F – Face drooping One side of the face may appear numb or sagging; you can’t smile evenly on both sides. Indicates possible weakness in facial muscles supplied by cranial nerves.
A – Arm weakness One arm may feel weak or limp when raised, or one hand may tremble. Reflects involvement of the motor cortex or corticospinal tract.
S – Speech difficulty Slurred, garbled, or unintelligible speech; you might be unable to form words or find them. Points to damage in Broca’s area or related language centers.
T – Time is critical If any of the above symptoms are present, call emergency services immediately. Early intervention dramatically improves outcomes.
Remember the mnemonic: "Time Is Speech Arm," a quick check for stroke signs.
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2. The "What’s Going On?" Narrative
> "I was watching my usual morning news when I noticed something odd about my own voice."
> "My words felt tangled, as if each syllable was being tugged by invisible hands."
> "I tried to speak, but the sentences slipped away, leaving me frustrated and embarrassed."
> "When a friend called it ‘slurred speech,’ I wondered whether my body had betrayed me again."
> "Could this be another stroke? Another neurological hiccup? The uncertainty gnawed at me."
This introspective vignette frames the core concerns—recognizing symptoms, assessing risk factors (stroke), and understanding personal health trajectories. It invites participants to reflect on their own experiences of dysarthria or speech impairment.
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3. "What If" Scenario
> Scenario: You have a sudden onset of slurred, slow, or uneven speech that you cannot attribute to fatigue or stress. You do not experience weakness in your limbs or face, and your vision remains clear.
a) Differential Diagnosis (Non‑Stroke)
Condition Typical Presentation Key Clinical Features
Dysarthria due to Upper Motor Neuron Lesion (e.g., stroke, multiple sclerosis) Slurred speech with preserved strength May have additional signs: facial weakness, limb spasticity, sensory loss
Dysarthria due to Lower Motor Neuron Lesion (e.g., ALS) Weakness in bulbar muscles, drooling, dysphagia Progressive muscle wasting, fasciculations
Myasthenia Gravis Variable speech weakness; worsens with fatigue Ptosis, diplopia, limb weakness that improves after rest
Central Nervous System Disorders (e.g., multiple sclerosis) Mixed speech deficits; may involve tremor Relapsing-remitting course, sensory changes
> Take‑away: In the emergency setting, a brainstem or cerebellar stroke is the most likely culprit for ataxic dysarthria and gait instability in a 70‑year‑old with vascular risk factors. Prompt imaging and management are essential.
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Suggested Next Steps
Action Rationale
Urgent non‑contrast head CT (or MRI if available) Rule out hemorrhage; identify acute ischemia, especially cerebellar or brainstem involvement.
Check blood pressure and glucose Hypertension and hyperglycemia can worsen stroke outcomes; aim for BP <180/105 mmHg in the first 24 hrs (per AHA/ASA).
Order complete metabolic panel + CBC Screen for electrolyte disturbances, anemia, or infection that may contribute to altered mental status.
Consider lumbar puncture if meningitis suspected If CSF shows pleocytosis, low glucose, or high protein; also rule out subarachnoid hemorrhage (though CT often picks up SAH).
Consult neurology and radiology for imaging interpretation Ensure accurate diagnosis; plan management strategy accordingly.
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4️⃣ Clinical Pearls & Decision Points
Scenario Key Question Action
Patient has a known intracranial lesion on CT but is now confused Is the lesion evolving? Re‑image (MRI/CT) promptly; look for hemorrhage, edema, infarction.
No lesion seen on CT, but patient remains obtunded Could there be early ischemia or subtle bleed? Get MRI with diffusion & susceptibility sequences—these detect changes earlier than CT.
CT shows a small hyperdense area that could represent acute hemorrhage Does the clinical picture match hemorrhagic stroke? If yes, treat aggressively (blood pressure control, possible surgical intervention).
Imaging shows no pathology but symptoms persist Is there an alternative etiology? Consider metabolic causes (hypoglycemia, hyponatremia), seizures, or drug toxicity.
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4. Key Take‑aways for Clinical Practice
Question Answer
What is the best imaging test for early detection of stroke in a patient with altered mental status? CT angiography (or CTA) is preferred because it quickly shows large vessel occlusion and offers therapeutic guidance.
Does a normal CT rule out ischemic stroke? No – early ischemia may be invisible on non‑contrast CT; consider CTA or MRI if suspicion remains high.
What are the most common imaging findings in early ischemic stroke? Hyperdense vessels (especially MCA), loss of gray/white matter differentiation, subtle hypodensity within minutes to hours.
How quickly can ischemia be seen on CT? As soon as 5–10 minutes after symptom onset for hyperdensity; cortical hypodensity may appear ~2–3 hours post‑onset.
When should MRI be used? In equivocal cases, when CTA is negative but clinical suspicion persists, or when patient cannot undergo CT contrast.
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Practical Take‑Away
Initial imaging: Non‑contrast head CT → Rapidly rule out hemorrhage; look for vessel hyperdensity.
If CT is normal but high clinical suspicion remains, obtain a CT angiogram or MRI/MRA to identify arterial occlusion and evaluate eligibility for reperfusion therapy.
Time matters: The sooner the imaging, the better the chance of timely treatment.
Feel free to reach out if you’d like deeper dives into any specific stroke subtype or imaging protocol!
