"Time is brain." It's the stroke equivalent of cardiology's "time is muscle," and it captures the same terrible urgency. During a stroke, blocked or bleeding blood vessels deprive brain tissue of oxygen. Every minute without treatment, nearly two million brain cells die. The window for the most effective interventions is measured in hours, and emergency departments miss strokes every day.
The Treatment Window
Clot-busting medication—tPA—can dramatically reverse stroke damage by dissolving the blockage and restoring blood flow. But it must be given within 4.5 hours of symptom onset. Beyond that window, tPA doesn't help and becomes dangerous, risking bleeding into already damaged brain tissue. Mechanical thrombectomy—physically removing the clot with a catheter—extends the window somewhat for certain stroke types, but sooner is always better.
Studies show that patients treated within 90 minutes of symptom onset have substantially better outcomes than those treated at three hours, who in turn do better than those treated at four hours. The relationship between time and outcome is steep and unforgiving. A missed diagnosis that delays treatment by even an hour can mean the difference between walking out of the hospital and spending the rest of your life in a wheelchair.
Beyond FAST
Public health campaigns have successfully taught civilians the FAST acronym: Face drooping, Arm weakness, Speech difficulty, Time to call 911. It's an effective screening tool that has probably saved many lives by prompting faster emergency response.
But healthcare providers should know that strokes don't always present this way. Posterior circulation strokes—affecting the brainstem and cerebellum—may cause primarily balance problems, coordination difficulties, and vision changes without the classic face and arm findings. Younger patients may have atypical presentations. "Wake-up strokes," where patients go to sleep fine and wake with deficits, create uncertainty about symptom timing that complicates treatment decisions. Vertigo and dizziness can be the predominant symptoms, easily mistaken for inner ear problems or benign causes.
Emergency physicians should consider stroke in any patient with sudden neurological symptoms. The index of suspicion should be especially high for patients with vascular risk factors—hypertension, diabetes, smoking, prior stroke or TIA—but stroke can happen to anyone.
How Strokes Get Missed
The middle-aged woman who comes in dizzy and unsteady looks like she has a problem with her inner ear. She gets meclizine for vertigo and discharge instructions. By the time she returns, unable to walk at all, the cerebellar stroke that was causing her symptoms has completed its damage. The window for intervention has closed.
The young man with a severe headache gets diagnosed with migraine, given pain medication, and sent home without imaging. The subarachnoid hemorrhage—bleeding around his brain that needed immediate neurosurgical attention—goes undetected until his family finds him unresponsive the next morning.
The patient with symptoms that came and went—a transient ischemic attack, or TIA—gets reassurance that since the symptoms resolved, everything is probably fine. Within 48 hours she has a full stroke. TIAs are warning strokes; a significant percentage of TIA patients have major strokes within days. Treating resolved symptoms as "probably nothing" misses the opportunity for interventions that could prevent the complete stroke to come.
The Standard of Care
Patients presenting with possible stroke symptoms require immediate evaluation. CT scan of the head should happen within minutes of the decision to image—stroke is a time-critical emergency, not a condition that waits for the scanner to free up. Neurology consultation should be obtained when stroke is in the differential. Patients meeting criteria for tPA should receive it within the treatment window. Hospitals without stroke capabilities should transfer patients to hospitals that have them rather than managing beyond their competence.
"Door to needle" time—the interval from emergency department arrival to tPA administration—should be under 60 minutes. Hospitals track this metric because it matters. Longer door-to-needle times translate directly into worse patient outcomes. When systemic delays push treatment beyond the therapeutic window, the hospital has failed its fundamental obligation to patients presenting with time-critical emergencies.
The Devastation of Delay
Stroke disability shapes every aspect of survivors' lives. Hemiplegia—paralysis of one side of the body—may leave patients unable to walk, unable to use an arm, dependent on others for basic care. Aphasia can rob patients of the ability to speak or understand language, trapping intact minds inside bodies that can't communicate. Vision loss, cognitive impairment, difficulty swallowing, emotional dysregulation, personality changes—the list of potential deficits is long and varied depending on which brain areas were damaged.
Many of these outcomes are preventable or reducible with timely treatment. The patient who presented with mild weakness, was misdiagnosed, and left with dense paralysis might have walked out of the hospital if tPA had been given in time. The treatment existed. The opportunity existed. What didn't exist was recognition of what was happening fast enough to act.
Building the Case
Stroke misdiagnosis cases center on timing. When did symptoms begin? When did the patient arrive at the emergency department? What workup was performed, and how long did it take? When was imaging completed? When was neurology consulted? When was the correct diagnosis finally made? Was the treatment window still open at that point?
Emergency department records are time-stamped throughout. Nursing notes record vital signs and clinical observations at specific times. Physician evaluations are documented with timestamps. Imaging orders, scan completions, and results all have recorded times. This documentation allows reconstruction of exactly what happened when—and reveals where delays occurred that shouldn't have.
Expert neurologists evaluate whether the care met standards and, critically, whether earlier treatment would have changed the outcome. The medical complexity of these cases is significant, but so are the stakes. When diagnostic delay costs patients brain function they didn't have to lose, someone should be held accountable.