What are the signs and symptoms of a stroke?

Signs and Symptoms of Stroke

Stroke presents with sudden onset of focal neurologic deficits, most commonly unilateral weakness (face, arm, and/or leg) and speech disturbance, which together account for 88% of all stroke presentations. 1

Cardinal Warning Signs

The hallmark of stroke is the abrupt onset or awakening with focal neurologic deficits that are sudden, persistent, and never experienced before. 2, 3

Most Common Presentations

• Unilateral weakness or paralysis affecting the face, arm, and/or leg on one side of the body 1, 2
• Speech disturbance or aphasia, including difficulty speaking or understanding language 1, 2
• Facial droop with sagging of one side of the face 1, 4

Additional Neurologic Symptoms

• Numbness or tingling on one side of the body (hemibody sensory symptoms) 1, 4
• Visual disturbances including:
  • Monocular vision loss (one eye) 1
  • Binocular diplopia (double vision) 1, 4
  • Hemifield vision loss (half of visual field) 1
  • Blurred vision 4
• Ataxia or trouble walking with loss of balance and coordination 1, 4
• Vertigo or dizziness 1, 4
• Sudden severe headache with no known cause 1, 4
• Confusion or altered mental status 1

The FAST Recognition Tool

The American Heart Association promotes the FAST mnemonic for rapid stroke recognition, which captures symptoms present in 88% of all strokes: 1

• Face weakness
• Arm weakness
• Speech difficulty
• Time to call 9-1-1

Risk Stratification by Symptom Pattern

Highest Risk Symptoms (Require Emergency Evaluation Within 24 Hours)

Patients with unilateral motor weakness (face, arm, and/or leg) OR speech disturbance/aphasia are at highest risk for stroke and require immediate emergency department evaluation. 1, 5

Moderate Risk Symptoms

Patients presenting with symptoms without motor weakness or speech disturbance—such as isolated hemibody sensory symptoms, monocular vision loss, diplopia, hemifield vision loss, or ataxia—are at increased but lower risk. 1

Critical Timing Considerations

The sudden onset is key—all stroke symptoms are perceived as sudden, persistent, and never experienced before. 3 This distinguishes stroke from gradual onset conditions.

• Symptoms starting within 48 hours place patients at very high risk requiring immediate ED transfer with advanced stroke capabilities 1, 5
• Symptoms between 48 hours and 2 weeks still require urgent evaluation by stroke specialists, ideally within 24 hours 1, 5

Important Clinical Pitfalls

Complex and Atypical Presentations

Many patients describe complex symptoms not typical of classic stroke presentations, which can delay recognition and treatment. 3 No single symptom is inherently more severe than another in patient perception. 3

Common Stroke Mimics to Consider

Conditions that can mimic stroke include seizure, conversion disorder, migraine headache, and hypoglycemia—these require diagnostic evaluation to exclude. 2

Public Knowledge Gaps

Research shows that 39-43% of patients presenting with stroke did not know a single sign or symptom of stroke at the time of their event, with elderly patients and ethnic minorities having lower awareness. 6, 7 Only 17% of the general population can correctly identify all stroke symptoms and know to call 9-1-1. 7

Immediate Action Required

Anyone experiencing sudden onset of these symptoms should immediately call 9-1-1 rather than waiting or driving themselves to the hospital. 1 EMS transport reduces prehospital delays and improves access to time-sensitive treatments. 1