Warning Signs of Stroke
The warning signs of stroke include sudden weakness or numbness of the face, arm, or leg (especially on one side of the body), sudden confusion or trouble speaking/understanding, sudden trouble seeing in one or both eyes, sudden trouble walking or loss of balance/coordination, and sudden severe headache with no known cause. 1
Primary Warning Signs
The American Heart Association identifies these cardinal warning signs that require immediate recognition 1:
- Sudden weakness or numbness affecting the face, arm, or leg, particularly when occurring on one side of the body 1
- Sudden confusion or difficulty speaking or understanding speech 1
- Sudden visual disturbances including trouble seeing in one or both eyes 1
- Sudden difficulty walking, dizziness, or loss of balance and coordination 1
- Sudden severe headache with no identifiable cause 1
Rapid Assessment Tools
The Cincinnati Prehospital Stroke Scale (CPSS) provides a practical bedside assessment checking three key findings: facial droop, arm drift, and abnormal speech, with a single abnormality conferring a 72% probability of stroke 2. This tool is specifically designed for rapid identification by both healthcare providers and the public 1.
The more comprehensive National Institutes of Health Stroke Scale (NIHSS) assesses 11 domains including level of consciousness, gaze, visual fields, facial palsy, motor function in arms and legs, limb ataxia, sensory function, language/aphasia, dysarthria, and extinction/inattention 2.
High-Risk Populations Requiring Enhanced Vigilance
Adults over 55 years with specific risk factors warrant particular attention 1:
- Hypertension is the single most important modifiable risk factor for stroke 3
- Diabetes mellitus more than doubles stroke risk and increases risk by 3% per year of disease duration 1
- Cardiovascular disease including coronary artery disease, atrial fibrillation, and heart failure significantly elevates stroke risk 1
- Hyperlipidemia particularly elevated LDL cholesterol and low HDL cholesterol 1
Critical Action Required
When stroke warning signs appear, the immediate action is to call 911—not to wait, not to call a primary care physician, but to activate emergency medical services immediately 1. Educational efforts must couple knowledge of warning signs with this specific action, as most strokes occur at home and delays in EMS access directly increase morbidity and mortality 1.
Important Caveats for Healthcare Providers
Establishing the exact time of symptom onset is critical because it determines eligibility for IV tPA (within 4.5 hours) or endovascular thrombectomy (up to 24 hours for select patients) 3, 2. If the patient woke with symptoms, the "last known well" time is when they went to sleep, not when they woke 2.
Do not delay care to obtain extensive vascular imaging—non-contrast CT is sufficient to initiate thrombolysis 3. Every minute of delay worsens outcomes 3.
Avoid treating hypertension aggressively in acute stroke unless BP exceeds 185/110 mmHg for tPA candidates or 220/120 mmHg otherwise, as cerebral perfusion depends on elevated blood pressure 3.
Knowledge Gaps in At-Risk Populations
Research demonstrates concerning deficits in stroke awareness 1, 4, 5:
- Approximately 40% of patients presenting with stroke symptoms could not identify a single warning sign 5
- Elderly patients (≥65 years) have significantly less knowledge than younger patients, with 47% unable to name a single sign or symptom compared to 28% of those under 65 5
- Only 57% of patients with hypertension recognized they were at increased stroke risk 1
- Knowledge of risk factors is even more limited than knowledge of warning signs 4, 6
This knowledge deficit is particularly problematic because the elderly face the highest stroke risk yet demonstrate the poorest recognition of warning signs 1, 5. Targeted education for older adults and those with multiple vascular risk factors is essential 1.