Let’s explore the critical topic of strokes. Strokes are a “brain attack” caused by an interruption of blood flow to a specific area of the brain. You may see different signs and symptoms depending on which part of the brain is affected.

Two Types of Strokes

Strokes come in two main types: ischemic and hemorrhagic.

Ischemic Strokes

These are more common, accounting for about 87% of all strokes. They occur because of a blood clot in the brain, blocking blood flow to a particular area.

Hemorrhagic Strokes

These make up about 13% of strokes and happen when a blood vessel bursts, leading to bleeding in the brain. This can occur due to high blood pressure, which increases the risk of a vessel bursting under the pressure.

You might hear people say that high blood pressure can cause a stroke, which usually refers to the risk of a hemorrhagic stroke due to the high pressure in the arteries, potentially causing a vessel to burst.

Emergencies That Can Mimic a Stroke

Here are some emergencies that can mimic a stroke:

  • Hypoglycemia: Low blood sugar can cause symptoms that resemble a stroke, so always check blood glucose levels.
  • Seizures: Certain seizures, like absence seizures or the postictal state after a seizure, can look like a stroke.
  • Head Trauma: Epidural or subdural bleeding due to head trauma can mimic stroke symptoms.
  • Any Altered Mental Status: Conditions causing changes in mental status should prompt a stroke evaluation using a stroke scale.
  • Migraines: Can present with nausea, vomiting, paralysis, slurred speech, and facial droop.

Now, let’s talk about the signs and symptoms of a stroke. Remember, other conditions can mimic a stroke, so you always need to check blood glucose levels first to rule out hypoglycemia.

Signs and Symptoms of a Stroke

Here are the key signs and symptoms of a stroke and a mnemonic to help you remember them:

  1. Facial Droop: One side of the face may droop. You can test this by asking the patient to smile and checking for asymmetry.
  2. Arm Drift: Ask the patient to hold both arms out. If one arm drifts down or they can’t lift one arm, it’s a sign of weakness on one side.
  3. Severe Headache and Nausea/Vomiting: Don’t overlook a sudden, severe headache, especially if it’s accompanied by nausea or vomiting.
  4. Speech Issues: Look for slurred speech, trouble speaking, or difficulty swallowing.
  5. Vertigo: If the patient feels like the room is spinning, pay attention.
  6. Vision Problems: Blurred vision or loss of vision in one eye are red flags.
  7. Balance and Gait Issues: Take note if the patient suddenly can’t walk or loses balance.

To help remember these symptoms, use the mnemonic BE FAST as an assessment tool.

  • B: Balance—loss of balance or coordination.
  • E: Eyes—sudden vision changes.
  • F: Face—facial drooping.
  • A: Arms—arm weakness or drift.
  • S: Speech—speech difficulty.
  • T: Time—note the time the symptoms started and act fast.

EMS providers need to be efficient and accurate in their assessments. BE FAST is a great tool for identifying general signs of a stroke quickly. Time is critical, as doctors have a small window, usually less than 4.5 hours, to treat a typical stroke effectively.

However, in the pre-hospital setting, we also need to identify Large Vessel Occlusions (LVOs), which have a treatment window of up to 24 hours. This makes it crucial to perform both the FAST and VAN assessments. An LVO involves a large vessel that branches from the base of the brain and supplies blood to smaller vessels. To determine if an LVO is present, we use the VAN assessment. This quick assessment evaluates all critical areas of the brain, including the cerebral cortex, Broca’s Area, the Parietal Lobe, the Occipital Lobe, and Wernicke’s Area.

  • V: Visual—Does the patient report double vision, loss of vision, or partial field of vision
  • A: Aphasia—Does the patient have difficulty forming words? Can they repeat a short sentence like, “The early bird catches the worm?” Can they follow simple commands or recognize two objects correctly? Do NOT count slurred speech because this could signify a smaller vessel involvement.
  • N: Neglect—Does the patient have issues with their senses and gaze? For example, can they follow your gaze with their eyes, or can they only track to one side? Make sure to track in all directions for accuracy. You may ask the patient to close their eyes and see if they feel a sensation when stimulated.

Using both BE FAST and VAN assessments helps ensure we accurately identify the type of stroke, allowing for timely and appropriate treatment.

When reporting to the ER, you would say FAST positive VAN negative or FAST Positive VAN positive. This implies that the patient is possibly having a stroke, and it involves or does not involve a large vessel.

Additionally, the most important information besides an assessment is to find out when the patient was last seen normally and compare their current state to their normal baseline if you have someone who knows them well.

Keep these signs and symptoms in mind, and remember the importance of quick action when dealing with potential strokes.