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This is a clinician-written, evidence-based guide aligned to the MCC Examination Objectives. It is structured by clinical presentation — the way the MCCQE tests and the way patients actually present. Management reflects current Canadian guidelines (CMA, CFPC, CPS). Always cross-reference with institutional protocols and clinical judgment.
Key points
- Sudden unilateral weakness, facial droop or aphasia is stroke until proven otherwise.
- Establish last-known-well, baseline function, anticoagulant use, glucose and severity of disabling deficit immediately.
- First-line imaging is non-contrast CT head plus vascular imaging where acute ischemic stroke is suspected and EVT may be relevant.
- Hypoglycaemia, seizure/Todd paresis, migraine, Bell palsy and functional neurological disorder are common mimics but should not delay stroke activation.
- Canadian Stroke Best Practices emphasize rapid triage, acute imaging, reperfusion eligibility and secondary prevention.
Approach to the Presentation
The acute focal weakness presentation is time-critical. Use a stroke-first algorithm: ABCs, glucose, last-known-well, NIHSS-style deficit assessment, anticoagulants, blood pressure, CT/CTA and consultation with a stroke team. The MCCQE1 typically tests the next best step: do not wait for MRI or outpatient neurology when the patient is within a reperfusion window or has a disabling deficit.
Differential Diagnosis
| diagnosis | likelihood | key features | distinguishing test |
|---|---|---|---|
| Acute ischemic stroke | must-not-miss | Sudden negative neurological deficit: unilateral weakness, aphasia, neglect, visual field loss; vascular risk factors | Non-contrast CT to exclude haemorrhage plus CTA for large vessel occlusion |
| Intracerebral haemorrhage | must-not-miss | Focal deficit with headache, vomiting, severe hypertension, anticoagulation, reduced consciousness | Non-contrast CT head |
| TIA | must-not-miss | Transient focal deficit, often resolved by assessment; high early stroke risk | Urgent CT/CTA, ECG/rhythm monitoring, carotid imaging and secondary prevention |
| Hypoglycaemia | must-not-miss | Focal deficits or confusion in diabetic patient; sweating/tremor may be present | Point-of-care glucose and rapid reversal |
| Seizure with Todd paresis | common | Witnessed seizure, post-ictal confusion, focal weakness resolving over hours | History, glucose/electrolytes, EEG if unclear; imaging if first event |
| Bell palsy | common | Isolated LMN facial weakness including forehead; no limb weakness/aphasia | Clinical cranial nerve exam |
| Hemiplegic migraine | less common | Migraine aura with motor weakness evolving over minutes, headache history, younger patient | Clinical after stroke exclusion |
| Functional neurological disorder | less common | Incongruent exam, Hoover sign, variability; diagnosis should be positive not by exclusion alone | Neurological examination showing internal inconsistency after danger excluded |
| Brain tumour/subdural | less common | Progressive or fluctuating focal deficits, seizure, cancer history or trauma | CT/MRI brain |
Red Flags & Key History
Symptoms
Sudden onset unilateral weakness or aphasia
Last-known-well within reperfusion window
Severe headache/vomiting/reduced consciousness
Anticoagulant use
Symptoms resolved but were focal
Signs
Face-arm-leg weakness, pronator drift, aphasia or neglect
Visual field cut or gaze deviation
Blood glucose abnormality
Forehead-sparing facial weakness
Approach to Investigation
First-line
Stroke protocol: ABCs, vitals, glucose, last-known-wellDo in parallel with imaging activation.
Non-contrast CT headExclude haemorrhage before thrombolysis.
CTA head/neckDetect large vessel occlusion and carotid disease.
ECG and basic labsDo not delay imaging; identify AF, platelets, INR/anticoagulant issues and mimics.
Second-line
CT perfusion or MRIFor extended-window or wake-up stroke depending on local pathway.
Carotid ultrasoundFor TIA/non-disabling stroke when CTA not definitive or for surgical planning.
Telemetry/HolterDetect paroxysmal AF.
Specialist
Stroke team / telestrokeImmediate for reperfusion decisions.
NeurosurgeryHaemorrhage with mass effect or cerebellar haemorrhage.
Management Principles
Canadian Stroke Best Practice Recommendations — Acute Stroke Management1
Acute stroke activation
- Call stroke team/telestroke, determine last-known-well and pre-stroke function
- Keep NPO until swallow screen
- Treat hypoglycaemia and fever; avoid aggressive BP lowering unless required for reperfusion eligibility or severe hypertension
2
Reperfusion
- IV thrombolysis for eligible disabling ischemic stroke within accepted window after haemorrhage excluded
- Endovascular thrombectomy for eligible large vessel occlusion, including selected extended-window patients
3
TIA/non-disabling stroke
- Urgent imaging and secondary prevention; high-risk TIA is not a routine outpatient problem
- Antiplatelet therapy after haemorrhage excluded; anticoagulate AF when appropriate
4
Secondary prevention
- Antiplatelet/anticoagulation, statin, BP/diabetes/smoking management, carotid intervention where indicated, rehabilitation and driving/work counselling
Complications & Pitfalls
- Waiting for MRI: CT/CTA is the acute pathway.
- Forgetting glucose: hypoglycaemia can mimic stroke and is rapidly reversible.
- Ignoring resolved symptoms: TIA has high early stroke risk and needs urgent workup.
- Calling isolated facial droop Bell palsy too soon: forehead-sparing or associated neuro signs require stroke pathway.
MCCQE1 Exam Tips
- 1Last-known-well is the most important history item in acute stroke.
- 2CT before thrombolysis; do not give thrombolysis until haemorrhage is excluded.
- 3CTA matters because large vessel occlusion changes treatment to thrombectomy.
- 4Hypoglycaemia is the classic reversible stroke mimic.
- 5TIA gets urgent imaging and secondary prevention, not reassurance.
- 6Bell palsy affects the forehead; cortical stroke usually spares it.
Put your reading into practice
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