Atypical Stroke Presentations

I had an interesting and challenging patient recently who had quite an atypical presentation of a massive and life-changing stroke.  

The patient was a 76-year-old African-American female. She went to bed around 10 one night, and the following morning her daughters heard commotion from her bedroom. They found her confused and babbling incoherently. They immediately called 9-1-1.

Upon arrival we found the patient combative and fluently repeating, almost chanting, prayers. Then she would break into verbal bursts that were almost like speaking in tongues. She would alternate between relatively coherent prayerlike speech and nonsensical phrases. 

Our quick general impression: Her airway was obviously patent. Breathing was nonlabored. Circulation was quickly determined to be good enough because her skin was normal in color and dry, and for the two seconds I was able to feel for a radial pulse before she pulled her hand away and tried to hit me, that felt adequate and regular.

Past medical history was diabetes and hypertension. Meds were the usual suspects. Nothing jumped out screaming toxicity or that maybe this was an accidental overdose or medication interaction. No allergies.

She didn’t appear to be having a stroke. Frankly, she appeared more psychotic than anything. She had no facial droop. Her speech was abnormal, but there was no slurring of words, and she was coherently and fluidly praying when she wasn’t speaking in tongues. There was certainly no motor deficit as she tried to hit and kick us. Her gait was normal. However, her family was adamant that she had no history of psychiatric issues or dementia. While not impossible, it was highly unlikely a 76-year-old with no prior behavioral issues was having a new psychotic break.

Her daughters were able to literally lead her to a corner in her upstairs hallway, kind of pin her in the corner (not forcefully), and we were able to place a BP cuff on her, get a quick blood pressure, and check her blood sugar. I thought maybe (hopefully) she was hypoglycemic and we could inject her with a glucagon shot to provide a fix.

No such luck. Her blood glucose was 153. BP was elevated at 188/112. 

A common cause of delirium in elderly patients is infection, but there were also no indications of infectious etiology. Our patient was afebrile, had no history of recent illness, and nobody in the house was sick.

She met no prehospital stroke score criteria for a stroke alert. In my area we use the modified RACE score. A score of 5 or greater triggers a prehospital stroke alert. She was a 2. I erred on the side of caution and scored her for having severe aphasia—that gave her the 2, and everything else was a 0. She also didn’t meet any criteria for a stroke alert under the Cincinnati Stroke Scale or Los Angeles Prehospital Stroke Score.

I didn’t know what was going on with her. All I knew was I had a 76-year-old with acute new-onset delirium.

Strokes Without Scores

Unfortunately, we tried everything to get her into the ambulance without avail and had to sedate her. We tried strapping her into the stair chair, and she was able to undo the straps and slide out of the chair—twice. She did this very purposefully, I should note. I ended up sedating her per our protocols, and the effect was nil. 

We ended up needing to place her into a Reeves litter, secure her safely, and then carry her to the stretcher. I started an IV, called the hospital and reported what was happening and monitored her during the short transport.

What was the outcome? She had a massive left-hemispheric stroke. It was newish but not fresh enough to receive tPA, and she was not a candidate for interventional radiography and clot retrieval, as imaging showed the stroke had completed. She was admitted to the ICU, and sadly her prognosis is poor.

I told you that in my jurisdiction she didn’t meet any criteria for a prehospital stroke alert. This raises the question of the efficacy of stroke scales. 

Note: I am not saying stroke scales are not useful, nor am I advocating for abandoning them. Stroke scales do indeed have high sensitivity for identifying major strokes. However, in one study, 46% of stroke-alert activations based on prehospital stroke scores were not strokes. In another the authors found for every patient who experiences a large vessel stroke and gets triaged to a comprehensive stroke center, five nonstrokes are triaged to one. 

A good rule of thumb is to consider a stroke in any patient who develops any kind of neurologic symptoms over a few minutes. There are many nonspecific symptoms. 

One other thing to keep in mind: Just like they do with cardiac events, women experience atypical symptoms of stroke more frequently than men. Also remember that African Americans have a high risk of stroke, so keep a high index of suspicion for it in neuro presentations with African-American patients.

Deficits, Dizziness, and More

Let’s talk about language deficits. My patient technically was aphasic. Yes, she was speaking, but she wasn’t making much sense. While she was coherently chanting prayers, she was also babbling incoherently. I called my father (a 40-plus-year neurologist who specialized in stroke) and asked him about this. He said based on what I told him, she was clearly aphasic; however, sometimes—and I found this really interesting—aphasic stroke patients can chant or sing what they want to say. He said this would account for why she could chant prayers at me but babble incoherently otherwise.

Typically we think of aphasia as global, where the patient knows what they want to say but can’t get the words out. However, that’s only one slice of the pie. Here are some other types of aphasia:

• Broca’s aphasia: This consists of nonfluency and sparse output;
• Wernicke’s aphasia: meaningless “word salad”;
• Conduction aphasia: preserved comprehension but frequent paraphrasic errors;
• Transcortical motor aphasia: nonfluency and difficulty initiating speech.

Dizziness is another common stroke presentation you don’t find anywhere in the scales. Most of us know dizziness and a lack of coordination can be signs of a cerebellar stroke, as the cerebellum is responsible for motor coordination.

Dizziness is common in stroke presentations in elderly patients. It is present in about 20% of geriatric strokes. Interestingly, nystagmus can help you rule out stroke, as nystagmus suggests a vertiginous etiology. However, dizziness and nystagmus with a gaze deviation suggest stroke. Suspect stroke also if the dizziness is sudden in onset, sustained, accompanied by nausea and/or vomiting, and the patient has head-motion intolerance. Dizziness with limb ataxia and difficulty maintaining an upright sitting position suggests a lateral medullary infarct.

We commonly associate headache with head bleeds and not ischemic strokes. This is a good rule of thumb, but it’s not decisive. You can have ischemic strokes with headache. A posterior inferior cerebellar artery stroke will cause a unilateral occipital headache. A central venous thrombosis will present with a headache that is worse lying supine.

Carotid dissection is almost always accompanied by a headache. These dissections cause clots to form that frequently break off and cause a stroke. Often these patients are younger, and often there is trauma involved. If you have a patient with recent neck, head, or thoracic trauma who now presents with a headache and neuro changes, think stroke.

Vision problems are often noted. Usually they involve the retinal artery or occipital lobe, which is responsible for vision. The hallmark sign of posterior cerebral artery (the artery that supplies the occipital lobe) stroke is vision problems, most commonly neglect, where the patient is unaware of the deficit and loses vision in the periphery or develops a visual cut. This is called hemianopsia. These are the patients you see walking into walls or shaving only one side of their face. They may experience blurry vision, light sensitivity, moving objects, a visual midline shift where things appear tilted or slanted, or double vision. You can also have patients with gaze deviation or new-onset strabismus (cross-eyes).

Stroke can cause altered mental status. A pontine stroke will cause global mental status changes. Remember, the pons is responsible for, among other things, wakefulness and maintaining consciousness. You will also see limb jerking, ataxia, and pinpoint but reactive pupils in a pontine stroke.

There are multiple case reports of amnesia as a sole or primary manifestation of stroke. If you have a decreased mental status along with behavioral abnormalities, be concerned about a brain stem stroke.

Delirium

As with the patient from the example, delirium is an ominous sign. Delirium as a stroke presentation is usually associated with elderly patients. One study had the mean age for stroke presentations as delirium as 76 years old. This is compared to 69 for overall stroke presentations.

When delirium is present, mortality is increased. It is often associated with left-side lesions.

Delirium as a presentation in stroke does happen, and yes, it’s not a good sign. However, delirium more commonly develops after a stroke completes. Remember, my patient had a stroke that had already completed. What likely happened was she had a stroke sometime overnight, and once the stroke completed and her brain was suffering the effects of that penumbra being damaged and no longer salvageable, she experienced an acute confusion state.

The studies researched for this article had rates of delirium developing in stroke patients as 24%–48%. According to the research 50% of stroke patients will develop delirium at some point during their hospital stay. This increases to 88% in hemorrhagic stroke patients.

Conclusion

Stroke is a life-threatening emergency that EMS providers routinely encounter in the prehospital environment. While stroke scales can help identify large vessel occlusions, it is important for the provider to be aware of the many diverse and dynamic presentations with which stroke can manifest. 

Resources

Gustafson Y, Olsson T, Eriksson S, Asplund K, Bucht G. Acute Confusional States (Delirium) in Stroke Patients. Cerebrovasc Dis, 1991; 1: 257–64. 

Hill J. Prehospital Stroke Triage. Taming the SRU, www.tamingthesru.com/blog/2019/10/22/prehospital-stroke-triage. 

Murano T, Myers K. Stroke: The Subtle, Atypical, and Enigmatic. Relias Media, 2019 Mar 15; www.reliasmedia.com/articles/144109-stroke-the-subtle-atypical-and-enigmatic. 

Nydahl P, Bartoszek G, Binder A, et al. Prevalence for delirium in stroke patients: A prospective controlled study. Brain Behav, 2017 Aug; 7(8): e00748. 

Pasinska P, Kowalska K, Klimiec E, Szyper-Maciejowska A, Wilk A, Klimkowicz-Mrowiec A. J Neurol, 2018 Apr; 265(4): 863–70. 

Shaw R, Drozdowska B, Taylor-Rowan M, et al. Delirium in an Acute Stroke Setting, Occurrence, and Risk Factors. Stroke, 2019; 50(11): 3,265–8.

Michael Carunchio, MS, NRP, FP-C, TP-C,  is an East Coast flight medic, TEMS medic, and educator. He is host of The World’s Okayest Medic Podcast.