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Diagnosis of Stroke and Stroke Mimics in the Emergency Setting

Diagnosis of Stroke and Stroke Mimics in the Emergency Setting

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CONTINUUM: Lifelong Learning in NeurologyDecember 2008; Volume 14(6) Acute Ischemic Stroke; pp 13-27
Barrett, Kevin M.; Levine, Joshua M.; Johnston, Karen C.
Relationship Disclosure:
Drs Barrett and Levine have nothing to disclose. Dr Johnston hasreceived personal compensation for activities with AstraZeneca, Boehringer IngelheimPharmaceuticals, Inc., Diffusion Pharmaceuticals LLC, NIH-National Institute of NeurologicalDisorders and Stroke, Ono Pharmaceutical Co., Ltd, Remedy Pharmaceuticals, and sanofi-aventis. Dr Johnston has received personal compensation in an editorial capacity from
Up-to- Date
Unlabeled Use of Products/Investigational Use Disclosure:
Drs Barrett and Levine have nothingto disclose. Dr Johnston discusses the unlabeled use of investigational therapies.
Patients with suspected stroke require urgent evaluation in order to identify those who may be eligible for time-sensitivetherapies. A focused and systematic approach to diagnosis improves the likelihood of identifying patients with probableischemic stroke and minimizes the chances of exposing patients with alternate diagnoses to potentially harmful treatment. Thischapter emphasizes the historical, examination, and neuroimaging findings useful in the rapid evaluation and diagnosis of patients with suspected ischemic stroke. Other entities that may present with strokelike symptoms will also be discussed.Back to top 
Note: Text referenced in the Quintessentials Preferred Responses, which appear later in this issue, is indicated inyellow shading throughout this chapter.
Stroke typically presents with the sudden onset of focal neurologic deficits. Appropriate delivery of acute stroke therapiesdepends on accurately establishing the time of symptom onset, performing a focused bedside assessment, and rapidlyinterpreting ancillary tests. This chapter emphasizes a systematic diagnostic approach that will facilitate expeditiousidentification of patients eligible for acute therapies. By necessity, the discussion that follows is presented sequentially.However, it is important to recognize that many elements of the stroke evaluation occur in parallel, depending on resourceavailability or clinical circumstances. Specific evidence-based stroke therapies are covered in a subsequent chapter.
The ability to treat acute ischemic stroke patients with IV thrombolysis or endovascular therapies depends on accuratelyestablishing the time of symptom onset. Under ideal circumstances, the patient is able to provide a detailed account of symptom onset. The history should focus on eliciting information that will establish eligibility for thrombolytic therapy or identifypotential exclusionary conditions. Situations may arise in which the precise time of symptom onset may be difficult to establish.The use of cues (eg, "before or after lunch?" or "before or after the evening news?") may be helpful in generating an estimatedtime of onset. If family or friends are present, it is wise to corroborate the patient's report of symptom onset with eyewitnesses.In some circumstances, a precise time of symptom onset will prove impossible to determine, and the line of questioning shouldthen shift to identifying when the patient was last neurologically normal. For those patients who awaken with symptoms, thetime of onset becomes the time at which they went to bed (assuming they were normal at that time). For patients withheralding symptoms or TIA, it is necessary to ensure complete resolution before the clock can be "reset."The nature of symptom onset should be obtained when possible. Symptoms that begin abruptly suggest a vascular etiology,whereas symptoms that begin in one region and gradually spread to involve other areas may support an alternate etiology (ie,migraine). Inquiry should be made regarding risk factors for vascular disease, as well as any history of seizures, migraine,insulin use, or drug abuse that may support another cause for the patient's symptoms. Information necessary for decisionsregarding thrombolysis must be obtained in a structured fashion to minimize the possibility of overlooking critical information(Table 1-1).
 Accompanying symptoms, particularly headache, warrant further exploration. Ictal, or so-called thunderclapheadache, should alert the clinician to the possibility of subarachnoid hemorrhage. Small bleeds or sentinel leaks fromunruptured intracranial aneurysms may not be evident on CT scan. Further evaluation with lumbar puncture to exclude the presence of blood in the subarachnoid space may be warranted 
TABLE 1-1 Important Historical Information in the Suspected Stroke PatientThe initial evaluation of the potential stroke patient often occurs in a high-acuity area. Medical personnel responsible for establishing IV access, initiating cardiorespiratory monitoring, performing blood draws, and performing electrocardiographycompete for the patient's attention. Additionally, the presence of aphasia or neglect may limit the patient's ability to provideaccurate information. To the physician performing the initial assessment, these activities pose significant challenges.Despite such barriers, critical elements of the history may be obtained indirectly. Emergency medical personnel provideimportant information regarding vital signs and blood glucose levels obtained in the field. Observations regarding level of consciousness, initial severity of deficits, and the presence of bowel or bladder incontinence at the scene provide useful cluesto the etiology of the presenting symptoms. Family members provide important observations and additional history. Reachinga family member by telephone may be necessary if no one is immediately available. In certain circumstances, attempting toreach the patient's primary care provider may prove useful. Documentation of prior stroke, TIA, or other neurologic morbidity inmedical records is valuable. Chronic or previously resolved deficits may potentially confound interpretation of neurologicexamination findings in the acute setting. The presence of advanced dementia or other neurodegenerative process mayinfluence the decision to pursue further aggressive interventions. Examination of medication bottles, if they accompany thepatient, may provide clues to coexisting medical conditions or anticoagulant use.
Neurologic Examination
The examination should focus on identifying signs of lateralized hemispheric or brainstem dysfunction consistent with focal cerebral ischemia.
Commonly encountered ischemic stroke syndromes are outlined in Table 1-2. The location of vascular  occlusion and the extent of collateral flow dictate whether the complete or partial syndrome is present. Frequently, importantexamination findings are observed while obtaining the history. Thus, level of consciousness and the presence of a gazedeviation, aphasia, neglect, or hemiparesis, may be established within minutes of the initial encounter. The NIH Stroke Scale(NIHSS) is a validated 15-item scale that is used to assess key components of the standard neurologic examination andmeasure stroke severity (Lyden et al, 1999). Although initially designed to measure clinical differences in experimental stroketherapy trials(Brott et al, 1989),
the NIHSS has gained widespread acceptance as a standard clinical assessment tool. Thescale assesses level of consciousness, ocular motility, facial and limb strength, sensory function, coordination, language,speech, and attention. Scores range from 0 (normal) to 42 (maximal score) ( 
 ). The NIHSS may be performed rapidly and predicts short-term and long-term neurologic outcomes ( 
 ). Even health care providers without expertisein the neurologic examination may be trained to perform the assessment reliably with only a few hours of instruction ( 
 ). Additionally, NIHSS severity may provide information regarding the likelihood of identifying a large vessel occlusion with vascular imaging 
TABLE 1-2 Common Ischemic Stroke SyndromesTABLE 1-3 NIH Stroke Scale

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