Symptoms That Prompt a Clinician to Call a Stroke Code
A clinician should call a stroke code when a patient presents with sudden onset of one or more of the following symptoms: facial drooping, arm weakness, speech difficulty, visual disturbances, dizziness/loss of balance, or sudden severe headache with no known cause. 1
Key Stroke Symptoms That Warrant Immediate Action
Primary Stroke Symptoms (FAST)
- Face: Sudden facial drooping or asymmetry, especially on one side 1
- Arm: Sudden unilateral weakness or numbness in the arm or leg 1
- Speech: Sudden speech disturbance, including:
- Slurred speech
- Inability to speak (global aphasia)
- Difficulty understanding speech 1
- Time: Recognition that time is critical 2
Additional Critical Symptoms
- Visual changes: Sudden trouble seeing in one or both eyes 1
- Balance/Coordination: Sudden dizziness, loss of balance or coordination 1
- Headache: Sudden severe headache with no known cause 1
- Confusion/Decreased consciousness: Altered mental status 3
Stroke Assessment Tools
The Cincinnati Prehospital Stroke Scale is a validated tool for stroke assessment:
| Assessment | Normal | Abnormal |
|---|---|---|
| Facial droop | Both sides move equally | One side doesn't move as well |
| Arm drift | Both arms move the same | One arm drifts down |
| Speech | Clear, appropriate speech | Slurred words, wrong words, or unable to speak |
Interpretation: If any 1 of these 3 signs is abnormal, the probability of stroke is 72%. 1
Public vs. Clinical Recognition Patterns
Research shows significant differences in which symptoms prompt emergency action:
- Speech disturbance (80%) and falling down (40%) are the most commonly reported symptoms in emergency calls 4
- The public is more likely to call 911 for weakness, confusion/decreased level of consciousness, and speech/language symptoms 3
- The public is less likely to call 911 for numbness or visual changes, despite their clinical significance 3, 5
Clinical Decision Algorithm
- Immediate assessment when any stroke symptom is observed
- Use standardized stroke scale (Cincinnati Prehospital Stroke Scale or NIHSS)
- Determine time of symptom onset - critical for treatment decisions 1, 2
- Activate stroke code if any positive findings on stroke scale
- Prioritize rapid imaging - CT or MRI to rule out hemorrhage 2
Risk Stratification
Patients presenting within 48 hours of symptom onset are at highest risk for recurrent stroke and require immediate evaluation 1, 2. This is especially true for:
- Unilateral weakness (face, arm, leg)
- Speech disturbance
- Visual field defects
Common Pitfalls to Avoid
- Delay in recognition: Failing to recognize less obvious stroke symptoms like isolated visual changes or dizziness 5
- Misattribution: Attributing symptoms to other conditions, especially in "stroke chameleons" where presentation suggests another disorder 6
- Inadequate history: Not establishing precise time of symptom onset, which is critical for treatment decisions 1
- Failure to prioritize: Not treating stroke as a true emergency requiring immediate action 2
- Incomplete assessment: Not performing a complete neurological examination to detect subtle cortical signs 4
Remember that "time is brain" - every minute delay in stroke treatment results in the loss of approximately 1.9 million neurons. Prompt recognition and activation of the stroke code is essential for improving outcomes and reducing mortality and long-term disability 1.