What are the signs of a Cerebrovascular Accident (CVA)?

Signs and Symptoms of Cerebrovascular Accident (CVA)

The most common signs of a cerebrovascular accident (stroke) include facial weakness, arm weakness, speech disturbance, balance/gait problems, and visual disturbances. These symptoms typically appear suddenly and require immediate medical attention to reduce mortality and improve outcomes.

Common Presentations of CVA

Motor and Sensory Signs

• Unilateral weakness (hemiparesis) affecting the face, arm, and/or leg is one of the most frequently recognized signs, present in up to 96% of stroke cases 1
• Numbness or sensory loss on one side of the body 2
• Facial drooping or asymmetry (present in approximately 70% of stroke patients) 1
• Leg weakness or gait disturbance (present in 42% of patients who don't exhibit the classic FAST symptoms) 3

Speech and Language Signs

• Speech disturbance (dysarthria or slurred speech) occurs in approximately 79% of stroke cases 1
• Aphasia (impaired language production or comprehension) 2
• Difficulty understanding others' speech 2

Visual Disturbances

• Visual field defects such as homonymous hemianopia (loss of vision in the same half of both eyes) 2
• Diplopia (double vision) 2
• Monocular blindness affecting one eye 2
• Visual symptoms occur in 40% of patients who don't show the classic FAST symptoms 3

Other Neurological Signs

• Hemispatial neglect (inability to respond to stimuli on one side) 2
• Ataxia (lack of coordination) 2
• Vertigo or dizziness 2
• Altered level of consciousness in severe cases, particularly with deep cerebral venous system involvement 2

Distinguishing Features by Stroke Type

Ischemic Stroke Signs

• Symptoms typically develop suddenly and may progress over minutes to hours 2
• Focal neurological deficits corresponding to the affected brain region 2
• Headache may be present but is less common than in hemorrhagic stroke 2
• Seizures occur in approximately 40% of patients with cerebral venous thrombosis 2

Hemorrhagic Stroke Signs

• Often presents with more severe headache that may have a thunderclap quality 2
• More likely to cause decreased level of consciousness 2
• Nausea and vomiting are more common 2
• May have signs of increased intracranial pressure such as papilledema 2

Timing and Progression

• Symptoms may be acute (onset <48 hours), subacute (48 hours to 30 days), or chronic (>30 days) 2
• In cerebral venous thrombosis, symptoms often progress more slowly than in arterial stroke, with a median delay from symptom onset to hospital admission of 4 days 2
• Transient ischemic attacks (TIAs) have the same symptoms as stroke but resolve within 24 hours (typically within 15 minutes) 2

BE-FAST Mnemonic for Stroke Recognition

The BE-FAST mnemonic helps identify stroke symptoms with greater sensitivity than the traditional FAST approach:

• Balance: Sudden loss of balance or coordination 3
• Eyes: Sudden visual changes, including blindness in one or both eyes 3
• Face: Facial drooping or asymmetry 3
• Arm: Arm weakness or inability to raise both arms equally 3
• Speech: Slurred speech or difficulty speaking 3
• Time: Time to call emergency services immediately 3

Adding balance and eye symptoms to the traditional FAST criteria reduces missed strokes from 14.1% to 4.4% 3.

Special Considerations

• Bilateral brain involvement may occur, particularly with cerebral venous thrombosis affecting the deep venous system, causing altered consciousness without focal signs 2
• Elderly patients (≥65 years) are less likely to recognize stroke symptoms than younger patients 4
• Symptoms may be masked in the periprocedural phase after cardiovascular interventions 2
• Stroke symptoms may differ based on which cerebral artery is affected (anterior vs. posterior circulation) 2

Clinical Implications

• Early recognition of stroke symptoms is critical as treatment efficacy diminishes with time 2
• Public education about stroke warning signs remains inadequate, with studies showing nearly 40% of stroke patients unable to identify a single stroke symptom 4
• Paramedic assessment using standardized tools like FAST shows good agreement with physician assessment, supporting the value of early recognition 1

Recognizing these signs promptly and seeking immediate medical attention is crucial for improving outcomes and reducing mortality in stroke patients.