About half of all patients who suffer a stroke do not seek immediate medical attention. Reasons for this include lack of recognition of symptoms as a stroke and hope that the deficits will improve without intervention. In some cases, there may be the belief that nothing can be done to reverse a stroke once it has occurred. Yet, evidence from 21 randomized, controlled clinical trials has clearly demonstrated the benefit of thrombolytic therapy following an ischemic stroke—but with time limits.
Unfortunately, the most frequent exclusion criteria noted for patients being unable to receive tPA is presentation beyond the therapeutic time window. With many studies showing rates of thrombolytic administration to acute stroke patients as low as 5%, increasing awareness in the community regarding stroke symptoms and how to appropriately seek medical attention can have a significant impact on improving outcomes from this devastating disease. Primary care physicians have an important role to play in this process, both in the education of their patients “prior to the fact” and also by providing correct recommendations to patients who call their office complaining of acute neurological symptoms.
The differential diagnosis for the acute onset of a new neurological deficit is limited—stroke or stroke mimickers. Stroke mimickers include non-convulsive seizures, Todd’s paralysis following a seizure, hypoglycemia (and less often hyperglycemia), hemiplegic migraines and conversion disorder (functional weakness). Neurological deficits due to toxicity, metabolic abnormalities, infectious mass and inflammatory lesions in the CNS tend to have a more sub-acute progressive timeline.
Strokes come in two main flavors, ischemic and hemorrhagic. Ischemic strokes typically manifest with maximum deficit at their onset followed in most cases by some level of improvement. The exceptions are those cases where there is progression of thrombosis resulting in a larger ischemic territory or when substantial edema and/or mass effect occur following the ischemic insult. Hemorrhagic strokes not infrequently cause symptoms that worsen over time, largely due to expansion of the hematoma after the initial bleed.continued ...