Stroke and the FAST Pathway

Stroke is screened with a validated tool such as FAST outside hospital and confirmed with a validated tool such as ROSIER in the emergency department, with hypoglycaemia excluded first. According to NICE guideline NG128, published on 1 May 2019, last updated on 13 April 2022 and last reviewed on 27 March 2026, immediate non-enhanced CT is needed if thrombolysis or thrombectomy might apply. At the CT1 anaesthetics interview the marks are for the time windows and for knowing why an anaesthetist is on this pathway at all.

Key takeaways

• FAST is the pre-hospital screening tool and ROSIER the emergency department tool, both named in NICE NG128 as examples of validated tools
• Exclude hypoglycaemia in anyone with sudden onset neurological symptoms before calling it a stroke
• Immediate CT is indicated for possible thrombolysis or thrombectomy, anticoagulation, bleeding tendency, a Glasgow Coma Scale score below 13, unexplained progressive or fluctuating symptoms, papilloedema, neck stiffness or fever, or severe headache at onset
• Thrombolysis with tenecteplase or alteplase is within 4.5 hours of symptom onset once intracranial haemorrhage is excluded
• Thrombectomy is offered within 6 hours for a proximal anterior circulation occlusion, and up to 24 hours including wake-up strokes if imaging shows salvageable brain
• Oxygen is given only if the saturation drops below 95%, and glucose is kept between 4 and 11 mmol/L

How do you recognise a stroke on the ward?

You recognise a stroke as a sudden focal neurological deficit, screened with a validated tool. NICE NG128 names FAST, the Face Arm Speech Test, for use outside hospital in anyone with sudden onset neurological symptoms.

In the emergency department the guideline asks you to establish the diagnosis rapidly using a validated tool such as ROSIER, the Recognition of Stroke in the Emergency Room, rather than relying on impression alone.

In practice an inpatient stroke is often found by a nurse noticing a new weakness or a change in speech. The time last known to be well, not the time of discovery, is the number that decides treatment.

What must you exclude before you call it a stroke?

Hypoglycaemia must be excluded in anyone with sudden onset neurological symptoms, and NG128 states this as its own recommendation. A bedside glucose takes seconds and changes the entire pathway.

The Resuscitation Council UK adds the detail for the treatment: below 4.0 mmol/L in an unconscious patient, give 50 ml of 10% glucose intravenously, repeatable each minute to a total of 250 ml.

Other mimics matter too. NICE lists seizure, migraine and intracranial infection among the alternatives, and NG240 notes that an intracranial bleed or ischaemia can look like meningitis and the reverse.

What happens in the first hour?

In the first hour of a suspected stroke the patient is screened, scanned and admitted to a specialist unit. NG128 says to admit everyone with suspected stroke directly to a specialist acute stroke unit after initial assessment.

• Establish the time last known to be well, because it sets both treatment windows
• Exclude hypoglycaemia and complete an ABCDE assessment, protecting the airway if consciousness is reduced
• Screen swallowing before any oral food, fluid or medication is given
• Arrange brain imaging: immediately if any of the criteria below apply, otherwise within 24 hours of symptom onset
• Add CT contrast angiography after the non-enhanced CT if thrombectomy might be indicated, plus CT perfusion if beyond 6 hours
• Give aspirin 300 mg as soon as possible and certainly within 24 hours once haemorrhage has been excluded

For a suspected transient ischaemic attack the pathway differs: aspirin 300 mg daily started immediately, immediate referral for specialist assessment within 24 hours, and no ABCD2 scoring to decide urgency.

When is the CT immediate rather than within 24 hours?

CT is immediate in a suspected stroke when any one of seven NG128 criteria is present. Otherwise scanning happens as soon as possible and within 24 hours of symptom onset.

• Indications for thrombolysis or thrombectomy
• The patient is on anticoagulant treatment
• A known bleeding tendency
• A depressed level of consciousness, specified as a Glasgow Coma Scale score below 13
• Unexplained progressive or fluctuating symptoms
• Papilloedema, neck stiffness or fever
• Severe headache at the onset of stroke symptoms

Three of those seven are anaesthetic flags. A patient with a Glasgow Coma Scale score below 13 and a suspected stroke is an airway problem as well as a neurological one.

Who gets thrombolysis, and inside what window?

Thrombolysis in acute ischaemic stroke is given within 4.5 hours of symptom onset once intracranial haemorrhage has been excluded on imaging. NG128 now points to two technology appraisals: tenecteplase from 2024 and alteplase from 2012.

It is delivered only within a well-organised stroke service with trained staff, nursing able to give level 1 and level 2 care, and immediate access to imaging and re-imaging with staff who can interpret it.

Blood pressure interacts with the decision. NG128 says a reduction to 185/110 mmHg or lower should be considered in people who are candidates for intravenous thrombolysis.

Who gets thrombectomy, and why does that involve the anaesthetist?

Thrombectomy is offered as soon as possible and within 6 hours of symptom onset, together with thrombolysis where not contraindicated, to people with a confirmed proximal anterior circulation occlusion on CT or MR angiography.

Between 6 and 24 hours, including wake-up strokes, it is offered if imaging such as CT perfusion or diffusion-weighted MRI shows a limited infarct core and therefore salvageable brain. Proximal posterior circulation occlusion is considered up to 24 hours.

Selection uses two numbers: a pre-stroke modified Rankin score below 3 and a National Institutes of Health Stroke Scale score above 5. The anaesthetist provides the sedation or general anaesthesia, the airway and the haemodynamic control in the radiology suite.

What about blood pressure, glucose, oxygen and swallowing?

Homeostasis in acute stroke is tightly specified, and most of it is restraint rather than intervention. NG128 gives supplemental oxygen only if the saturation drops below 95%, and says routine oxygen is not recommended in patients who are not hypoxic.

• Glucose: maintain between 4 and 11 mmol/L, with optimal insulin therapy for adults with type 1 diabetes and threatened or actual stroke
• Ischaemic stroke blood pressure: antihypertensives only in a hypertensive emergency, such as encephalopathy, nephropathy, cardiac failure or myocardial infarction, aortic dissection, or pre-eclampsia and eclampsia
• Intracerebral haemorrhage: consider rapid lowering within 6 hours if the systolic is 150 to 220 mmHg, aiming for 140 mmHg or lower without a fall of more than 60 mmHg in the first hour
• Do not lower rapidly if there is a structural cause, a Glasgow Coma Scale score below 6, planned early neurosurgery, or a massive haematoma with a poor prognosis
• Swallowing: screened on admission before any oral food, fluid or medication, with specialist assessment preferably within 24 hours and no more than 72 hours
• Nasogastric feeding within 24 hours of admission if oral intake is inadequate, unless the patient has been thrombolysed

The swallow screen is the one a ward doctor most often gets wrong. Giving oral medication before it has been done is a preventable aspiration, and it is a patient safety point an assessor will recognise.

Who do you call, and when?

In a stroke scenario you call the stroke team immediately, because the entire pathway is time-critical and the treatment windows are theirs to use. Admission is direct to a specialist acute stroke unit.

As an anaesthetic CT1 you call critical care or your own registrar for a second reason: airway protection in a patient with a reduced conscious level, or anaesthesia for a thrombectomy that may start within the hour.

Say the time last known to be well in the first sentence of your referral. It is the single fact that determines whether the team is racing or investigating.

What do the assessors score besides the pathway?

Beyond the pathway, the assessors in a stroke scenario score whether you recognise a decision that is not yours and act to get it made quickly. The stroke physician decides on thrombolysis; your job is to remove every delay.

Reflective practice is a named domain, so an honest example lands: a patient whose stroke you noticed late, or a swallow screen that was missed, and the checking habit you changed afterwards.

Working under pressure is scored in how you handle a moving clock. Doing the reversible things first, glucose, airway, imaging request, while the specialist team is on the way, reads as competence rather than panic.

Which mistakes cost marks in a stroke scenario?

The stroke mistakes at interview are mostly about time and about forgetting that this pathway belongs to somebody else who needs to be called now.

• Not checking a glucose, when NG128 makes excluding hypoglycaemia its own recommendation
• Quoting the time symptoms were noticed instead of the time last known to be well
• Naming alteplase only, when NG128 now points to tenecteplase (TA990, 2024) as well
• Using ABCD2 to decide the urgency of a transient ischaemic attack referral, which the guideline says not to do
• Giving routine oxygen, when the threshold is a saturation below 95%
• Giving oral aspirin or medication before the swallow screen

How this comes up at the CT1 anaesthetics interview

Stroke reaches the clinical judgement station as a ward referral with a clock attached: a patient found with a new weakness, or a thrombectomy list case needing anaesthesia. The station is 15 minutes after five minutes of reading, marked out of 50.

Clinical judgement and decision making is scored on the screening tool, the imaging trigger and the windows. Reflective practice is scored on the safety habit you changed, and working under pressure on how you order the first hour.

The follow-up usually asks you to anaesthetise: general anaesthesia or sedation for thrombectomy, and what blood pressure you would hold. anaestheticinterview's bank of 340 questions carries AI-marked spoken practice for that kind of follow-up.