1. Things to bear in mind
• Time is brain – stroke referrals are time-critical. Establish exact time last known well (LKW) immediately.
• Confirm the presentation: sudden-onset focal neurological deficit (e.g. weakness, aphasia, facial droop, visual loss, ataxia, sensory change).
• Exclude common mimics: seizure with Todd’s paresis, hypoglycaemia, migraine, sepsis, functional symptoms, intoxication, post-ictal states.
• Stabilise the patient first – A-E assessment, glucose, temperature, hydration, oxygen if hypoxic.
• Check for anticoagulant use (especially warfarin, DOACs, heparin).
• Perform a focused neurological assessment: FAST or NIHSS if trained.
• Record exact onset and nature of symptoms (e.g. improving, fluctuating, persistent).
• Arrange urgent non-contrast CT head
• If unsure whether it’s a stroke or mimic, call early stroke teams prefer over-referral to missed cases.
Know your local stroke pathway
• Most regions have designated Hyperacute Stroke Units (HASUs) responsible for emergency thrombolysis and thrombectomy.
• Confirm whether your hospital is a HASU (provides 24/7 reperfusion services) or a non-HASU (stabilises and transfers).
• If you’re non-HASU, activate the regional transfer pathway immediately if the patient may be eligible for reperfusion therapy.
• In some cases, this may involve blue lighting the patient to the HASU straight away, without doing a CT head, if suspicion is very high and imaging would cause unnecessary delay.
• HASUs typically have direct imaging access and stroke consultant cover.
• Always document time of referral, who you spoke to, and the accepting centre/consultant if a transfer is arranged.
2. What to Refer to Stroke Medicine
Urgent (time-critical) referrals:
• Suspected acute ischaemic stroke within the thrombolysis window (<4.5h) or thrombectomy window (up to 24h depending on imaging).
• Rapidly improving or fluctuating deficits (still discuss).
• Posterior circulation strokes (ataxia, diplopia, dysarthria, vertigo, collapse).
• Stroke on anticoagulation (requires discussion regarding reversal and imaging).
Non-urgent / secondary prevention referrals:
• TIA or minor stroke (>24h since onset, symptoms resolved).
• Stroke mimics requiring confirmation or exclusion.
• Cryptogenic stroke, PFO, or other complex aetiologies.
• Inpatient review for ongoing stroke management, swallow assessment, or rehab planning.
• Stroke units may not accept referrals for SDH/SAH
3. Information to have ready
• Patient identifiers and exact location.
• Time of onset/last known well.
• Presenting symptoms: weakness, speech, vision, coordination, sensory loss.
• Examination findings: limb strength, gaze, facial droop, speech, neglect, visual fields.
• Observations: BP, HR, O₂ sats, glucose, temp.
• Medication history: anticoagulants (name, dose, last taken), antiplatelets.
• Relevant PMH: previous stroke/TIA, AF, IHD, hypertension, diabetes.
• Imaging: CT/MRI head
• Bloods: INR, U&Es, FBC, glucose.
• Premorbid function: mobility, independence (mRS).
• Your specific question: e.g. “Eligible for thrombolysis?”, “Transfer for thrombectomy?”, “Admit for rehab or secondary prevention?”
Common scenarios
Acute stroke (<4.5h):
• LKW time.
• FAST/NIHSS findings.
• CT head result (ASAP).
• BP, glucose, INR.
• Anticoagulant/antiplatelet history.
• Family contact and consent if thrombolysis likely.
Extended window (6-24h) / thrombectomy candidate:
• Imaging results.
• Neurological deficit severity.
• Premorbid independence (mRS 0–2).
• Haemodynamic stability.
• Transfer logistics (ambulance availability).
TIA / minor stroke:
• Symptom description and timing.
• Duration (resolved or ongoing).
• PMH: AF, diabetes, hypertension.
• Medications (anticoagulant/antiplatelet use).
• ECG, FBC, U&Es, glucose.
• Suitable for TIA clinic referral if >24h since onset and stable.
Stroke on anticoagulation:
• Drug, dose, and last taken time.
• INR or renal function.
• CT result.
• Discussion re reversal or delay to thrombolysis.
Posterior circulation stroke:
• Dizziness, diplopia, dysarthria, ataxia, nausea/vomiting.
• Cranial nerve findings.
• Imaging findings.
• Vital signs, oxygenation.
5. Tips for Effective Stroke Referrals
• Always know and document LKW time, it determines treatment eligibility.
• Get CT head urgently (other imaging if indicated) before calling.
• Check anticoagulant use early and get INR or renal function.
• Don’t delay referral for mild or improving symptoms, still discuss with stroke team.
• Be clear about your aim: thrombolysis, thrombectomy, advice or admission.
• If non-HASU site, activate transfer protocol immediately for eligible patients. If not sure what this is, discuss with senior ASAP
• Record time of referral, who you spoke to, and their advice/plan.
• If transferred to HASU, ensure copies of imaging, bloods, and drug chart go with the patient.
With special thanks to Dr Shyamala Manibalan, former stroke SpR at Croydon University Hospital for her role in helping to draft the article
