MICA · FIRST-LINE LEARNING NOTES
Understand, prioritise and organise follow-up
Assess a recent neurological deficit by its timing, localisation and severity; sudden onset gives priority to the stroke pathway.
Identify a neurological emergency
Sudden facial or limb weakness, language disturbance, visual loss or imbalance may indicate stroke. Immediately activate the appropriate pathway and check capillary glucose. Spontaneous resolution does not make the event benign: suspected TIA also requires urgent specialist assessment. Impaired consciousness or respiratory difficulty requires simultaneous support of vital functions.
[1][2][3]Describe the deficit and onset
Record onset time or, when unknown, the last time the person was known to be well, including who provided that information. Describe motor, sensory, language, gaze, visual-field and coordination findings within available expertise. Establish previous function, anticoagulants, trauma, seizures and associated headache. A negative FAST screen does not exclude posterior circulation disease. After correcting hypoglycaemia, reassess any persisting deficit.
[4][3][2]Resolution of a deficit does not make the episode harmless; establish its duration and features. Transient weakness, language disturbance or visual loss may indicate ischaemia. Sudden vertigo with inability to walk, diplopia or ataxia needs urgent neurological assessment. An unremarkable screening score is not a diagnostic exclusion.
[3][2]Choose the appropriate pathway
Distinguishing ischaemia, haemorrhage and mimics requires specialist assessment and appropriate imaging; an exhaustive outpatient workup must not delay transfer. Rapidly progressive bilateral weakness, impaired swallowing or breathlessness raises a neuromuscular emergency. Back pain with weakness, new perineal sensory loss or sphincter dysfunction requires immediate referral for possible cauda equina compression.
[3][2]Make handover safe
Communicate timing, examination, glucose and medicines, with contact details for an available witness. In suspected acute stroke, withhold oral intake until a trained professional has assessed swallowing. After specialist assessment, confirm the working diagnosis, prescribed treatment changes, rehabilitation needs and instructions for recurrence. Any new deterioration reactivates the emergency pathway, even after an initially reassuring assessment.
[4][1]A learning situation
FICTIONAL CASE · SELF-REFLECTION WITHOUT A SCORE
A woman wakes with right-arm weakness and difficulty speaking. Her partner last saw her symptom-free at bedtime. She is conscious and wishes to wait because hand movement is returning.
Which information should take priority in handover?
Read the reasoning
Report last-known-well time, discovery time, observed deficits, glucose and medicines, especially anticoagulants. Activate the stroke pathway: improvement and onset during sleep do not remove the need for specialist care. Treatment options subsequently depend on imaging and stroke-team expertise.
References and scope
- Stroke and transient ischaemic attack in over 16s — NG128: Recommendations (updated April 2022) ↗
- Suspected neurological conditions — NG127: Recommendations for adults aged over 16 ↗
- Canadian Stroke Best Practices — Acute Stroke Management, Section 4: Emergency Department Evaluation and Management of Patients with Transient Ischemic Attack and Acute Stroke (2022 update, interim EVT links updated2025) ↗
- Canadian Stroke Best Practices — Acute Stroke Management, Section 3: Emergency Medical Services Management of Acute Stroke Patients (2022 update) ↗
Original educational synthesis for adult first-line practice. International references must be interpreted with the clinical setting and local care pathways. Independent human scientific review remains to be confirmed.