Always obtain blood glucose, which is commonly overlooked (more embarrassing if you give tPA)
Find out last known normal of affected deficit and write it down in chart
Labs
POC glucose
CBC
Chemistry
Coags
Troponin
T&S
ECG
In large ICH or<unk>  may see deep TWI and prolong QT, occ ST changes
Head CT (non-contrast)
In ischemia<unk> CT has sensitivity 42%, specificity 91%
In acute ICH the sensitivity is 95-100%
The goal of CTH is to identify<unk> mimics (ICH, mass lesions, etc .)
Also consider:
CTA brain and neck
To check for large vessel occlusion for potential thrombectomy
Determine if there is carotid stenosis that warrants endarterectomy urgently
Pregnancy test
CXR (if infection suspected)
UA (if infection suspected)
Utox (if ingestion suspected)
POC glucose
CBC
Chemistry
Coags
Troponin
T&S
In large ICH or<unk>  may see deep TWI and prolong QT, occ ST changes
In ischemia<unk> CT has sensitivity 42%, specificity 91%
In acute ICH the sensitivity is 95-100%
The goal of CTH is to identify<unk> mimics (ICH, mass lesions, etc .)
CTA brain and neck
To check for large vessel occlusion for potential thrombectomy
Determine if there is carotid stenosis that warrants endarterectomy urgently
Pregnancy test
CXR (if infection suspected)
UA (if infection suspected)
Utox (if ingestion suspected)
To check for large vessel occlusion for potential thrombectomy
Determine if there is carotid stenosis that warrants endarterectomy urgently
MRI Brain with DWI, ADC (without contrast) AND
Cervical vascular imaging (ACEP Level B in patients with high short-term risk for<unk> :
MRA brain (without contrast) AND
MRA neck (without contrast)
May instead use Carotid CTA or US (Carotid US slightly less sensitive than MRA) (ACEP Level C)
MRA brain (without contrast) AND
MRA neck (without contrast)
May instead use Carotid CTA or US (Carotid US slightly less sensitive than MRA) (ACEP Level C)
May instead use Carotid CTA or US (Carotid US slightly less sensitive than MRA) (ACEP Level C)
"Cortical<unk> " of ICA, MCA, and some ACA occlusions are most likely to benefit from thrombectomy
CT perfusion study is the key factor in determining brain tissue salvageability from symptom onset to thrombectomy of 6-24 hours
If CT perfusion unavailable, use ASPECT score
NIHSS score ≥ 6 is nearly 100% sensitive for emergent large vessel occlusion, which may be amenable to thrombectomy
VAN score is just as sensitive, but also may be more specific (~90%)
Weakness must be present, plus one or all of the VAN to be VAN positive
Weakness qualifying findings -- if no weakness, the pt is VAN negative
Mild (minor drift)
Moderate (severe drift—touches or nearly touches ground)
Severe (flaccid or no antigravity)
Visual disturbance qualifying findings
Field cut (which side) (4 quadrants)
Double vision (ask patient to look to right then left; evaluate for uneven eyes)
Blind new onset
Aphasia qualifying findings
Expressive (inability to speak or paraphasic errors); do not count slurring of words (repeat and name 2 objects)
Receptive (not understanding or following commands) (close eyes, make fist)
Mixed
Neglect qualifying findings
Forced gaze or inability to track to one side
Unable to feel both sides at the same time, or unable to identify own arm
Ignoring one side
If VAN positive, CT and CTA of the head should be ordered for consideration of thrombectomy plus/minus tPA
Weakness must be present, plus one or all of the VAN to be VAN positive
Weakness qualifying findings -- if no weakness, the pt is VAN negative
Mild (minor drift)
Moderate (severe drift—touches or nearly touches ground)
Severe (flaccid or no antigravity)
Visual disturbance qualifying findings
Field cut (which side) (4 quadrants)
Double vision (ask patient to look to right then left; evaluate for uneven eyes)
Blind new onset
Aphasia qualifying findings
Expressive (inability to speak or paraphasic errors); do not count slurring of words (repeat and name 2 objects)
Receptive (not understanding or following commands) (close eyes, make fist)
Mixed
Neglect qualifying findings
Forced gaze or inability to track to one side
Unable to feel both sides at the same time, or unable to identify own arm
Ignoring one side
If VAN positive, CT and CTA of the head should be ordered for consideration of thrombectomy plus/minus tPA
Weakness qualifying findings -- if no weakness, the pt is VAN negative
Mild (minor drift)
Moderate (severe drift—touches or nearly touches ground)
Severe (flaccid or no antigravity)
Visual disturbance qualifying findings
Field cut (which side) (4 quadrants)
Double vision (ask patient to look to right then left; evaluate for uneven eyes)
Blind new onset
Aphasia qualifying findings
Expressive (inability to speak or paraphasic errors); do not count slurring of words (repeat and name 2 objects)
Receptive (not understanding or following commands) (close eyes, make fist)
Mixed
Neglect qualifying findings
Forced gaze or inability to track to one side
Unable to feel both sides at the same time, or unable to identify own arm
Ignoring one side
Mild (minor drift)
Moderate (severe drift—touches or nearly touches ground)
Severe (flaccid or no antigravity)
Field cut (which side) (4 quadrants)
Double vision (ask patient to look to right then left; evaluate for uneven eyes)
Blind new onset
Expressive (inability to speak or paraphasic errors); do not count slurring of words (repeat and name 2 objects)
Receptive (not understanding or following commands) (close eyes, make fist)
Mixed
Forced gaze or inability to track to one side
Unable to feel both sides at the same time, or unable to identify own arm
Ignoring one side
Stroke 
Stroke
Subarachnoid hemorrhage
Seizures/postictal paralysis 
Ischemic stroke
Syncope
Hemorrhagic stroke
Subdural hemorrhage