History

&
Diagnosis of
stroke
History & Examination
-An accurate history profiling the timing of neurological
events is obtained from the patient or from family
members in the case of the unconscious or
noncommunicative patient.
-particular importance are the exact time and pattern
of symptom onset
& abrupt
onset with worsening symptoms and decreasing level
of consciousness is suggestive of
cerebral hemorrhage.
- Severe headache described as “the worst
headache of my life” is suggestive of subarachnoid
hemorrhage.
- An embolus also occurs rapidly, with no
warning, and is frequently associated with heart disease
and/or heart complications more variable and uneven
onset is typical with thrombosis.
- The patient’s past history, including episodes of
TI s or head trauma, presence of major or minor risk
factors,medications, persistent family history and any
recent alterations in patient
function (either transient or permanent) are
thoroughly investigated.
- Stroke can mimic a number of other conditions
that must be ruled out, including seizures,
 space-occupying lesions (e.g., subdural
hematoma,cerebral abscess/
infection, tumor, syncope, somatization, and delirium
secondary to sepsis)
- The physical examination of the patient includes
an investigation of vital signs (BP, HR,RR) are signs of
cardiac decompensation, and function of the cerebral
hemispheres, cerebellum, cranial nerves, eyes, and
sensorimotor system.
-The presenting symptoms will help to determine the
location of the lesion and comparison of both sides of
the body will reveal the side of the lesion.

- Bilateral signs are suggestive

of brainstem lesions or massive cerebral involvemen
 Tests and Measures
The National Institutes of Health Stroke Scale
(NIHSS) is a valuable screening tool that focuses on
initial & serial examination of impairments following
acute stroke.
-The scale includes 11 items and uses a variable ordinal
scale. Some items are scored 0–2 or 0–3 (level of
consciousness, best gaze, visual fields,
facial palsy,limb ataxia, sensory, best language,
dysarthria, extinction, and inattention); other items
are scored 0–4(motor arm and motor leg). -Specific
descriptors are attached to each score. It was
designed to be completed in 5 to 8 minutes.
- The NIHSS has been used to discriminate between
stroke subtypes. -34-36 number of biomarkers can be
used to help identify acute cerebral ischemia.
-These include inflammatory mediators such as IL-6,
matrix metalloproteinase [MMP-9],
markers of glial activation, and so forth.
-Biomarker assays may play an increasing role in the
diagnosis of acute stroke as more research becomes
available.

-Standardized set of blood analyses is performed,

including hematological studies, serum electrolyte
levels,renal and hepatic tests. hese tests are used to
rule out metabolic abnormalities, as well as blood,
kidney or liver conditions.
-Cerebrovascular imaging is the main tool to
establishthe diagnosis of suspected ischemic stroke
and to rule out hemorrhagic stroke and other types of
central nervous system (CNS) lesions (e.g., tumor or
abscess).
-Advanced neuroimaging can rapidly identify the
occluded artery and estimate the size of the core and
the penumbra. It is also used to guide ischemic stroke
therapy.
-Lack of imaging use is high in acute stroke primarily
because many patients arrive beyond
the strict 3-hourtime window.
-Computed Tomography
Computed tomography (CT) scan is the most
commonly used and readily
available neuroimaging
 technique. -CT resolution allows
identification of large
arteries and veins and venous sinuses. It demonstrates
poor sensitivity for detecting small infarcts and
infarction in the posterior fossa.
-Many times CT scans during
the acute phase are negative with no clear evidence of
abnormalities.
 However, acute bleeding and hemorrhagic
transformation
are visible on CT
scanning.
-In the subacute phase, CT scans can delineate the
development of cerebral edema (within 3
days),which then fades over the next 2 to 3 weeks.
 -Cerebral infarction (within 3 to 5 days) is visible
with the addition of contrast material by
showing areas of decreased density.
Long-term parenchymal changes consistent
with scar formation are also visible on CT. It is
important to remember that
the extent of CT lesion does not necessarily correlate
with clinical signs or
changes in function
 -Magnetic Resonance Imaging
Magnetic resonance imaging (MRI) has evolved to
become the first-line imaging in some stroke
centers,whereas in other facilities it is used when CT
has not provided clear evidence of lesion location.
-MRI measures nuclear particles as they interact
with a powerful
magnetic field.
 MRI,especially diffusion/perfusion MRI, shows
greater resolution of the brain and its structural
detail than with a
CT scan(Fig. 15.6).
-MRI is more sensitive in the diagnosis of acute strokes,
allowing detection of cerebral ischemia as early as 30
minutes after vascular occlusion andinfarction within 2
to 6 hours.
-It is also able to detail the extent of infarction or
hemorrhage and can detect
smaller lesionsthan a CT
scan.
-Use of contrast enhancement allows documentation
of changes in an infarct
over the first 2 to 3
weeks.
 -MRI scans cannot be performed on individuals with
certain implantable devices (e.g., pacemakers) or
with patients who are claustrophobic.
Doppler Ultrasound
-Doppler ultrasound imaging is a noninvasive
technique that sends
sound waves into the
body.
 -Echoes bounce off the moving blood and artery
and are formed into animage.
Diagnostically, transcranial Doppler is used
to
examine the posterior circulation of the brain (the
vertebrobasilar system).
-Carotid Doppler is used to examine
the carotid arteries and typically precedes carotid
endarterectomy. It is also used to examine the
peripheral arteries in the diagnosis of P D.
Arteriography and Digital Subtraction
Angiography
rteriography is an x-
ray
of
the
caro
tid
arter
y
with
a
 speci
al
dye injected into an artery in the leg
or arm.
Digital subtraction
angiograp
hy DS is
also an x-
 ray of the
carotid
artery with less dye used. hese procedures are considered
invasive and carry a small risk of causing a strokee