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Lesson

Stroke Mimics

11 min Medical Skip to quiz

Objective: Treat the mimics you can fix, and check low glucose first. Last known well is the last time they were seen normal. If a disabling deficit remains, record that time and transport as a stroke.

Why this matters

A migraine, or a seizure that was not a stroke, can make you under-call the next one. First, check glucose. Low glucose mimics stroke, and you can treat it. Last known well is the last time they were seen normal. If a disabling deficit remains after you correct the sugar, record that time and transport as a stroke. Keep the scene short, and go to the right stroke hospital. The mimics stay on the list. They do not clear the call by themselves.

Key points
  • Check glucose first on every one-sided deficit. Treat severe hypoglycemia. Recheck the exam.
  • Record last known well, the last time they were seen normal. Also record when they were found, anticoagulants, a seizure at the start, and the screen your system uses, such as FAST, CPSS, LAMS, or RACE.
  • Keep scene time short. Many systems aim for 15 minutes or less. Do not stay to prove it is not a mimic.

Clinical sequence

  1. Protect the airway, breathing, and circulation. Check glucose. Treat symptomatic hypoglycemia using your protocol cutoff. Teaching is often under 70 mg/dL. Many EMS cards still use 60. Do not invent a cutoff from this page. Recheck the neurologic exam after correction.
  2. If deficits remain, do the stroke screen, record last known well, and choose the destination in your protocol: comprehensive stroke center, primary stroke center, or the nearest appropriate hospital.
  3. A seizure with lingering one-sided weakness, Todd paralysis, is still a stroke workup until imaging. Do not cancel because they seized.
  4. Migraine, a functional presentation, and Bell palsy exist. A forehead that is spared, plus arm weakness, plus speech trouble, is not Bell palsy. When you are unsure, activate the stroke pathway.
  5. Notify the hospital. Keep the scene short. Protect the airway if they cannot handle secretions.

Teaching points

  • Treat what you can. Glucose is the mimic you can reverse in the ambulance. Check it before any hospital clot-busting drug. You can record that result now. Do not give a thrombolytic in the field.
  • A deficit that remains. If disabling stroke symptoms are still there after glucose correction, they still need a stroke center.
  • A seizure at the start does not prove it is not a stroke. It also does not prove that it is. Destination still matters.
  • You cannot clear a stroke on scene. Missing a large-vessel occlusion costs treatment time. Transporting a mimic is the smaller error.
Verbalize
  • Say the glucose. If it is low, I am treating it, then I will re-examine.
  • Say last known well, the last time they were seen normal.
  • The screen is positive, or the deficit remains. This is a stroke alert.
  • The scene stays short. Then we go to the right stroke hospital.

Common errors

  • Do not cancel a stroke alert because they had a seizure.
  • Do not skip glucose on an “obvious stroke.” Check low sugar first.
  • Do not stay 25 minutes to get a perfect history from three family members.

Practice

One-minute check

The right arm is dense, and they cannot speak. Glucose is 38. State the action. The exam is still dense when glucose is 110. Say the radio sentence. Then the whole side of the face droops, including the forehead, with no arm weakness and no speech trouble. What is that picture 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

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

1. Every focal neurologic deficit in the field should get:
2. Disabling deficits that persist after glucose is corrected:
3. A seizure at the onset of hemiparesis (one-sided weakness):
4. The cheaper prehospital error is:
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