A 72-year-old man arrives in ED with sudden right-sided weakness and slurred speech, started 1 hour ago. Walk us through your management.

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This is an acute focal neurological deficit so I would treat it as a hyperacute stroke until proven otherwise. My immediate priority is ABCDE assessment while simultaneously activating the stroke pathway. I would stabilise airway, breathing and circulation, check observations, gain IV access and check a capillary glucose to exclude hypoglycaemia as a stroke mimic, while establishing exact time last known well — at one hour he is potentially eligible for reperfusion. Focused neuro assessment including GCS, pupils, limb power, speech and a formal NIHSS, and urgently involve the stroke team. He needs an urgent non-contrast CT head to exclude haemorrhage and ideally CT angiography to assess for large vessel occlusion; urgent FBC, U&E, coagulation, glucose, group and save, and an ECG for AF. If CT confirms ischaemic stroke with no haemorrhage and no contraindications, I would assess him for IV thrombolysis within the 4.5-hour window and consider mechanical thrombectomy if there is a large vessel occlusion, particularly in the anterior circulation. I would ensure BP is below 185/110, keep him nil by mouth until swallow assessment, monitor neuro status closely and admit to a specialist stroke unit. If not suitable for thrombolysis I would start aspirin 300 mg once haemorrhage is excluded, continue stroke unit care and initiate secondary prevention after determining the cause.

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