When to seek emergency care

Common causes

• Stroke: ischemic stroke from an arterial blockage, or hemorrhagic stroke from bleeding. This is the leading acute cause.
• Brain tumor, abscess, head injury, or subdural hematoma
• Demyelinating disease, such as multiple sclerosis
• Brain infection or inflammation
• Migraine with motor aura, seizures with temporary post-seizure weakness
• Spinal cord disease, though the pattern often differs
• Functional neurological disorder, after structural causes have been properly excluded
• In children, cerebral palsy can cause longstanding spastic hemiplegia.

Diagnosis

1. Clinical assessment

• Onset and time course: sudden onset favors stroke; gradual progression can suggest tumor or another structural disease.
• Associated symptoms: aphasia, neglect, visual-field loss, headache, seizure, altered consciousness, sensory loss, swallowing difficulty.
• Risk factors: hypertension, diabetes, smoking, atrial fibrillation, high cholesterol, anticoagulant use, recent trauma.

2. Emergency tests for suspected acute stroke

• Immediate non-contrast CT brain to distinguish hemorrhage from ischemia
• CT angiography or MR angiography to identify large-vessel blockage
• MRI with diffusion imaging when needed, especially if CT is initially unrevealing
• Blood glucose, full blood count, electrolytes, kidney function, coagulation tests, ECG, and oxygen assessment
• Further cause evaluation: carotid imaging, echocardiography, prolonged rhythm monitoring for atrial fibrillation, and vascular-risk assessment.

Treatment

A. Acute ischemic stroke

• Intravenous thrombolysis may be used rapidly in an appropriate time window after onset, following assessment for bleeding risk and contraindications.
• Mechanical thrombectomy may remove a clot in selected patients with a large-vessel occlusion. It can benefit carefully selected patients even many hours after onset, depending on imaging and clinical criteria.
• Antiplatelet therapy, commonly aspirin, is started when safe and once hemorrhage has been excluded. The exact timing depends on whether thrombolysis was used.
• Anticoagulation is used for selected causes such as atrial fibrillation, but usually not immediately in every patient. Timing depends on infarct size and bleeding risk.
• Control oxygen deficiency, fever, markedly abnormal glucose, dehydration, and blood pressure according to stroke protocols.

B. Hemorrhagic stroke

• Rapid blood-pressure management
• Reversal of anticoagulants when applicable
• Neurosurgical or neurointerventional assessment for evacuation, aneurysm treatment, hydrocephalus, or raised intracranial pressure
• Intensive monitoring and management of complications.

C. Treating the underlying non-stroke cause

• Tumor or abscess: neurosurgical, oncology, antimicrobial, and sometimes steroid treatment according to cause
• Seizure-related weakness: manage seizures and confirm that weakness resolves as expected
• Multiple sclerosis relapse: specialist-directed treatment
• Functional neurological disorder: clear explanation, neurological and rehabilitation care, and treatment of contributing psychological symptoms where present.

Rehabilitation

• Physiotherapy: strengthening, task-specific practice, balance, walking, transfers, range-of-motion work, and prevention of contractures.
• Occupational therapy: dressing, bathing, hand function, home adaptations, work and driving assessment.
• Speech and language therapy: aphasia, communication, cognition, and swallowing assessment.
• Swallowing management: screen before oral food or fluids; use appropriate diet texture or tube feeding if needed.
• Spasticity treatment: regular stretching and positioning, splints or orthoses, physiotherapy; oral agents or botulinum toxin injections may be considered for focal problematic spasticity.
• Mobility aids: ankle-foot orthosis, cane, walker, wheelchair, and fall-prevention strategies as appropriate.
• Psychological care: screen and treat depression, anxiety, fatigue, sleep issues, and caregiver strain.

Preventing complications and recurrence

• Prevent pressure injuries, shoulder pain/subluxation, falls, aspiration pneumonia, deep-vein thrombosis, urinary issues, and constipation.
• Manage blood pressure, diabetes, cholesterol, smoking, weight, alcohol intake, sleep apnea, and physical inactivity.
• For stroke survivors, use cause-specific secondary prevention: antiplatelet or anticoagulant therapy when indicated, statin therapy where appropriate, and carotid intervention in selected people with significant symptomatic carotid stenosis.

Key treatment updates in the 2026 AHA/ASA ischemic-stroke guideline

• Treat suspected stroke as an emergency: rapid EMS recognition, pre-notification, urgent brain imaging, and coordinated transfer to a stroke-capable or thrombectomy-capable center.
• IV thrombolysis: for eligible adults within 4.5 hours of last-known-well, either tenecteplase or alteplase is recommended. Tenecteplase has practical advantages because it is given as a single IV bolus.
• Extended-window thrombolysis: selected patients with unknown-onset stroke or presentation beyond 4.5 hours may be considered for IV thrombolysis when advanced imaging shows salvageable ischemic brain tissue.
• Mechanical thrombectomy: eligibility is broadened. It remains central for large-vessel occlusion and is recommended in appropriately selected patients up to 24 hours from last-known-well, based on vessel imaging and brain-tissue imaging. The guideline incorporates newer evidence for patients with larger ischemic cores and some posterior-circulation occlusions.
• Do not delay thrombectomy: if a patient qualifies for both IV thrombolysis and thrombectomy, give IV thrombolysis promptly but do not postpone endovascular treatment.
• Mild stroke: distinguish disabling from non-disabling deficits. Disabling symptoms may warrant thrombolysis even when the NIHSS score is low; dual antiplatelet therapy is favored rather than thrombolysis for selected non-disabling presentations.
• Supportive care: avoid hypoxia, treat fever, screen swallowing before oral intake, and avoid overly intensive glucose or blood-pressure reduction without a specific indication.
• Pediatric stroke: the guideline provides its first dedicated recommendations for children, emphasizing urgent MRI/MRA where feasible and specialist stroke-center involvement.