Monday Morning Medical Director’s Message November 3, 2025

Monday Morning Medical Director’s Message

There are two types of strokes. The most common type, accounting for 85% of all strokes, are ischemic strokes. An ischemic stroke happens when a blood vessel supplying the brain becomes blocked by a blood clot or buildup of plaque. Conversely, a hemorrhagic stroke occurs when a blood vessel in the brain ruptures, causing bleeding into or around the brain. More specifically, bleeding into the brain tissue, or parenchyma, is known as an intracerebral hemorrhage, and bleeding around the brain is known as a subarachnoid hemorrhage. Hemorrhagic strokes make up the remaining 15% of all strokes, with approximately 10% being intracerebral hemorrhage and 5% subarachnoid hemorrhage.  

Transient Ischemic Attack, known as TIAs, are like ischemic strokes, but the blockage or disruption in blood flow is only temporary, and symptoms only last a few minutes. Brain tissue is not permanently damaged, and ischemia will not be found on an MRI. However, TIAs should be treated seriously, as data has demonstrated that 40% of patients with TIAs brought to the emergency room go on to have a stroke in the future. These patients are typically admitted for further testing and risk factor management. Stroke is preventable! 

Each year, about 795,000 people have a stroke in the United States. In 2024, there were 2,898 patients coded with a stroke in University Hospitals Health System. Around 60% of EMS patients transferred in as a brain attack are diagnosed with a stroke, so there is a high likelihood that many paramedics have transported a stroke patient at some point.  

With stroke being the 4th leading cause of death and a top cause of disability, early recognition plays a dramatic role in patient outcomes. Every 15-minute delay in treatment is a loss of a healthy day for a patient. It is vital for all prehospital providers to be proficient at recognizing and managing these patients while in their care.  

A patient’s presentation may suggest the type of stroke the patient is having. Ischemic stroke typically presents with focal neurological deficits, is sudden in onset, and may or may not be accompanied by a headache, whereas a depressed consciousness is uncommon (except for some brainstem infarctions). A patient experiencing an intracerebral hemorrhage often has progressive focal neurological deficits worsening over the minutes to hours since the symptoms start and are commonly accompanied by a sudden increasing headache and will progressively develop a decreased level of consciousness. Patients with a subarachnoid hemorrhage typically complain of the “worst headache of my life,” do not have focal neurological deficits, and experience a decline in consciousness. Syncope is common at the time of onset, and some severe subarachnoid hemorrhages may cause coma.   

The following is a helpful diagram to assist in localizing deficits: 

Posterior circulation strokes present differently and are commonly missed by most stroke assessment tools in the field and in the hospital setting. Brainstem strokes are the most devastating stroke due to the small area and location of nerves that serve critical body functions. These patients often have crossed signs or symptoms found on both sides of the body. Nerve pathways cross in the brainstem, so weakness and sensory loss can occur on one side of the face and the opposite side of the body. The following “D” symptoms are common with posterior circulation strokes:

• Decreased level of consciousness (LOC)
• Dysphagia
• Dysarthria
• Dizziness
• Diplopia or visual field cut
• Dysconjugate gaze

One stroke type of posterior circulation stroke, involving the cerebellum, tends to cause dizziness, inability to walk normally (ataxia), and falling to one side. To help recognize posterior stroke, remember to consider “dizziness +” in patients who are experiencing. Dizziness, along with another neurological symptom, should raise your suspicion of stroke.  

There are many other stroke mimics, the most common is hypoglycemia, so it is essential to check blood glucose in all patients with stroke-like symptoms or altered mental status. Seizures and migraine headaches can also cause patients to experience stroke-like symptoms and are often clinically indistinguishable in the prehospital environment. When in doubt, if there are new neurological symptoms, assume it could be a stroke and activate the pre-hospital notification for a Brain Attack. An additional history of seizure or a history of similar symptoms with migraine headaches can be very important to pass on to the emergency department providers to aid in proper diagnosis.  

Having an understanding of which symptoms are common with various stroke types can give you confidence to activate a brain attack in the field. However, even neurologists must confirm their suspicions with a non-contrast head CT scan before treating stroke. CTs are useful in that they can identify hemorrhage almost instantly, whereas ischemic stroke tissue may take 4-6 hours. The CT scan drives all stroke care in the hospital setting, so getting a patient to the nearest hospital is critical.  

Overall, recognition and timing are the most important aspects for prehospital care. With any suspicion of stroke, paramedics are encouraged to activate a brain attack in the field. Hospital teams expect and welcome overcalls!

Thank you for your care, 

Amanda Opaskar, MD  

Vascular Neurology 

University Hospitals Neurological Institute 

Primary stroke center director, UH St. John Medical Center 

Medical Director, LT4, UH Cleveland Medical Center 

Assistant Professor of Neurology, Case Western Reserve University School of Medicine