▾

Allergy and Dermatology7▾

Musculoskeletal and Extremities14▾

Trauma and Wounds14▾

ENT, Eye, Dental10▾

Endocrine, Metabolic, and Abnormal Labs9▾

Toxicology and Behavioral14▾

Pediatrics16▾

Environmental and Exposure4▾

01History/hx48

HPI snapshot

›Symptom characterization

›Primary deficit pattern

›Witnessed language disturbance versus dysarthria versus confusion

›Time last known well

OPQRST Onset

›Onset

›Exact time last known normal

›Sudden maximal at onset versus gradual progression

›Wake up symptoms

OPQRST Provocation/Palliation

›Provocation and palliation

›Fluctuating deficits

›Triggered by exertion

›Triggered by posture change

›Triggered by Valsalva

OPQRST Quality

›Quality

›Expressive aphasia

›Receptive aphasia

›Global aphasia

›Anomia

›Paraphasic errors

OPQRST Region/Radiation

›Region and associated neurologic territory clues

›Right sided weakness or sensory loss

›Gaze deviation

›Visual field loss

OPQRST Severity

›Severity

›Complete inability to produce language

›Mild word finding difficulty

›Functional impact on safety

OPQRST Timing

›Timing

›Persistent deficit duration

›Resolved deficit duration

›Recurrent stereotyped episodes

Associated symptoms

›Associated symptoms

›Headache

›Seizure activity

›Fever

›Neck pain

›Chest pain

›Palpitations

›Hypoglycemia symptoms

Baseline and prior episodes

›Baseline neurologic and language function

›Prior stroke or TIA baseline

›Baseline dementia or primary progressive aphasia history

›Baseline hearing or vision impairment

Time critical treatment modifiers

›Reperfusion eligibility modifiers

›Recent major surgery or trauma

›Recent intracranial hemorrhage history

›Anticoagulant use and last dose time

›Pregnancy status

02Alarm Features/alarm27

First 5 minutes triggers

›Immediate escalation triggers

›Airway risk

›Hypoxia

›Hypotension

›Refractory seizure

›Rapidly worsening mental status

Stroke and hemorrhage red flags

›Life threatening neurologic triggers

›Sudden aphasia with unilateral weakness

›Sudden aphasia with gaze deviation

›Severe thunderclap headache

›Meningismus

›Anticoagulated with new neurologic deficit

Vital sign danger thresholds

›Vital sign danger thresholds

›Glucose less than 3.0 mmol/L

›Oxygen saturation less than 92 percent

›SBP less than 90 mmHg

›SBP greater than 220 mmHg

›Temperature 38.0 C or higher

Exam danger findings

›High risk exam findings

›Depressed level of consciousness

›New anisocoria

›Cushing response pattern

›Papilledema

Do not delay pathways

›Do not delay

›Noncontrast CT head for suspected stroke or hemorrhage

›Point of care glucose

›Stroke team activation local protocol dependent

03Medications/meds15

Current and recent exposures

›Medication reconciliation

›Anticoagulants

›Antiplatelets

›Antiseizure medications

›Insulin or sulfonylureas

›Sedatives

›Antipsychotics

High risk interactions and reversals

›High risk medication implications

›DOAC last dose time and renal function dependence

›Warfarin with INR relevance

›Opioids or sedatives contributing to delirium

Contraindications to common therapies

›Contraindications and cautions

›Contrast allergy history for CTA

›Metformin with severe renal dysfunction context for contrast local protocol dependent

›Pregnancy considerations for radiation imaging

04Diet/diet9

Intake and metabolic risk

›Intake pattern

›Poor oral intake

›Recent vomiting or dehydration

›Alcohol binge exposure

›Energy drink or caffeine excess

Glucose and electrolyte triggers

›Metabolic triggers

›Prolonged fasting

›Recent insulin dosing change

›Recent diarrhea with electrolyte loss

05Review of Systems/ros23

Neurologic

›Neurologic symptoms

›Weakness

›Numbness

›Vision loss

›Diplopia

›Vertigo

›Ataxia

›Headache

›Seizure

Infectious and inflammatory

›Systemic symptoms

›Fever

›Chills

›Rash

›Recent infection

Cardiopulmonary

›Cardiopulmonary symptoms

›Chest pain

›Dyspnea

›Palpitations

›Syncope

Toxic exposures

›Exposure symptoms

›Substance use

›Carbon monoxide exposure risk

›Recent medication overdose risk

06Collateral History and Family History/chafh8

Collateral source

›Collateral and reliability

›Witness account of last known well

›EMS report timeline

›Baseline language function confirmation

Family history

›Family history

›Early stroke or MI

›Inherited thrombophilia history

›Epilepsy history

07Risk Factors/rf24

Cerebrovascular

›Stroke and TIA risk factors

›Atrial fibrillation

›Hypertension (I10)

›Diabetes mellitus type 2 (E11.9)

›Hyperlipidemia (E78.5)

›Smoking

›Prior stroke (I63.9) or TIA (G45.9)

Hemorrhage

›Intracranial hemorrhage risk factors

›Anticoagulant use

›Thrombocytopenia history

›Liver disease

›Uncontrolled hypertension

Seizure and metabolic

›Seizure and mimic risks

›Known epilepsy (G40.909)

›Alcohol withdrawal

›Hypoglycemia risk

Infection and endocarditis

›Embolic and infectious risks

›Endocarditis risk factors

›IV drug use

›Prosthetic valve

Special populations

›Population specific risks

›Pregnancy and postpartum hypercoagulability

›Cancer associated thrombosis

›Sickle cell disease (D57.1)

08Differential Diagnosis/ddx53

Life threatening

›Life threatening causes

›Acute ischemic stroke (I63.9)

›Sudden onset focal deficit

›Cortical signs

›Intracerebral hemorrhage (I61.9)

›Headache

›Vomiting

›Decreased level of consciousness

›Subarachnoid hemorrhage (I60.9)

›Thunderclap headache

›Meningismus

›Large vessel occlusion

›Gaze deviation

›Dense hemiparesis

›Nonconvulsive status epilepticus (G41.90)

›Fluctuating aphasia

›Unexplained altered mental status

›Hypoglycemia (E16.2)

›Diaphoresis

›Tremor

›CNS infection

›Fever

›Neck stiffness

Common

›Common causes

›TIA (G45.9)

›Resolved deficit

›High short term stroke risk

›Postictal aphasia

›Witnessed seizure

›Gradual recovery

›Migraine with aura (G43.109)

›Gradual spread of symptoms

›Headache association

›Toxic metabolic encephalopathy

›Medication effect

›Renal failure

›Hepatic failure

Less common

›Less common causes

›Brain tumor or mass lesion (C71.9)

›Subacute progression

›Morning headache

›Brain abscess (G06.0)

›Fever

›Immunocompromise

›Cerebral venous sinus thrombosis (I67.6)

›Headache

›Pregnancy postpartum

›Demyelinating disease

›Prior neurologic episodes

›Young adult presentation

›Functional neurologic symptom disorder (F44.4)

›Inconsistent exam

›Nonanatomic features

09Past Medical History/pmh13

Neurologic and vascular history

›Relevant comorbidities

›Prior stroke or TIA details

›Carotid stenosis history

›Atrial fibrillation history

›Seizure disorder history

Procedures and devices

›Procedures and devices

›Mechanical heart valve

›Pacemaker or ICD

›Recent cardiac ablation

Baseline function

›Baseline function

›Independent activities of daily living

›Baseline speech or language impairment

›Baseline mobility limitations

10Physical Exam/exam39

General and vitals interpretation

›General and vitals

›Temperature pattern

›Oxygenation status

›Perfusion status

›BP pattern relevant to stroke treatment thresholds

Neurologic rapid screen

›Focused neurologic exam

›Level of consciousness

›Gaze and visual fields

›Facial symmetry

›Arm drift

›Leg drift

›Sensation asymmetry

Language and speech breakdown

›Language versus speech differentiation

›Aphasia features

›Naming

›Repetition

›Comprehension

›Fluency

›Dysarthria features

›Slurred articulation

›Normal comprehension and naming

›Apraxia of speech features

›Effortful groping

›Inconsistent sound errors

NIH Stroke Scale elements

›NIHSS relevant elements

›Language item scoring impact

›Neglect assessment

›Limb ataxia assessment

Cardiovascular

›Cardiovascular exam

›Irregularly irregular rhythm

›New murmur

›Signs of endocarditis

Head and neck

›Head and neck

›Carotid bruit

›Meningismus

›Tongue bite evidence

Pitfalls

›Pitfalls and subtle findings

›Hearing loss mimicking comprehension deficit

›Delirium or intoxication confounding language testing

11Lab Studies/labs19

Point of care and immediate labs

›Immediate tests

›Point of care glucose

›Electrolytes

›CBC

›Creatinine and eGFR

›PT INR

›aPTT

Stroke pathway labs

›Stroke pathway labs

›Troponin

›Lipids local protocol dependent

›HbA1c local protocol dependent

Infection and mimic labs

›Mimic evaluation labs

›Blood cultures if febrile with embolic concern

›CRP or ESR local protocol dependent

›Toxicology screen local protocol dependent

Interpretation pearls and limitations

›Limitations and pitfalls

›Normal labs do not exclude ischemic stroke

›Early infection markers may be normal

›Anticoagulant effect may not be captured by PT INR for some DOACs

12Imaging/img31

Scoring Systems

›Imaging based risk and selection tools

›ASPECTS for anterior circulation ischemic stroke

›Lower scores correlate with larger core infarct

›Interrater variability limitation

›ABCD2 score for TIA risk stratification

›Use for short term stroke risk estimation

›Do not use to exclude need for urgent imaging

MRI

›MRI brain pathways

›DWI MRI for acute ischemia

›Higher sensitivity than CT for early infarct

›False negative possible early or posterior circulation

›MRI contraindications screen

›Non MRI compatible implants

›Severe agitation requiring airway risk sedation

›CT based acute stroke imaging

›Noncontrast CT head

›Primary role hemorrhage exclusion

›Early ischemic change may be subtle

›CTA head and neck

›Large vessel occlusion detection

›Contrast nephropathy risk low but local protocol dependent

›CT perfusion local protocol dependent

›Selection for late window thrombectomy

›Software and thresholds vary

Ultrasound

›Ultrasound and POCUS adjuncts

›Carotid duplex local protocol dependent

›Stenosis assessment for secondary prevention

›Operator dependence limitation

›TTE or TEE local protocol dependent

›Cardioembolic source evaluation

›Not a substitute for emergent CT or CTA

13Special Tests/spec15

Bedside differentiation tests

›Bedside language testing

›Picture description

›Object naming

›Repetition phrase testing

›Simple command following

Seizure evaluation

›EEG considerations

›Persistent aphasia with normal imaging

›Fluctuating deficits with altered awareness

›Nonconvulsive status epilepticus suspicion

Lumbar puncture indications

›CSF evaluation indications

›Suspected meningitis or encephalitis

›Suspected SAH with negative CT and ongoing high suspicion local protocol dependent

Swallow assessment

›Aspiration risk screening

›NPO until swallow screen completed

›Early speech language pathology involvement local protocol dependent

14ECG/ecg11

Rhythm and ischemia evaluation

›ECG role

›Atrial fibrillation detection

›Acute ischemia screening

›QT prolongation for toxicologic concerns

Cardioembolic source clues

›ECG findings and implications

›New atrial fibrillation

›Recent MI pattern

›Frequent ectopy as arrhythmia marker

Serial and monitoring logic

›Monitoring

›Continuous telemetry for suspected cardioembolic stroke local protocol dependent

›Repeat ECG if chest pain or troponin rise

15Assessment/ax18

Problem representation

›Acute aphasia or speech disturbance

›Suspected cortical syndrome

›Time last known well defined versus unknown

›Persistent versus resolved deficit

Severity and risk stratification

›Severity and risk

›NIHSS language component influence on reperfusion decisions

›High risk TIA features

›Posterior circulation concern features

Key must not miss complications

›Complications to rule out

›Intracranial hemorrhage

›Large vessel occlusion

›Hypoglycemia

›Seizure or status epilepticus

Diagnostic uncertainty and mimics

›Mimic framework

›Toxic metabolic encephalopathy

›Migraine aura

›Functional symptoms

›CNS infection

16Plan/plan35

First 5 minutes

›Time critical workflow

›Stroke activation local protocol dependent

›Glucose correction if low

›Oxygen for hypoxia

›Two IV lines if candidate for thrombolysis or thrombectomy

›Noncontrast CT head target within 20 minutes local protocol dependent

Acute stroke pathway

›Reperfusion decision workflow

›Noncontrast CT head for hemorrhage exclusion

›CTA head and neck for large vessel occlusion when eligible local protocol dependent

›Thrombolysis eligibility screen local protocol dependent

›Thrombectomy eligibility screen local protocol dependent

Blood pressure targets

›Blood pressure management local protocol dependent

›If thrombolysis planned maintain BP below 185 over 110 mmHg

›After thrombolysis maintain BP below 180 over 105 mmHg

›If no thrombolysis and BP greater than 220 over 120 mmHg consider cautious reduction

Glucose and temperature

›Physiologic targets

›Glucose target 7 to 10 mmol/L local protocol dependent

›Treat hypoglycemia immediately

›Treat fever and search source

Antithrombotic therapy

›Antiplatelet and anticoagulation local protocol dependent

›Aspirin after hemorrhage excluded

›Dual antiplatelet for high risk TIA or minor stroke when appropriate local protocol dependent

›Anticoagulation timing for atrial fibrillation stroke depends on infarct size local protocol dependent

Seizure management

›Seizure treatment if present

›Lorazepam IV 2 mg

›Repeat 2 mg every 2 minutes up to 8 mg total local protocol dependent

›Airway risk monitoring

›Levetiracetam IV 60 mg per kg

›Maximum 4500 mg

›Renal adjustment local protocol dependent

Reassessment loop

›Reassessment loop

›Neuro checks frequency local protocol dependent

›Repeat glucose after correction

›Repeat vitals after BP interventions

›Escalate for worsening NIHSS or declining consciousness

17Disposition/dispo23

Level of care criteria

›ICU or higher acuity criteria

›Intracranial hemorrhage

›Large vessel occlusion awaiting intervention

›Airway compromise

›Refractory seizure

›Severe BP instability

Admission and observation

›Admission criteria

›Persistent neurologic deficit

›TIA with high short term stroke risk features

›Need for urgent carotid or cardioembolic workup

›Anticoagulation management complexity

›Observation pathway criteria local protocol dependent

›Resolved deficit with rapid access imaging and neurology follow up

›Stable vitals and reliable supervision

Transfer criteria

›Transfer to thrombectomy capable center local protocol dependent

›Suspected large vessel occlusion

›Within endovascular time window per protocol

›No prohibitive comorbidity or goals of care limitations

Discharge criteria

›Discharge criteria

›Stroke and hemorrhage excluded with appropriate imaging

›Mimic identified and treated

›Normal neurologic exam at baseline

›Reliable follow up within 24 to 72 hours for TIA pathway local protocol dependent

18Discharge Instructions/di20

Copy discharge instructions

›Summary

›You were seen for a sudden change in speech or language

›Your tests today did not show bleeding in the brain

›A stroke can still happen even if symptoms improve

›Medications

›Take medications exactly as prescribed

›Do not stop blood thinners without medical advice

›Activity

›Do not drive until cleared if you had a seizure or stroke concern

›Avoid alcohol and sedating substances until symptoms fully resolved

›Follow up

›Return for urgent follow up within 24 to 72 hours if advised

›Neurology or stroke clinic follow up timing as arranged

›Return to ED now for

›Any new or worsening weakness

›Any new or worsening speech or understanding problems

›Severe sudden headache

›Seizure

›Confusion or fainting

›Chest pain or trouble breathing

19References/r6

Guidelines and key sources

›Evidence based references

›American Heart Association American Stroke Association guidelines for early management of acute ischemic stroke 2019 update

›American Heart Association American Stroke Association guideline for the prevention of stroke in patients with stroke and TIA 2021

›European Stroke Organisation guidelines for management of acute ischemic stroke and TIA 2021 to 2023 local protocol dependent

›Society of NeuroInterventional Surgery recommendations for endovascular thrombectomy systems of care 2021 local protocol dependent

›NIH Stroke Scale training and certification materials current version local protocol dependent

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed February 24, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.

Acute Aphasia and Speech DisturbanceAPPROACH

NEUROLOGIC · 19 SECTIONS

⚲

437 items

☷ Legend

⚲

Resuscitation and Universal Approaches9▾

Chest and Cardiovascular12▾

Respiratory11▾

Abdominal and Gastrointestinal24▾

Renal and Urinary7▾

Neurologic11▾

Back and Neck8▾

Women's Health, Pregnancy, and GU11▾

Infectious Disease and Fever Syndromes11▾

Allergy and Dermatology7▾

Musculoskeletal and Extremities14▾

Trauma and Wounds14▾

ENT, Eye, Dental10▾

Endocrine, Metabolic, and Abnormal Labs9▾

Toxicology and Behavioral14▾

Pediatrics16▾

Environmental and Exposure4▾

01History/hx48

HPI snapshot

›Symptom characterization

›Primary deficit pattern

›Witnessed language disturbance versus dysarthria versus confusion

›Time last known well

OPQRST Onset

›Onset

›Exact time last known normal

›Sudden maximal at onset versus gradual progression

›Wake up symptoms

OPQRST Provocation/Palliation

›Provocation and palliation

›Fluctuating deficits

›Triggered by exertion

›Triggered by posture change

›Triggered by Valsalva

OPQRST Quality

›Quality

›Expressive aphasia

›Receptive aphasia

›Global aphasia

›Anomia

›Paraphasic errors

OPQRST Region/Radiation

›Region and associated neurologic territory clues

›Right sided weakness or sensory loss

›Gaze deviation

›Visual field loss

OPQRST Severity

›Severity

›Complete inability to produce language

›Mild word finding difficulty

›Functional impact on safety

OPQRST Timing

›Timing

›Persistent deficit duration

›Resolved deficit duration

›Recurrent stereotyped episodes

Associated symptoms

›Associated symptoms

›Headache

›Seizure activity

›Fever

›Neck pain

›Chest pain

›Palpitations

›Hypoglycemia symptoms

Baseline and prior episodes

›Baseline neurologic and language function

›Prior stroke or TIA baseline

›Baseline dementia or primary progressive aphasia history

›Baseline hearing or vision impairment

Time critical treatment modifiers

›Reperfusion eligibility modifiers

›Recent major surgery or trauma

›Recent intracranial hemorrhage history

›Anticoagulant use and last dose time

›Pregnancy status

02Alarm Features/alarm27

First 5 minutes triggers

›Immediate escalation triggers

›Airway risk

›Hypoxia

›Hypotension

›Refractory seizure

›Rapidly worsening mental status

Stroke and hemorrhage red flags

›Life threatening neurologic triggers

›Sudden aphasia with unilateral weakness

›Sudden aphasia with gaze deviation

›Severe thunderclap headache

›Meningismus

›Anticoagulated with new neurologic deficit

Vital sign danger thresholds

›Vital sign danger thresholds

›Glucose less than 3.0 mmol/L

›Oxygen saturation less than 92 percent

›SBP less than 90 mmHg

›SBP greater than 220 mmHg

›Temperature 38.0 C or higher

Exam danger findings

›High risk exam findings

›Depressed level of consciousness

›New anisocoria

›Cushing response pattern

›Papilledema

Do not delay pathways

›Do not delay

›Noncontrast CT head for suspected stroke or hemorrhage

›Point of care glucose

›Stroke team activation local protocol dependent

03Medications/meds15

Current and recent exposures

›Medication reconciliation

›Anticoagulants

›Antiplatelets

›Antiseizure medications

›Insulin or sulfonylureas

›Sedatives

›Antipsychotics

High risk interactions and reversals

›High risk medication implications

›DOAC last dose time and renal function dependence

›Warfarin with INR relevance

›Opioids or sedatives contributing to delirium

Contraindications to common therapies

›Contraindications and cautions

›Contrast allergy history for CTA

›Metformin with severe renal dysfunction context for contrast local protocol dependent

›Pregnancy considerations for radiation imaging

04Diet/diet9

Intake and metabolic risk

›Intake pattern

›Poor oral intake

›Recent vomiting or dehydration

›Alcohol binge exposure

›Energy drink or caffeine excess

Glucose and electrolyte triggers

›Metabolic triggers

›Prolonged fasting

›Recent insulin dosing change

›Recent diarrhea with electrolyte loss

05Review of Systems/ros23

Neurologic

›Neurologic symptoms

›Weakness

›Numbness

›Vision loss

›Diplopia

›Vertigo

›Ataxia

›Headache

›Seizure

Infectious and inflammatory

›Systemic symptoms

›Fever

›Chills

›Rash

›Recent infection

Cardiopulmonary

›Cardiopulmonary symptoms

›Chest pain

›Dyspnea

›Palpitations

›Syncope

Toxic exposures

›Exposure symptoms

›Substance use

›Carbon monoxide exposure risk

›Recent medication overdose risk

06Collateral History and Family History/chafh8

Collateral source

›Collateral and reliability

›Witness account of last known well

›EMS report timeline

›Baseline language function confirmation

Family history

›Family history

›Early stroke or MI

›Inherited thrombophilia history

›Epilepsy history

07Risk Factors/rf24

Cerebrovascular

›Stroke and TIA risk factors

›Atrial fibrillation

›Hypertension (I10)

›Diabetes mellitus type 2 (E11.9)

›Hyperlipidemia (E78.5)

›Smoking

›Prior stroke (I63.9) or TIA (G45.9)

Hemorrhage

›Intracranial hemorrhage risk factors

›Anticoagulant use

›Thrombocytopenia history

›Liver disease

›Uncontrolled hypertension

Seizure and metabolic

›Seizure and mimic risks

›Known epilepsy (G40.909)

›Alcohol withdrawal

›Hypoglycemia risk

Infection and endocarditis

›Embolic and infectious risks

›Endocarditis risk factors

›IV drug use

›Prosthetic valve

Special populations

›Population specific risks

›Pregnancy and postpartum hypercoagulability

›Cancer associated thrombosis

›Sickle cell disease (D57.1)

08Differential Diagnosis/ddx53

Life threatening

›Life threatening causes

›Acute ischemic stroke (I63.9)

›Sudden onset focal deficit

›Cortical signs

›Intracerebral hemorrhage (I61.9)

›Headache

›Vomiting

›Decreased level of consciousness

›Subarachnoid hemorrhage (I60.9)

›Thunderclap headache

›Meningismus

›Large vessel occlusion

›Gaze deviation

›Dense hemiparesis

›Nonconvulsive status epilepticus (G41.90)

›Fluctuating aphasia

›Unexplained altered mental status

›Hypoglycemia (E16.2)

›Diaphoresis

›Tremor

›CNS infection

›Fever

›Neck stiffness

Common

›Common causes

›TIA (G45.9)

›Resolved deficit

›High short term stroke risk

›Postictal aphasia

›Witnessed seizure

›Gradual recovery

›Migraine with aura (G43.109)

›Gradual spread of symptoms

›Headache association

›Toxic metabolic encephalopathy

›Medication effect

›Renal failure

›Hepatic failure

Less common

›Less common causes

›Brain tumor or mass lesion (C71.9)

›Subacute progression

›Morning headache

›Brain abscess (G06.0)

›Fever

›Immunocompromise

›Cerebral venous sinus thrombosis (I67.6)

›Headache

›Pregnancy postpartum

›Demyelinating disease

›Prior neurologic episodes

›Young adult presentation

›Functional neurologic symptom disorder (F44.4)

›Inconsistent exam

›Nonanatomic features

09Past Medical History/pmh13

Neurologic and vascular history

›Relevant comorbidities

›Prior stroke or TIA details

›Carotid stenosis history

›Atrial fibrillation history

›Seizure disorder history

Procedures and devices

›Procedures and devices

›Mechanical heart valve

›Pacemaker or ICD

›Recent cardiac ablation

Baseline function

›Baseline function

›Independent activities of daily living

›Baseline speech or language impairment

›Baseline mobility limitations

10Physical Exam/exam39

General and vitals interpretation

›General and vitals

›Temperature pattern

›Oxygenation status

›Perfusion status

›BP pattern relevant to stroke treatment thresholds

Neurologic rapid screen

›Focused neurologic exam

›Level of consciousness

›Gaze and visual fields

›Facial symmetry

›Arm drift

›Leg drift

›Sensation asymmetry

Language and speech breakdown

›Language versus speech differentiation

›Aphasia features

›Naming

›Repetition

›Comprehension

›Fluency

›Dysarthria features

›Slurred articulation

›Normal comprehension and naming

›Apraxia of speech features

›Effortful groping

›Inconsistent sound errors

NIH Stroke Scale elements

›NIHSS relevant elements

›Language item scoring impact

›Neglect assessment

›Limb ataxia assessment

Cardiovascular

›Cardiovascular exam

›Irregularly irregular rhythm

›New murmur

›Signs of endocarditis

Head and neck

›Head and neck

›Carotid bruit

›Meningismus

›Tongue bite evidence

Pitfalls

›Pitfalls and subtle findings

›Hearing loss mimicking comprehension deficit

›Delirium or intoxication confounding language testing

11Lab Studies/labs19

Point of care and immediate labs

›Immediate tests

›Point of care glucose

›Electrolytes

›CBC

›Creatinine and eGFR

›PT INR

›aPTT

Stroke pathway labs

›Stroke pathway labs

›Troponin

›Lipids local protocol dependent

›HbA1c local protocol dependent

Infection and mimic labs

›Mimic evaluation labs

›Blood cultures if febrile with embolic concern

›CRP or ESR local protocol dependent

›Toxicology screen local protocol dependent

Interpretation pearls and limitations

›Limitations and pitfalls

›Normal labs do not exclude ischemic stroke

›Early infection markers may be normal

›Anticoagulant effect may not be captured by PT INR for some DOACs

12Imaging/img31

Scoring Systems

›Imaging based risk and selection tools

›ASPECTS for anterior circulation ischemic stroke

›Lower scores correlate with larger core infarct

›Interrater variability limitation

›ABCD2 score for TIA risk stratification

›Use for short term stroke risk estimation

›Do not use to exclude need for urgent imaging

MRI

›MRI brain pathways

›DWI MRI for acute ischemia

›Higher sensitivity than CT for early infarct

›False negative possible early or posterior circulation

›MRI contraindications screen

›Non MRI compatible implants

›Severe agitation requiring airway risk sedation

›CT based acute stroke imaging

›Noncontrast CT head

›Primary role hemorrhage exclusion

›Early ischemic change may be subtle

›CTA head and neck

›Large vessel occlusion detection

›Contrast nephropathy risk low but local protocol dependent

›CT perfusion local protocol dependent

›Selection for late window thrombectomy

›Software and thresholds vary

Ultrasound

›Ultrasound and POCUS adjuncts

›Carotid duplex local protocol dependent

›Stenosis assessment for secondary prevention

›Operator dependence limitation

›TTE or TEE local protocol dependent

›Cardioembolic source evaluation

›Not a substitute for emergent CT or CTA

13Special Tests/spec15

Bedside differentiation tests

›Bedside language testing

›Picture description

›Object naming

›Repetition phrase testing

›Simple command following

Seizure evaluation

›EEG considerations

›Persistent aphasia with normal imaging

›Fluctuating deficits with altered awareness

›Nonconvulsive status epilepticus suspicion

Lumbar puncture indications

›CSF evaluation indications

›Suspected meningitis or encephalitis

›Suspected SAH with negative CT and ongoing high suspicion local protocol dependent

Swallow assessment

›Aspiration risk screening

›NPO until swallow screen completed

›Early speech language pathology involvement local protocol dependent

14ECG/ecg11

Rhythm and ischemia evaluation

›ECG role

›Atrial fibrillation detection

›Acute ischemia screening

›QT prolongation for toxicologic concerns

Cardioembolic source clues

›ECG findings and implications

›New atrial fibrillation

›Recent MI pattern

›Frequent ectopy as arrhythmia marker

Serial and monitoring logic

›Monitoring

›Continuous telemetry for suspected cardioembolic stroke local protocol dependent

›Repeat ECG if chest pain or troponin rise

15Assessment/ax18

Problem representation

›Acute aphasia or speech disturbance

›Suspected cortical syndrome

›Time last known well defined versus unknown

›Persistent versus resolved deficit

Severity and risk stratification

›Severity and risk

›NIHSS language component influence on reperfusion decisions

›High risk TIA features

›Posterior circulation concern features

Key must not miss complications

›Complications to rule out

›Intracranial hemorrhage

›Large vessel occlusion

›Hypoglycemia

›Seizure or status epilepticus

Diagnostic uncertainty and mimics

›Mimic framework

›Toxic metabolic encephalopathy

›Migraine aura

›Functional symptoms

›CNS infection

16Plan/plan35

First 5 minutes

›Time critical workflow

›Stroke activation local protocol dependent

›Glucose correction if low

›Oxygen for hypoxia

›Two IV lines if candidate for thrombolysis or thrombectomy

›Noncontrast CT head target within 20 minutes local protocol dependent

Acute stroke pathway

›Reperfusion decision workflow

›Noncontrast CT head for hemorrhage exclusion

›CTA head and neck for large vessel occlusion when eligible local protocol dependent

›Thrombolysis eligibility screen local protocol dependent

›Thrombectomy eligibility screen local protocol dependent

Blood pressure targets

›Blood pressure management local protocol dependent

›If thrombolysis planned maintain BP below 185 over 110 mmHg

›After thrombolysis maintain BP below 180 over 105 mmHg

›If no thrombolysis and BP greater than 220 over 120 mmHg consider cautious reduction

Glucose and temperature

›Physiologic targets

›Glucose target 7 to 10 mmol/L local protocol dependent

›Treat hypoglycemia immediately

›Treat fever and search source

Antithrombotic therapy

›Antiplatelet and anticoagulation local protocol dependent

›Aspirin after hemorrhage excluded

›Dual antiplatelet for high risk TIA or minor stroke when appropriate local protocol dependent

›Anticoagulation timing for atrial fibrillation stroke depends on infarct size local protocol dependent

Seizure management

›Seizure treatment if present

›Lorazepam IV 2 mg

›Repeat 2 mg every 2 minutes up to 8 mg total local protocol dependent

›Airway risk monitoring

›Levetiracetam IV 60 mg per kg

›Maximum 4500 mg

›Renal adjustment local protocol dependent

Reassessment loop

›Reassessment loop

›Neuro checks frequency local protocol dependent

›Repeat glucose after correction

›Repeat vitals after BP interventions

›Escalate for worsening NIHSS or declining consciousness

17Disposition/dispo23

Level of care criteria

›ICU or higher acuity criteria

›Intracranial hemorrhage

›Large vessel occlusion awaiting intervention

›Airway compromise

›Refractory seizure

›Severe BP instability

Admission and observation

›Admission criteria

›Persistent neurologic deficit

›TIA with high short term stroke risk features

›Need for urgent carotid or cardioembolic workup

›Anticoagulation management complexity

›Observation pathway criteria local protocol dependent

›Resolved deficit with rapid access imaging and neurology follow up

›Stable vitals and reliable supervision

Transfer criteria

›Transfer to thrombectomy capable center local protocol dependent

›Suspected large vessel occlusion

›Within endovascular time window per protocol

›No prohibitive comorbidity or goals of care limitations

Discharge criteria

›Discharge criteria

›Stroke and hemorrhage excluded with appropriate imaging

›Mimic identified and treated

›Normal neurologic exam at baseline

›Reliable follow up within 24 to 72 hours for TIA pathway local protocol dependent

18Discharge Instructions/di20

Copy discharge instructions

›Summary

›You were seen for a sudden change in speech or language

›Your tests today did not show bleeding in the brain

›A stroke can still happen even if symptoms improve

›Medications

›Take medications exactly as prescribed

›Do not stop blood thinners without medical advice

›Activity

›Do not drive until cleared if you had a seizure or stroke concern

›Avoid alcohol and sedating substances until symptoms fully resolved

›Follow up

›Return for urgent follow up within 24 to 72 hours if advised

›Neurology or stroke clinic follow up timing as arranged

›Return to ED now for

›Any new or worsening weakness

›Any new or worsening speech or understanding problems

›Severe sudden headache

›Seizure

›Confusion or fainting

›Chest pain or trouble breathing

19References/r6

Guidelines and key sources

›Evidence based references

›American Heart Association American Stroke Association guidelines for early management of acute ischemic stroke 2019 update

›American Heart Association American Stroke Association guideline for the prevention of stroke in patients with stroke and TIA 2021

›European Stroke Organisation guidelines for management of acute ischemic stroke and TIA 2021 to 2023 local protocol dependent

›Society of NeuroInterventional Surgery recommendations for endovascular thrombectomy systems of care 2021 local protocol dependent

›NIH Stroke Scale training and certification materials current version local protocol dependent

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed February 24, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.