We are amidst a paradigm shift in the emergency management of acute ischemic stroke. The traditional way of categorizing ischemic strokes as 'minor' vs 'major' is no longer relevant to what we do in the ED. It's now about 'disabling' vs 'non-disabling' strokes. And this is no small change. This categorization dictates urgency of ED work-up and treatments, imaging choices, treatment decisions and goals of care. In this Part 1 or our 2-part main episodes EM Cases podcast series on management of ischemic stroke with Dr. Walter Himmel and Dr. Katie Lin, we answer questions like: How can we best rapidly determine if an ischemic stroke is disabling or non-disabling at the bedside? In what ways are 'wake up strokes' managed uniquely and what's the latest thinking on their pathophysiology? How should we best prioritize imaging depending on timing, geography and resources? How do we best predict large vessel occlusion amenable to endovascular therapy (EVT) at the bedside? How can we efficiently establish goals of care at the bedside to inform our emergency decision making around strokes? Which is better for thrombolysis in ischemic stroke - Tenecteplase or Alteplase? How have contraindications to IV thrombolysis changed over the last decade? When should we consider bridge therapy with EVT after IV thrombolysis? What are 4 key items the ED physician should have ready for the stroke neurologist on the first call? and many more...



Podcast production, sound design & editing by Anton Helman; Voice editing by Braedon Paul

Written Summary and blog post by Anton Helman October, 2025

Cite this podcast as: Helman, A. Himmel, W. Lin, K. A Paradigm Shift in Ischemic Stroke Management Part 1: Disabling Strokes. Emergency Medicine Cases. October, 2025. https://emergencymedicinecases.com/ischemic-stroke-management-disabling-strokes. Accessed October 28, 2025

Résumés EM CasesMajor vs Minor Stroke - An impractical categorization of stroke

The historical “major (NIHSS ≥5) vs minor (NIHSS  <5)” dichotomy is convenient for research stratification but problematic clinically: so-called “minor” presentations (e.g., isolated aphasia, dense hemianopia, disabling distal limb weakness of the dominant hand) frequently carry marked functional morbidity and should not be excluded from reperfusion solely on the basis of a low NIHSS. The contemporary approach reframes categorization around disability and patient-centred outcomes rather than an arbitrary score threshold.

NIHSS is a descriptor, not a decision tool. A low score can still be functionally catastrophic and should not exclude reperfusion.

Pitfall: One pitfall in the decision to employ IV thrombolytics and/or endovascular therapy (EVT) is to assume that a minor stroke (NIHSS <5) is not eligible for such therapies. Many patients who have an NIHSS <5 have disabling stroke that do fulfill criteria for these aggressive, time dependent therapies.

Disabling vs Non-disabling - The practical categorization of ischemic stroke

Reframe the first decision point as disabling vs non-disabling. A structured conversation around values helps determine whether a deficit is “disabling” for this patient. At the bedside, determine whether the deficit is disabling for this patient—i.e., likely to compromise independent living, employment, or meaningful communication. Cortical signs (aphasia/dysphasia, neglect, gaze deviation,