Let's be honest — stroke questions make a lot of FRCEM candidates nervous. There's so much to know: time windows, imaging criteria, risk scores, antiplatelet regimens. It feels overwhelming.
But here's the thing: 6–8 stroke and TIA questions appear in every sitting, and they follow predictable patterns. Once you know those patterns — and the clinical decision points that actually get tested — these become some of the most reliable marks in the exam.
This guide walks you through exactly what FRCEM tests on stroke and TIA, updated to reflect the latest UK National Clinical Guideline for Stroke. There are some significant changes from older resources, including one that will catch out anyone who hasn't revised recently: ABCD2 scoring has been abandoned. More on that shortly.
First: The Definitions FRCEM Actually Tests
Before anything else, nail these two definitions — because FRCEM deliberately tests the updated version.
Stroke: A neurological deficit lasting >24 hours, OR infarction confirmed on imaging — regardless of how long symptoms lasted.
TIA: Symptoms resolve completely within 24 hours with no infarction on imaging.
The twist? If a patient's symptoms have fully resolved but imaging shows a fresh infarct, that's still classified as a stroke, not a TIA. This tissue-based definition is specifically what examiners test. Don't get caught calling it a TIA just because the patient is back to normal clinically.
⚠️ ABCD2 Score: What You Need to Know (and Unlearn)
If you've been revising from older resources or question banks, you've probably been taught to calculate an ABCD2 score for every TIA and use it to decide on referral timing. Score ≥4 = see within 24 hours. Score <4 = see within a week.
That guidance has been withdrawn.
The latest UK National Clinical Guideline for Stroke and NICE guidance now explicitly state: do not use scoring systems such as ABCD2 to assess risk of subsequent stroke, inform urgency of referral, or guide treatment decisions.
Why was it dropped? Because the evidence showed it simply didn't work well enough. Around 20% of high-risk patients — particularly those with AF or significant carotid stenosis — scored low on ABCD2 and would have been triaged into the slower-track group. That's dangerous.
What replaced it: All patients with a suspected TIA should be referred immediately for specialist assessment, with MRI (preferred over CT) within 24 hours. Urgency is now based on clinical judgement and imaging, not a number.
High-risk features that warrant immediate specialist input:
Unilateral weakness or speech disturbance lasting >5 minutes
Crescendo TIA (recurrent episodes over hours or days)
Suspected large artery disease — ipsilateral carotid stenosis, intracranial stenosis
Likely cardioembolic source (e.g. known AF)
NIHSS 0–3 with infarction visible on DWI
For the exam: Some older question banks still include ABCD2 scenarios. Know the scoring system exists, understand why it was abandoned, and know that the correct current answer for any TIA is: immediate specialist referral, not score-based triage.
This connects directly to the broader FRCEM SLO 1 preparation approach — guidelines update, and the exam reflects current practice.
SBA Case Pattern #1: TIA — Admit or Refer?
This is the bread-and-butter TIA question FRCEM uses. The scenario describes a patient whose symptoms have resolved, and the question asks what you do next.
Admit immediately if:
Symptoms are still ongoing or fluctuating
Crescendo TIA (multiple episodes)
AF identified — anticoagulation decision needed urgently
Suspected large vessel disease requiring intervention
High clinical suspicion of ongoing ischaemia
For most resolved single-episode TIA → urgent specialist referral, same day, with MRI within 24 hours.
Worked Example
68-year-old, 45-minute episode of right arm weakness now fully resolved. BP 155/90, known diabetic, no AF, no carotid bruit.
The answer is: immediate referral to TIA clinic for same-day specialist assessment and MRI. Don't calculate ABCD2. Don't discharge home without arranging review. Don't admit unless there are high-risk features listed above.
The exam often presents a similar scenario with multiple choice options that include "calculate ABCD2 and triage accordingly." In the context of current guidelines, that answer is wrong.
SBA Case Pattern #2: Thrombolysis Eligibility
This is the most commonly tested stroke scenario — and it's worth knowing in detail, because the contraindication questions are very specific.
The Standard Window
Thrombolysis should be considered in patients with acute ischaemic stroke when treatment can be started within 4.5 hours of known onset, CT has excluded haemorrhage, and there are no absolute contraindications.
Crucially, the latest guideline removed previous restrictions: thrombolysis should now be considered regardless of age or stroke severity. An 85-year-old with severe stroke is still a candidate. Don't let exam scenarios trick you into excluding patients on age alone.
Thrombolytic agent: Either alteplase or tenecteplase (0.25 mg/kg as a single IV bolus). Tenecteplase is now recognised as equivalent in efficacy and safety and is increasingly preferred in clinical practice due to simpler administration — know it exists.
The Extended Window (Updated — High Yield)
Patients who were last known well more than 4.5 hours ago — including wake-up strokes — can still receive thrombolysis with alteplase if:
Treatment can start between 4.5–9 hours of known onset, OR within 9 hours of the midpoint of sleep for wake-up strokes
AND imaging shows salvageable brain tissue: CT/MR perfusion mismatch or MRI DWI-FLAIR mismatch
The wake-up stroke scenario is a favourite. Work out the sleep midpoint, check it falls within 9 hours, confirm imaging mismatch — eligible.
Absolute Contraindications FRCEM Tests Directly
Intracranial haemorrhage on CT
BP >185/110 mmHg despite treatment — must be lowered first
Blood glucose <2.8 or >22 mmol/L
Active major bleeding
Recent intracranial surgery (<3 months)
Seizure at stroke onset (if presenting as a mimic)
DOAC anticoagulation — exclude unless both PT and aPTT are normal
Previous ischaemic stroke is NOT a contraindication. This catches people out every time.
Worked Example #1
72-year-old, 3 hours after onset of left hemiparesis. CT: no haemorrhage. BP 192/102. Previous ischaemic stroke 2 years ago.
Eligible — but BP must be lowered to <185/110 first. Previous ischaemic stroke is irrelevant. Treat BP, then give thrombolysis.
Worked Example #2
Patient woke at 7am with right-sided weakness. Last seen well at 11pm the previous night. MRI shows DWI-FLAIR mismatch.
Sleep midpoint: approximately 3am. Nine hours from 3am = 12pm. If the patient is assessed before midday, they fall within the window. DWI-FLAIR mismatch confirms salvageable tissue. Eligible for thrombolysis — this is the updated wake-up stroke pathway.
SBA Case Pattern #3: Blood Pressure in Acute Stroke
FRCEM tests this principle repeatedly because the instinct is always to treat a high BP. Resist it.
Situation | Action |
|---|---|
Ischaemic stroke, BP <220/120, no thrombolysis planned | Do NOT treat |
Ischaemic stroke, BP ≥220/120 | Consider cautious lowering |
Before thrombolysis, BP >185/110 | Must lower to <185/110 first |
Haemorrhagic stroke | Target systolic <140 mmHg |
Why? The ischaemic penumbra — the at-risk brain tissue surrounding the infarct core — survives on collateral circulation driven by systemic BP. Drop the BP and you may extend the infarct.
Worked Example
Acute ischaemic stroke, BP 198/102, no thrombolysis planned.
Answer: monitor BP, give no antihypertensives. BP below 220/120 with no thrombolysis planned does not require acute treatment.
The classic FRCEM trap is offering a BP of 190/95 and listing antihypertensives as one of the options. The correct answer is to observe.
NIHSS: What You Actually Need to Know
FRCEM doesn't ask you to calculate NIHSS component by component under exam conditions. What it tests is your understanding of what the score means and how it guides management.
The scale runs 0–42. Higher = worse.
Score | Severity |
|---|---|
0 | No deficit |
1–4 | Minor stroke |
5–15 | Moderate stroke |
16–20 | Moderate-severe |
21–42 | Severe stroke |
The components cover: consciousness, gaze, visual fields, facial palsy, motor arms and legs, limb ataxia, sensation, language, speech, and extinction/neglect. Know they exist — you won't be asked to score each one.
How FRCEM uses NIHSS in questions:
A patient with NIHSS 22 → severe stroke. A patient with NIHSS 3 → minor stroke, consider DAPT rather than reflexively thrombolysing. Serial scores that rise during treatment → suspect haemorrhagic transformation or re-occlusion. Serial scores that improve → treatment working. That's the level of knowledge you need.
The "minor stroke" threshold of NIHSS 0–3 also appears in antiplatelet guidance — which brings us to the next major update.
SBA Case Pattern #4: Antiplatelet Therapy — Updated Guidance
This is one of the biggest clinical changes in recent guidelines, and many question banks haven't caught up yet.
Aspirin monotherapy alone is no longer the default for TIA or minor stroke.
TIA and Minor Stroke (NIHSS 0–3) — DAPT Now Recommended
For patients presenting within 24 hours of TIA or minor ischaemic stroke, the latest National Clinical Guideline for Stroke recommends considering dual antiplatelet therapy (DAPT):
Aspirin + clopidogrel (clopidogrel loading dose 300 mg, then 75 mg daily) for 21 days, then long-term clopidogrel monotherapy — this is the preferred regimen
Aspirin + ticagrelor for 30 days — an alternative, particularly where clopidogrel resistance is suspected
Both options are given after CT excludes haemorrhage. Do not wait for MRI before starting.
Moderate/Severe Ischaemic Stroke
Aspirin 300 mg within 24 hours of confirmed ischaemic stroke (post-CT). Continue for 2 weeks, then switch to clopidogrel monotherapy for long-term secondary prevention.
If thrombolysed: Give aspirin 300 mg 24 hours after thrombolysis, once repeat CT confirms no haemorrhagic transformation. Never give antiplatelets before CT.
Long-Term Secondary Prevention
Clopidogrel 75 mg daily is now the preferred long-term antiplatelet — not aspirin alone
High-intensity statin for all ischaemic stroke and TIA
DOAC (not warfarin as first choice) for AF-related stroke — start within 5 days for mild stroke
Worked Example
TIA confirmed, CT excludes haemorrhage, patient presents 6 hours after onset.
Answer: Aspirin + clopidogrel (DAPT) — clopidogrel 300 mg loading dose then 75 mg daily, aspirin 75–300 mg, for 21 days. Then clopidogrel monotherapy.
The old answer of "aspirin 300 mg" alone would now be incorrect for TIA in current guidelines.
SBA Case Pattern #5: Posterior Circulation Stroke
Posterior stroke is a high-yield scenario because it looks nothing like the classic anterior stroke. FRCEM presents it specifically to test whether you miss it.
Classic features — the "3 Ds" of posterior stroke:
Dizziness/Vertigo (sudden, not positional)
Diplopia
Dysarthria
Plus ataxia, nystagmus, and crossed signs (ipsilateral facial signs with contralateral body deficit — a hallmark of lateral medullary syndrome).
How to distinguish from benign vestibular vertigo:
Sudden onset (not triggered by position change)
Age >50 with vascular risk factors (hypertension, diabetes, smoking, AF)
Cannot stand or walk — truncal ataxia
Any additional cranial nerve or cerebellar signs
Headache, especially occipital
Worked Example
70-year-old, sudden onset severe vertigo, nystagmus, left-sided ataxia, cannot walk. BP 168/95.
Answer: Posterior circulation stroke until proven otherwise. CT brain immediately, stroke team activation. Do not give vestibular suppressants. Do not discharge with a vestibular diagnosis.
If you're preparing for the breadth of FRCEM cardiology and neurology scenarios, the ECG and ACS guide covers similar high-yield pattern recognition.
SBA Case Pattern #6: Stroke Mimics
FRCEM uses mimics to test one principle: investigate appropriately even when you suspect a non-stroke diagnosis. Never withhold CT based on clinical suspicion alone.
Mimic | Key clue | Management |
|---|---|---|
Hypoglycaemia | Diabetic patient, any age | Check BM first — focal deficit reverses with glucose correction |
Todd's paresis | Post-ictal, witnessed seizure | Resolves over hours; tongue bite/incontinence clue |
Hemiplegic migraine | Young patient, known migraines, prominent headache | Stroke protocol still required; exclude with CT/MRI |
Functional neurological disorder | Inconsistent signs, younger patient | Positive signs (Hoover's, give-way) but still investigate |
Check glucose in every single suspected stroke — this is a FRCEM exam point as much as a clinical one.
Worked Example
25-year-old, right hemiparesis, severe headache, known migraines. CT normal.
Answer: Likely hemiplegic migraine — but CT was still appropriate. MRI may be needed to fully exclude ischaemia. Do not diagnose migraine clinically without appropriate imaging in this presentation.
SBA Case Pattern #7: Mechanical Thrombectomy
The thrombectomy window is much longer than thrombolysis — and FRCEM tests it.
For large vessel occlusion (LVO) confirmed on CT angiogram:
Within 6 hours of onset: all eligible patients
6–24 hours: selected patients with imaging-confirmed salvageable tissue (CT perfusion or MRI mismatch)
If the patient is eligible for both thrombolysis and thrombectomy: give IV thrombolysis first, as rapidly as possible, then proceed to thrombectomy. Never delay thrombolysis to wait for thrombectomy.
Worked Example
Ischaemic stroke, onset 5 hours ago, large MCA occlusion on CTA. Within thrombolysis window.
Answer: Give IV thrombolysis immediately (alteplase or tenecteplase), then proceed directly to mechanical thrombectomy. Both should happen — not one or the other.
For the resuscitation and time-critical management framework that underpins stroke care in the ED, the FRCEM SLO 3 resuscitation guide is worth reviewing alongside this.
Common FRCEM Mistakes — Ranked by How Often They Appear
1. Using ABCD2 to triage TIA — withdrawn. All suspected TIA = immediate specialist referral.
2. Aspirin monotherapy for TIA — current guidance is DAPT (aspirin + clopidogrel) for 21 days for TIA and minor stroke presenting within 24 hours.
3. Lowering BP routinely in ischaemic stroke — only lower if >220/120 (no thrombolysis) or >185/110 (before thrombolysis).
4. Giving aspirin before CT — always exclude haemorrhage first.
5. Excluding older patients from thrombolysis — latest guideline: no age restriction.
6. Dismissing wake-up stroke — 4.5–9 hour window applies if imaging shows salvageable tissue.
7. Missing posterior circulation stroke — sudden vertigo + neurological signs = stroke until proven otherwise.
Practice SBA Questions
Case 1: A 60-year-old man presents to the ED with right arm weakness that started 90 minutes ago but has now completely resolved. His neurological exam is normal. BP is 158/92, and ECG shows sinus rhythm.
Question: What is the most appropriate immediate management plan?
Answer: Immediate referral for same-day specialist assessment and an MRI head within 24 hours. Under current guidelines, you do not use the ABCD2 score, nor do you admit him since he lacks high-risk ongoing features.
Case 2: A 68-year-old woman presents with sudden onset left-sided hemiparesis. She was last seen well 3.5 hours ago. CT excludes haemorrhage. BP is 188/104 mmHg. She had an ischaemic stroke 2 years ago.
Question: What must be done before administering IV thrombolysis?
Answer: Her blood pressure must be safely lowered to <185/110 mmHg. She is eligible for thrombolysis (a previous stroke is not a contraindication), but severe hypertension is an absolute contraindication until corrected.
Case 3: A 72-year-old man wakes up at 07:00 with right-sided weakness. He went to sleep perfectly well at 23:00. An urgent MRI head demonstrates a clear DWI-FLAIR mismatch.
Question: Is this patient eligible for IV thrombolysis?
Answer: Yes. The sleep midpoint is roughly 03:00. Because imaging confirms salvageable tissue (mismatch) and he can be treated within 9 hours of that midpoint, he is eligible under the extended wake-up stroke guidelines.
Case 4: A 55-year-old woman is diagnosed with a TIA after a 2-hour episode of aphasia that has now resolved. Symptom onset was 8 hours ago. CT head is normal.
Question: What is the most appropriate initial antiplatelet therapy?
Answer: Dual Antiplatelet Therapy (DAPT). Current guidelines recommend a loading dose of Clopidogrel 300mg plus Aspirin, continued for 21 days before stepping down to Clopidogrel monotherapy. Aspirin monotherapy is no longer the standard.
Case 5: A 78-year-old man presents with an acute ischaemic stroke 8 hours after onset. Imaging shows no salvageable tissue. His blood pressure is 205/108 mmHg.
Question: How should his blood pressure be managed in the ED?
Answer: Observe only. In acute ischaemic stroke where thrombolysis is not planned, blood pressure should not be routinely lowered unless it exceeds 220/120 mmHg, to maintain perfusion to the ischaemic penumbra.
Frequently Asked Questions
Do I still need to know ABCD2 scoring for FRCEM?
Know that it exists and understand its components — some older questions still use it. But know that current UK guidance does not recommend it, and the correct answer for TIA management is now immediate specialist referral regardless of any score.
Is tenecteplase tested in detail?
Awareness that it's now an alternative to alteplase is sufficient. Know it exists and is given as a single IV bolus — you won't be asked for exact dosing.
Are wake-up strokes always eligible?
No. Eligibility requires imaging evidence of salvageable tissue (DWI-FLAIR mismatch or CT perfusion mismatch). Wake-up time alone is not enough.
How many stroke/TIA questions appear in FRCEM?
6–8 across the 180-question SBA paper, primarily in SLO 1. Consistent preparation on the patterns above covers the majority of them.
Stroke and TIA questions reward preparation. The patterns are consistent, the decision points are predictable, and the guidelines — though updated — follow logical clinical principles once you understand them.
The most important updates to lock in: ABCD2 is gone, DAPT replaces aspirin monotherapy for TIA and minor stroke, thrombolysis has no age restriction, and the wake-up stroke window now extends to 9 hours from sleep midpoint with imaging support.
Get these right, and 6–8 marks become a reliable part of your SBA strategy.
Want to practise these scenarios in the real exam format? Register with StudyFRCEM to access our full FRCEM SBA Question Bank. You'll get comprehensive, SLO-mapped Stroke & TIA cases, detailed explanations covering the newest 2023/2024 guidelines, and personalized performance tracking to ensure you are exam-ready.
Guidelines referenced:
National Clinical Guideline for Stroke (latest edition) — strokeguideline.org
NICE NG128: Stroke and TIA in over 16s (latest update) — nice.org.uk
