Stroke: Common symptoms of a stroke include sudden onset unilateral facial droop, unilateral motor weakness as well as numbness and tingling, visual impairment, speech disturbances, headache, and gait instability. A stroke occurs due to either blockage or rupture of a blood vessel that supplies oxygen and nutrients to the brain. When this occurs, the area of the brain affected is not perfused and, consequently, brain cells die. The most common type of stroke is an ischemic stroke, one in which a blockage in a blood vessel occurs. The most common blockages are from a thrombus (blood clot) that forms within the blood vessel itself or an embolism (blood clot that forms elsewhere, breaks off, and travels to the brain). The standard of care for a suspected acute ischemic stroke is administration of intravenous alteplase, also known as tissue plasminogen activator (tPA). However, tPA must be administered within 3-4.5 hours of symptom onset to be effective. There are circumstances in which it can be administered when symptom onset is unclear, as with a wake- up stroke. Another time-sensitive treatment available to stroke patients is mechanical thrombectomy, which is to treat large vessel occlusion. Such therapy is only considered within 6-24 hours of symptom onset. When acute stroke is suspected or verified, urgent evaluation by a certified stroke neurologist (a.k.a. vascular neurologist) and/or neurointerventionalist is warranted to determine if the patient is a candidate for tPA and/or mechanical thrombectomy. Admission to the hospital for further work-up including telemetry monitoring, echocardiogram, MRI brain, MRA head, and either MRA neck or carotid ultrasound is also indicated. 

TIA: A transient ischemic attack (TIA) is often referred to as a mini-stroke and typically signifies a temporary blockage of blood flow to the brain by a blood clot. The clot can dissolve on its own or become dislodged. Presenting clinical symptoms are similar to a stroke and can include weakness, numbness, or paralysis of one side of the body. Furthermore, speech may be impaired, vision loss can occur, and severe headache can be present. TIA symptoms typically resolve shortly after onset but, despite that, a TIA can signify that a stroke is about to occur, which is why the management and treatment of a TIA is similar to a stroke.

Complex/Complicated Migraine: Also known as hemiplegic migraine, complex or complicated migraine is not a common presentation of migraines. In fact, it has a reported prevalence of 0.01%, with women three times more likely than men to have this condition. There is a familial type (known family history) and a sporadic type (no family history). This migraine is associated with a preceding aura that can be characterized by unilateral motor weakness, sensory changes, and speech or visual disturbances. Motor symptoms typically begin in the hand and gradually involve the arm and then the face, lasting from a few minutes to several hours and, in some cases, a few days. Symptoms mimic those of stroke and require work-up to exclude a vascular event. This is a diagnosis of exclusion, meaning that all other explanations for a patient’s neurologic symptoms, such as acute stroke and TIA, have been ruled out and brain imaging is noted to be normal.

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