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Acute Stroke (Sudden Stroke) Signs & Symptoms

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When blood flow becomes abnormal to the point that flow to the brain is interrupted, this event is what leads to a stroke. There are two known variations of a stroke: ischemic and hemorrhagic. In the case of ischemic stroke, a clot forms in one of the brain’s blood vessels, blocking the flow through the vessel. In a hemorrhagic stroke, a blood vessel in the brain erupts and spews out blood into the brain tissue. Ischemic and hemorrhagic stroke account for 87% and 13% of total incidents, respectively. Generally, the symptoms of both types of strokes are similar. It is the treatments that are different from each other.

Symptoms of Stroke

  • Sudden weakness in the leg, face, arm
  • Problems with vision
  • Confusion
  • Vomiting or nausea
  • Trouble forming words with communication
  • Locomotive problems such as inability to walk properly

• Use 100% oxygen initially; titrate when possible


• Check glucose; hypoglycemia can mimic acute stroke


• Determine precise time of symptom onset from patient and witnesses


• Determine patient deficits (gross motor, gross sensory, cranial nerves)


• Institute seizure precautions

IV Access

• Large gauge IV in antecubital fossa

Notify Hospital

• Take to stroke center if possible

Figure 43

Within 10 minutes of arrival, a collective team of physicians and other experts should immediately assess the patient with suspected stroke at the emergency department (ED).
Within 25 minutes, the CT scan should be completed and should be assessed within the patient’s first 45 minutes in the hospital.

The region of the brain that is affected by the stroke determines the clinical signs, due to the decreased or blocked blood flow in certain areas. Certain symptoms may include having difficulty walking and with balance; a loss of vision; slurred and broken speech; facial droop; severe change of consciousness; headaches and vomiting; and numbness or weakness in the leg, arm, or face. The symptoms that may show depend entirely on the affected cerebral artery; not all symptoms may be found to be present.

In diagnosing whether or not a stroke is present in a patient, the Cincinnati Prehospital Stroke Scale (CPSS) is used if certain physical findings are seen, such as broken and abnormal speech, arm drift, or facial droop. There is a 72% probability of an ischemic stroke present in a patient that is displaying even one of these three findings. The probability of an acute stroke rises to more than 85% if all three findings are observed. It is recommended to become proficient with the tool, FAST, used by the rescuers’ EMS system. The usage and training of these screening tools can be facilitated by practice and mock scenarios.

FAST: Face Drooping, Arm Weakness, Speech, and Time Symptoms Started

Aspirin should be administered to patients with ischemic stroke who are not candidates for fibrinolytic therapy unless they have an allergy to aspirin. The Neurologic Intensive Care Unit must accept all stroke patients if possible. Proper stroke treatment includes a variety of services, including blood glucose monitoring, body temperature, airway support as needed, physical/occupational/speech therapy evaluation, regular neurological checks, precaution training for seizures, and blood pressure observation and regulation as per protocol. Signs of bleeding or hemorrhage must be anticipated in patients who have received fibrinolytic therapy. Up to 4.5 hours after the onset of certain symptoms, some patients (mostly those between the ages of 18 and 79 with just mild or moderate strokes) may be administered tPA (tissue plasminogen activator). However, not knowing the exact time of the symptoms’ onset can automatically disqualify a patient for tPA. If time of symptom onset is known, there are certain time goals established by the National Institute of Neurological Disorders and Strokes (NINDS).

10 Minutes of Arrival
  • The expert’s general assessment should be conducted
  • An urgent CT scan without contrast must be ordered
25 Minutes of Arrival
  • Perform CT scan without contrast
  • Neurological assessment
  • Within 45 minutes, CT scan must be read
60 Minutes of Arrival
  • Evaluate criteria, and apply fibrinolytic therapy or clot buster
  • Within 3 to 4.5 hours in some cases of symptom onset, use fibrinolytic therapy
180 Minutes of Arrival
  • Admission to stroke unit

Figure 44

Take Note
  • A bedside swallow screening is required before anything is swallowed, whether food or medication. Upon admission, all acute stroke individuals are automatically considered NPO.
  • Patients with suspected strokes must be assessed within 10 minutes of arrival in the emergency department by the stroke team and other experts.
  • Within 25 minutes, the CT scan must be completed, and within 45 minutes it must be read.

Emergency Department Staff

Complete EMS Care Targeted Stroke Evaluation Establish Symptom Onset Time CT Scan of Brain Stat Obtain 12-Lead ECG Check Glucose and Lipids Contact Stroke Team


Confirm time of symptom onset
Perform targeted neurological exam
(NIH Stroke Scale)
Complete fibrinolytic checklist


Consult Neurosurgery
Coagulation panel, type, and screen
ACLS Acute Stroke Emergency Department Exclusions/Criteria

Figure 45

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