For a patient who wakes with symptoms or is found unwell, the time of onset is the last moment they were known to be at their baseline — often when they went to bed. Recording it precisely, along with the name of the witness, is the single most useful thing a first clinician can do for the stroke team.
Large-vessel occlusion is suggested by cortical signs such as gaze deviation, aphasia or neglect, alongside weakness. Even a low NIHSS score does not exclude it.
- Record the exact time the patient was last seen at baseline, and who saw them.
- Wake-up and unwitnessed strokes start from last known well, not from discovery.
- Look for gaze deviation, aphasia or neglect as clues to large-vessel occlusion.
- A low NIHSS score does not exclude large-vessel occlusion; ask for vessel imaging.
Why it matters
Treatment windows are widening, and every eligibility decision starts from that one time.
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