Clues Pointing TO This Diagnosis

Why It's NOT the Similar Diseases

NOT hemorrhagic stroke — hemorrhagic stroke causes sudden severe headache — worst of life — vomiting — rapid deterioration — CT shows hyperdense blood. Linda has no headache — no vomiting — and responded to thrombolytic therapy. Giving thrombolytics in hemorrhagic stroke is fatal — CT before treatment is critical.
NOT TIA — TIA causes identical symptoms but resolves completely within 24 hours — typically within minutes to hours. Linda's symptoms persisted — imaging shows infarct — this is stroke not TIA.
NOT Todd's paralysis post-seizure — Todd's paralysis is transient weakness after a seizure — but Linda had no witnessed seizure — no tongue biting — no postictal confusion.
NOT Bell's palsy — Bell's palsy causes unilateral facial weakness but SPARES the forehead — peripheral nerve. Stroke causes contralateral face and arm weakness — central pattern. Linda has arm AND face weakness — pointing to central not peripheral.
NOT hypoglycemia — hypoglycemia can cause focal neurological deficits mimicking stroke — always check glucose immediately — but Linda's glucose was normal.

Differential Diagnosis List

Hemorrhagic stroke — ruled out by CT head showing no blood — response to thrombolytics
TIA — ruled out by persistent symptoms and imaging showing infarct
Todd's paralysis — ruled out by no witnessed seizure
Bell's palsy — ruled out by arm weakness — central pattern
Hypoglycemia — ruled out by normal glucose — point of care glucose is always first step

Key Distinguishing Test

Non-contrast CT head — immediate — rules out hemorrhage before thrombolytics. CT angiography or MRI — identifies vessel occlusion and penumbra. Point-of-care glucose — rules out hypoglycemia. ECG — identifies atrial fibrillation as cardioembolic source. Time of symptom onset — determines thrombolytic eligibility window — 4.5 hours from last known well.

Board Note

📝 STROKE TREATMENT UPDATE: The 4.5-hour window from last known well applies to thrombolytic therapy — alteplase or tenecteplase. Per 2026 AHA/ASA guidelines tenecteplase is now recommended as an option given noninferiority data and ease of single-bolus administration. Blood pressure must be below 185/110 before thrombolytics. Mechanical thrombectomy for large vessel occlusion up to 24 hours in selected patients. Cardioembolic stroke from AFib requires anticoagulation for secondary prevention — not antiplatelet therapy alone. CHECK GLUCOSE FIRST — hypoglycemia is the most important stroke mimic.

“Linda’s Story”