AcuteCare Telemedicine Blog


Recognizing the Symptoms of Stroke

While stroke awareness is a major concern for both men and women, a recent study concluded that women are less likely to recognize stroke symptoms. Only half of those surveyed know that sudden weakness or numbness on one side of the face, arms or legs is a warning sign of a stroke. 44 percent are aware that speech difficulty is a stroke sign while less than 1-in-4 could identify sudden severe headache, unexplained dizziness and sudden vision loss, or vision loss in one eye as the top symptoms of stroke. The study surveyed more than 1,200 women in the United States to assess their understanding of stroke’s warning signs.

The signs and symptoms of a stroke vary from person to person but usually begin suddenly. As different parts of the brain control different parts of the body, your symptoms depend upon the part of the brain affected and the extent of the damage.

The main stroke symptoms can be remembered with the word F.A.S.T.: Face-Arms-Speech-Time.

  • Face – the face may have dropped on one side, the person may not be able to smile or their mouth or eye may have drooped
  • Arms – the person with suspected stroke may not be able to lift one or both arms and keep them there because of arm weakness or numbness
  • Speech – speech may be slurred or garbled, or the person may not be able to talk at all despite appearing to be awake
  • Time – it is time to dial 911 immediately if any of these signs or symptoms at the earliest onset of these symptoms

For those living with or who care for somebody in a high-risk group, such as someone who is elderly or has diabetes or high blood pressure, being aware of the symptoms is even more important.

The acronym “FAST” is also meant to underscore the importance of rapidly delivering treatment to stroke patients. If given in time, a clot-busting drug administered during a stroke can lead to better outcomes and a decrease in the likelihood that a patient will suffer long-term disability. A recent study examined the effectiveness of tissue plasminogen activator (tPA) relative to the delay in administering this clot busting drug. Researchers found that every minute tPA was delayed cost nearly 2 days of disability free survival. The researchers commented that their message is literally “Save a Minute, Save a Day.”

Although many Americans live relatively close to a hospital where emergency stroke treatment is available, few actually receive the recommended therapies. Researchers found that only 4 percent of the more than 370,000 Medicare patients who suffered a stroke in 2011 were treated with tPA. Most stroke victims fail to recognize the symptoms of stroke or call 911 early enough to receive the necessary treatment. tPA is most effective when administered within a 4 hour window of time.

Every minute counts for stroke patients. Remember to act F.A.S.T.!



Stroke Mimics in the Emergency Setting

The role of the neurologist in treatment of acute stroke often focuses on the decision to use clot busting medication (tissue plasminogen activator; tPA), recommending care setting (e.g. ICU vs routine admission) based on patient deficits and prognosis, and of course, patient education in the midst of this emotionally charged experience. However, an often overlooked mandate for the neurologist is the proper recognition of stroke itself. Dr. J. Stephen Huff, Associate Professor of Neurology at the University of Virginia, provides a clear and comprehensive review of what are termed stroke “mimics” – disorders which may appear to be a stroke, but are not.

Stroke, broadly defined, is any prolonged disruption of focal neurologic function due to decreased blood flow from blood clotting in a specific region of brain. If that disruption is transient or intermittent it is typically referred to as a transient ischemic attack (TIA). If brain function is disrupted by a cause other than a blood clot, treatment with tPA may not only lack benefit but expose the patient to unnecessary harm. Recognition of “stroke syndromes” that result from specific artery involvement is the bread and butter of neurology. The abrupt onset of aphasia (language deficit) and right sided weakness almost certainly indicates a patient has blocked their left middle cerebral artery. Blocking this same artery on the right results in the classic presentation of left sided weakness and “neglect,” an inability to recognize one’s own physical deficits. In either case, the immediate administration of tPA can be life-saving.

Other disorders may cause brain dysfunction unrelated to a blood clot. This is the case in approximately 13-20% of patients presenting with presumed stroke. If the duration of symptoms is unclear, this number may even be as high as 30%. The most common mimic is seizure. Excessive electrical and chemical brain activity may result in focal weakness (Todd’s paralysis) and other deficits. If the seizure was not witnessed (especially in patients with previous stroke as the cause of seizures), excluding an acute stroke can be difficult. Focal neurologic injury from brain tumor, inflammation (e.g. multiple sclerosis), or even peripheral nerve palsy may be mistaken for stroke.

Stroke can be mimicked without direct injury to the brain. The most common mimic in this category is a complex migraine in which visual disturbance, weakness, numbness and even aphasia can occur. Hypoglycemia or, less often, hyperglycemia (low and high blood sugar) can cause general symptoms of lethargy or coma, but focal brain dysfunction (particularly weakness) often occurs and can outlast normalization of blood glucose. Finally, 30% of patients presenting with psychiatric causes of physical illness (i.e. conversion disorder) exhibit neurologic deficits, typically weakness.

Determining the cause of a patient’s deficits can sometimes be accomplished in an emergency setting through the use of CT imaging and appropriate diagnostic tests. Often the results of serial examinations, detailed history and, increasingly, advances in MR imaging can eventually lead to the correct diagnosis. However, certain diagnoses, notably migraine and conversion, are diagnoses of exclusion, so repeated events and extensive negative testing may be required for confirmation.

Among patients presenting with neurologic deficits, emergency department physicians correctly identify stroke before applying diagnostic studies in about 75% of cases. This means as many as 1 in 4 cases are incorrectly diagnosed. It is the role of stroke experts, like those of AcuteCare Telemedicine, to quickly and accurately determine the likely cause of neurologic deficits, the risks and benefits of multiple treatment options and convey a plan of action simply yet fully to the patient and loved ones. It is a difficult but rewarding task.