• An acute onset of symptoms (seconds to minutes) is suggestive of a

vascular or convulsive problem (e.g. the explosive severe headache of

subarachnoid haemorrhage or the rapid onset of a seizure).
• These episodes of sudden onset may feature a precipitating event (e.g.
exercise) or warning (aura) may be present.
• The aura that precedes a seizure is in fact a partial (focal) seizure, and
may be localising (e.g. auditory hallucinations, an unusual smell or taste,
loss of speech or motor changes) or non-localising (e.g. a feeling of
apprehension).
• The occurrence of an aura followed by sudden unconsciousness is very
suggestive of the diagnosis of a complex partial seizure
• A strokea usually causes symptoms that appear over seconds to
minutes. However, symptoms may present when the patient wakes
from sleep
• The hallmark of stroke is focal neurological dysfunction arising from a
localised insult to the brain, and reflects this area.
• Patients may be unable to move one side of the body (hemiplegia) or
have difficulty with speech or swallowing.
• There may have been previous episodes. When there is resolution of the
symptoms within 24 hours the episode is called a transient ischaemic attack
(TIA), though symptoms longer than an hour or two are typically associated
with abnormality on imaging and are termed a stroke. The rapid onset of
focal symptoms without seizure almost always has a vascular cause:
infarction or haemorrhage.
• If the patient can answer questions it is important to ask about the onset of
the symptoms and about risk factors for stroke The onset of weakness on
one side of the body followed by resolution and a severe headache is
characteristic of hemiplegic migraine, but in elderly patients especially
there may be no headache. This makes the distinction from a transient
ischaemic episode difficult.
• A subacute onset occurs with infection (meningitis or encephalitis;
hours to days) and inflammatory disorders (e.g. Guillain–Barréc
syndrome—acute inflammatory polyradiculoneuropathy, myasthenia
gravis, polymyositis; days to weeks).
• A more insidious onset suggests that the underlying disorder may be
related to either a tumour (weeks to months) or a degenerative
process (months to years).