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Lesson

Stroke Mimics: Still Protect the Clock

11 min Medical Skip to quiz

Objective: Catch the mimics you can treat on the truck (especially glucose), then still run last-known-well and destination as a stroke if the deficit remains.

Why This Is Hard

You have been burned by a migraine and by a seizure. So you under-call. 2026 AHA/ASA acute ischemic stroke: EMS should screen with a validated tool, check glucose, keep scene short, and triage to the right stroke hospital. Hypoglycemia mimics stroke and must be treated — but if disabling deficits persist after correction, the stroke pathway still runs.

On this truck
  • Glucose on every focal deficit. Treat severe hypoglycemia. Recheck the exam.
  • Last known well, time of discovery, anticoagulants, seizure at onset, and a validated screen (CPSS/FAST/LAMS/RACE — whatever your system uses).
  • Scene time discipline (systems often target ≤15 minutes). Do not stay to “prove it is not a mimic.”

Street Sequence

  1. ABCs. Glucose. If <60 mg/dL (or your protocol cut-off), treat. Recheck the neuro exam.
  2. If deficits persist: stroke screen, LKW, destination per protocol (CSC vs PSC vs nearest).
  3. Seizure with a lingering hemiparesis (Todd’s) is still a stroke workup until imaging. Do not cancel because they seized.
  4. Migraine, conversion, and Bell’s palsy exist. Asymmetric forehead-sparing face + arm + speech is not Bell’s. When unsure, activate.
  5. Notify. Short scene. Protect the airway if they cannot handle secretions.

Field Rules (Education)

  • Treat what you can: glucose is the mimic you reverse on the truck. AHA/ASA: check glucose before thrombolysis in hospital — you can start that clock now.
  • Persistent deficit: if symptoms of disabling stroke remain after glucose correction, they still need a stroke center.
  • Seizure at onset does not prove it is not a stroke (and does not prove it is). Destination still matters.
  • You are not the CT scanner: under-calling costs ELVO minutes. Over-calling a mimic is the cheaper error.
Say out loud
  • Glucose is __ — treating if low, then re-exam
  • Last known well __
  • Screen positive / deficit persists — stroke alert
  • Scene time, then the right stroke hospital

Field Pitfalls

  • Canceling a stroke alert because they had a seizure.
  • Skipping glucose on a “obvious CVA.”
  • Staying 25 minutes to get a perfect history from three family members.

Practice

60-second drill

Right arm dense, aphasic, glu 38. Action, then the exam is still dense at glu 110. Radio sentence. Then: forehead-including facial droop only, no arm, no speech. What is it probably not?

Related: Stroke Recognition & Last Known Well, Seizure & Status.

Sources & Further Study

Named guidelines for further study. They are not clinical orders and do not replace your protocol or medical direction.

Education only. Apply learning within your protocols and medical direction. This is not clinical care guidance.

Check Your Understanding

Street decisions from this lesson only. After you check, the key is highlighted. Education practice — not a certification exam.

1. Every focal neuro deficit on the truck should get:
2. Disabling deficits that persist after glucose is corrected:
3. A seizure at the onset of hemiparesis:
4. The cheaper prehospital error is:
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