Stroke for NEET PG Medicine: BE-FAST, CT First, Thrombolysis and Thrombectomy, TIA, Intracerebral and Subarachnoid Haemorrhage

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🎯 Exam priority: Very high. Expect: BE-FAST, first steps, CT before anything, tPA window, dose and BP limits, thrombectomy window, aspirin and DAPT, BP thresholds with and without lysis, AF anticoagulation, TIA duration and ABCD2, amaurosis fugax, ICH site and BP target, anticoagulant reversal, SAH presentation, CT then LP, xanthochromia, nimodipine.

CBME mapping: GM 18.1–18.16. Neuroanatomy of stroke syndromes is in Anatomy; cerebral infarct pathology in Pathology; antiplatelet and anticoagulant drugs in Pharmacology; neurosurgery in Surgery.

Stroke types, ICMR first hour, thrombolysis and secondary prevention. Drawn by TrackNation.

Recognition and the First Hour

• Stroke: sudden persistent focal neurological deficit from cerebral, spinal or retinal infarction or haemorrhage. Types (ICMR): ischaemic, intracerebral haemorrhage, SAH, cerebral venous thrombosis; TIA is transient ischaemia without infarction. About 80% are ischaemic.

• BE-FAST: Balance, Eyes, Face droop, Arm drift, Speech, Time. Headache, vomiting and reduced consciousness favour haemorrhage.

• ICMR first steps: ABCs, cardiac monitoring, SpO2 > 94%, IV access, check and treat glucose (hypoglycaemia mimics stroke), record time last known normal, rapid transfer to a CT-capable centre. Non-contrast CT (or MRI), ECG, glucose; NIHSS.

• Occlusion is most often in the middle cerebral artery; small deep perforator occlusion gives lacunar infarcts.

Secondary Prevention and Stroke Unit

• Aspirin for ischaemic stroke; antihypertensives, lipid-lowering and antidiabetic drugs; AF → warfarin or a DOAC (dabigatran, apixaban, rivaroxaban, edoxaban); carotid endarterectomy or stenting when indicated.

• Stroke unit: BP and glucose control, swallow assessment, DVT prophylaxis, pneumonia prevention. Rehabilitation: physiotherapy, speech and occupational therapy. ICMR follow-up at 2 weeks, 1, 3 and 6 months.

• TIA: symptoms usually < 1 h (most < 5 min). ABCD2 score estimates stroke risk (Age ≥ 60, BP ≥ 140/90, Clinical features — weakness 2, speech 1, Duration ≥ 60 min 2, Diabetes 1). Amaurosis fugax = transient monocular blindness (ophthalmic artery).

Haemorrhagic Stroke

• Intracerebral haemorrhage: basal ganglia, lobes, cerebellum, pons. Hypertension → putamen; cerebral amyloid angiopathy → lobar bleeds in older adults. Lower SBP to 140 if it is 150–220. Reverse anticoagulation (FFP, PCC, vitamin K, platelets; idarucizumab for dabigatran, andexanet for factor Xa inhibitors). Cerebellar haematomas can block the 4th ventricle (hydrocephalus).

• Subarachnoid haemorrhage: sudden "worst headache of life", often with loss of consciousness; berry (saccular) aneurysm in ~85%. Non-contrast CT; if negative, lumbar puncture for xanthochromia. Complications: vasospasm, seizures, hydrocephalus. Treat with nimodipine to prevent vasospasm and secure the aneurysm by clipping or coiling.

Traps the Examiner Sets

• Check glucose before calling it a stroke — and it is the only blood test needed before tPA.

• Unknown onset: time starts when last seen well.

• Do not lower BP in ischaemic stroke without lysis unless ≥ 220/120.

• CT-negative thunderclap headache → LP for xanthochromia.

• Nimodipine prevents vasospasm in SAH.

Memory Hooks & Shortcuts

Shortcuts to lock in this article's numbers and lists. Each one only re-packages facts proven above.

• 🧠 BE-FAST — Balance and Eyes before FAST — warning signs

• 🧠 tPA '0.9-90-10-60': 0.9 mg/kg, max 90, 10% bolus, 60-min infusion — tPA dose

• 🧠 Lysis BP '185 to give, 180 to live' (before < 185, after < 180) — BP limits

• 🧠 No lysis: 'Leave it till 220' — permissive hypertension

• 🧠 SAH: 'CT, then Tap for yellow' (xanthochromia) — SAH work-up

• 🧠 Nimodipine — 'Nimo for the spasm' — vasospasm

Rapid-Revision Cards

• BE-FAST

  Balance, Eyes, Face, Arm, Speech, Time.

• Stroke types

  ~80% ischaemic, 20% haemorrhagic.

• First steps (ICMR)

  ABC, SpO2 > 94%, glucose, last-known-normal time, CT centre.

• Imaging

  Non-contrast CT/MRI first.

• tPA window

  ≤ 4.5 h (from last seen well).

• Thrombectomy (ICMR)

  4.5–24 h if eligible.

• tPA dose

  0.9 mg/kg, max 90; 10% bolus, rest 60 min.

• Pre-tPA BP

  SBP < 185, DBP < 105 (MSD).

• Only blood test pre-tPA

  Glucose.

• Post-tPA BP

  < 180/105 × 24 h.

• No lysis BP

  Treat only if ≥ 220/120.

• Aspirin

  Within 48 h.

• DAPT

  Minor stroke/ABCD2 ≥ 4, within 24 h.

• AF stroke

  Warfarin or DOAC.

• Lacunar

  Small deep perforators.

• TIA

  < 1 h (most < 5 min); ABCD2.

• Amaurosis fugax

  Transient monocular blindness.

• Hypertensive ICH

  Putamen.

• Lobar ICH elderly

  Amyloid angiopathy.

• ICH BP

  SBP → 140 if 150–220.

• DOAC reversal

  Idarucizumab (dabigatran); andexanet (Xa).

• SAH

  Worst headache; berry aneurysm 85%.

• SAH work-up

  CT → LP (xanthochromia).

• SAH drug

  Nimodipine.

Sources

Facts in this article were checked against these documents.

• Standard Treatment Workflow: Management of Stroke — Indian Council of Medical Research, DHR, 2019 (link)

• MSD Manual Professional: Overview of Stroke; Ischemic Stroke; Transient Ischemic Attack; Intracerebral Hemorrhage; Subarachnoid Hemorrhage — Merck & Co. (MSD Manuals), reviewed 2025–26 (link)

• Competency Based Undergraduate Curriculum, General Medicine (GM 18) — National Medical Commission, 2024

Test Yourself: Practice Questions

Thirty questions in NEET PG style, most of them clinical vignettes.

Practice Questions (NEET PG pattern)

Original questions written in the style of the exam: +4 for a correct answer, −1 for a wrong one. Every answer was checked against the sources listed above. NEET PG papers are not published by NBEMS, so these are not past-paper questions.

Q1. The ICMR stroke warning-sign mnemonic is

• (a) MONA

• (b) AVPU

• (c) BE-FAST: Balance, Eyes, Face, Arm, Speech, Time

• (d) SAMPLE

Q2. A man develops sudden right arm weakness and slurred speech. Per ICMR, oxygen saturation should be kept above

• (a) 88%

• (b) 85%

• (c) 94%

• (d) 99%

Q3. A patient with sudden hemiparesis has capillary glucose 38 mg/dL. The first action is

• (a) do MRI first

• (b) give tPA

• (c) give aspirin

• (d) treat the hypoglycaemia — it can mimic stroke

Q4. A patient woke up with a hemiparesis; he was last seen well at 11 pm. For thrombolysis decisions, onset time is taken as

• (a) the time he woke up

• (b) the time he reached hospital

• (c) the time he was last seen well

• (d) irrelevant

Q5. The first imaging study in suspected acute stroke is

• (a) EEG

• (b) contrast CT abdomen

• (c) carotid Doppler

• (d) non-contrast CT (or MRI) of the brain

Q6. Per the ICMR workflow, IV thrombolysis for ischaemic stroke is given within

• (a) 4.5 hours of onset

• (b) 1 week

• (c) 24 hours

• (d) 12 hours

Q7. A patient with large-vessel occlusion arrives 9 hours after onset. Per ICMR, the reperfusion option is

• (a) no option

• (b) IV tPA

• (c) heparin infusion

• (d) mechanical thrombectomy with a stent retriever if eligible

Q8. The dose of IV alteplase in acute ischaemic stroke is

• (a) 0.1 mg/kg

• (b) 0.9 mg/kg (max 90 mg), 10% as bolus and the rest over 60 minutes

• (c) 100 mg fixed over 2 hours

• (d) 1.5 mg/kg bolus

Q9. Before tPA, the patient's blood pressure must be below

• (a) 220/120

• (b) 140/90

• (c) 160/100

• (d) systolic 185 and diastolic 105 mm Hg (per MSD)

Q10. The only blood test required in all patients before thrombolysis is

• (a) platelet count

• (b) troponin

• (c) INR

• (d) blood glucose

Q11. After thrombolysis, blood pressure is kept below

• (a) 120/80

• (b) 180/105 mm Hg for at least 24 hours

• (c) 200/110

• (d) 220/120

Q12. In ischaemic stroke not receiving reperfusion therapy, BP is lowered (by about 15%) only when it is

• (a) always

• (b) ≥ 160/100

• (c) ≥ 140/90

• (d) ≥ 220/120 mm Hg on two readings

Q13. A patient with an ischaemic stroke not eligible for thrombolysis should receive

• (a) no antithrombotic

• (b) heparin infusion

• (c) warfarin immediately

• (d) aspirin within 48 hours

Q14. Dual antiplatelet therapy (aspirin + clopidogrel) within 24 hours is indicated for

• (a) minor stroke or high-risk TIA (ABCD2 ≥ 4)

• (b) all haemorrhagic strokes

• (c) SAH

• (d) large completed stroke

Q15. Secondary prevention after a cardioembolic stroke due to non-valvular AF includes

• (a) no therapy

• (b) anticoagulation with warfarin or a DOAC

• (c) clopidogrel alone

• (d) aspirin alone

Q16. Thrombotic occlusion in ischaemic stroke most often involves

• (a) the vertebral artery only

• (b) the posterior communicating artery only

• (c) the anterior spinal artery

• (d) the main trunk of the middle cerebral artery and its branches

Q17. Occlusion of small, deep perforating arteries produces

• (a) lacunar infarcts

• (b) watershed infarcts

• (c) cardioembolic infarcts

• (d) venous infarcts

Q18. Which features favour haemorrhagic over ischaemic stroke?

• (a) gradual onset over weeks

• (b) normal BP

• (c) isolated facial droop

• (d) headache, vomiting and reduced consciousness

Q19. A transient ischaemic attack usually lasts

• (a) exactly 24 hours

• (b) more than 24 hours

• (c) several days

• (d) less than 1 hour (most under 5 minutes)

Q20. Sudden loss of vision in one eye for 3 minutes that fully recovers is

• (a) optic neuritis

• (b) migraine aura in both eyes

• (c) amaurosis fugax (ophthalmic artery)

• (d) retinal detachment

Q21. The ABCD2 score is used to

• (a) score coma

• (b) estimate stroke risk after a TIA

• (c) decide tPA dose

• (d) grade SAH

Q22. The commonest site of hypertensive intracerebral haemorrhage is the

• (a) occipital lobe

• (b) corpus callosum

• (c) putamen

• (d) medulla

Q23. Recurrent lobar haemorrhages in an older adult suggest

• (a) AV malformation in all

• (b) hypertensive bleed

• (c) cerebral amyloid angiopathy

• (d) berry aneurysm

Q24. In acute intracerebral haemorrhage with systolic BP 190 mm Hg, the guideline target is

• (a) systolic 220

• (b) systolic below 100

• (c) systolic about 140 mm Hg

• (d) no lowering

Q25. A patient on dabigatran has an intracerebral haemorrhage. The specific reversal agent is

• (a) idarucizumab

• (b) vitamin K

• (c) protamine

• (d) andexanet alfa

Q26. A cerebellar haematoma is dangerous because it can

• (a) cause aphasia

• (b) cause hemiplegia only

• (c) never expand

• (d) block the 4th ventricle causing hydrocephalus

Q27. A woman has sudden 'worst headache of my life' and neck stiffness; non-contrast CT is normal. The next investigation is

• (a) EEG

• (b) lumbar puncture for xanthochromia and red cells

• (c) MRI after 1 week

• (d) discharge with analgesia

Q28. Non-traumatic subarachnoid haemorrhage is most commonly due to

• (a) amyloid angiopathy

• (b) hypertension

• (c) AV fistula

• (d) a ruptured saccular (berry) aneurysm (~85%)

Q29. A drug given in SAH to prevent delayed ischaemia from vasospasm is

• (a) nimodipine

• (b) heparin

• (c) tPA

• (d) nifedipine sublingual

Q30. Per ICMR, rehabilitation after stroke includes

• (a) bed rest for 3 months

• (b) physiotherapy, speech therapy and occupational therapy

• (c) no rehabilitation until 6 months

• (d) only drug therapy

Active Recall

From memory: list BE-FAST and the ICMR first-hour steps, give the tPA window, dose and BP and glucose limits, the thrombectomy window, BP thresholds with and without lysis, antiplatelet and AF rules, TIA definition and ABCD2, and the features and management of intracerebral and subarachnoid haemorrhage.