Can you differentiate SAH, ischemic stroke?

Is it possible that you could miss the signs of an ischemic stroke or subarachnoid hemorrhage (SAH) when your waiting room is full of sick and injured patients?

"I think it is easy for either type of stroke to be overlooked in a busy ED," says Judy Guzy, RN, research coordinator of the University of California-Los Angeles Stroke Network. "Treatment should be initiated as soon as possible with either type of stroke."

To avoid missing signs of stroke, do the following:

• Know differences in presentation for each type of stroke.

The "worst headache of my life" is the single most important distinction when distinguishing ischemic stroke from SAH, says Donna Zadrozny, RN, BSN, an ED nurse at St. Joseph’s Hospital and Medical Center in Phoenix. She gives the example of patient in the middle of a routine activity who suddenly passes out, awakening with severe headache and vomiting.

"Both SAH and ischemic strokes can present with a sudden onset, but patients with SAH almost always have a headache while ischemic stroke rarely does," she says.

Patients with ischemic stroke may report numbness and tingling and then loss of function of a limb or the ability to speak, she says. "Also, in stroke, a patient may wake up with symptoms of weakness, loss of function, or unsteady gait," says Zadrozny. Here are symptoms of ischemic stroke with assessment tips for each:

  • Sudden onset of numbness or weakness of the face, arm, or leg, especially on one side of the body. Evaluate this situation by having the patient hold up each arm and leg, and ask the patient to smile for you to test facial droop, advises Guzy. "Numbness can be tested by asking the patient if a pinprick feels the same on the upper arm, leg, or face of each side," she says.
  • Sudden confusion, trouble speaking, or understanding. For a quick test, ask the patient to tell you the month and his or her age, and to follow two simple commands: "Open and close your eyes" and "Squeeze my hand," says Guzy.
  • Sudden trouble seeing in one or both eyes. Ask the patient to look directly at you, then hold up one or two fingers on the right and left periphery and ask "How many fingers?" without the patient taking his or her eyes off you, says Guzy. "Patients who do not comply with this direction can be evaluated by a response to threat: They blink when a hand is waived on either side," she adds.
  • Sudden trouble walking, dizziness, and loss of balance or coordination. A simple test for coordination is to have patients touch their noses with their fingers and then touch your finger, says Guzy. Evaluate both sides, she adds.

• Start a stroke protocol immediately.

A stroke is like any code situation and needs to be acted on immediately to save brain tissue, emphasizes Guzy. "Ask for the neurologist to be paged immediately," she says. "If your hospital has a stroke team, keep the emergency number available in the ED and use it."

At St. Joseph’s, the stroke protocol is initiated at triage for SAH and ischemic stroke, says Zadrozny. The following steps occur: The triage nurse gets the patient a bed, obtains vital signs, starts an intravenous line, orders labs, and sends the patient to obtain a computed tomography (CT) scan of the head.

The CT scan is read immediately by the stroke team, and a diagnosis is made. If SAH is suspected, neurosurgery is consulted. If the diagnosis is stroke, thrombolytics are considered.

• Determine the time of stroke onset.

This doesn’t refer to the time the patient was found with symptoms; instead, it means the last time the patient was known to be without symptoms, says Guzy.

"If the onset of symptoms were witnessed by someone, a very important thing for nurses to do is to keep the witness at the bedside so that the doctor can confirm the time of onset," she says.

Stroke patients may not be able to communicate this information themselves, and they may not even recognize that they have had a stroke, says Guzy. "If the patient was brought in alone by the paramedics, question the paramedics about how the patient was found, and get the telephone number of the person calling in the report," she recommends.

• Make the decision to transfer as soon as possible.

Treatment must be started as soon as possible once the transfer is made, emphasizes Guzy. "Treatment doesn’t stop once the decision to transfer is made," she says. "When we arrange transfers, we make sure that the transport knows to come with lights and siren. That applies to helicopter transfers that have a ground component, too."


For more information on stroke assessment, contact:

  • Judy Guzy, RN, Research Coordinator, University of California-Los Angeles Stroke Network, 924 Westwood Blvd, No. 300, Los Angeles CA 90024-1777. Telephone: (310) 794-0600. Fax: (310) 794-0599. E-mail:
  • Donna Zadrozny, RN, BSN, Emergency Department, St. Joseph’s Hospital and Medical Center, 350 W. Thomas Road, Phoenix, AZ 85012. E-mail: