Diagnosis of acute stroke

Kenneth S Yew, Eric M Cheng
American Family Physician 2015 April 15, 91 (8): 528-36
Stroke can be categorized as ischemic stroke, intracerebral hemorrhage, or subarachnoid hemorrhage. Awakening with or experiencing the abrupt onset of focal neurologic deficits is the hallmark of the diagnosis of ischemic stroke. The most common presenting symptoms of ischemic stroke are speech disturbance and weakness on one-half of the body. The most common conditions that can mimic a stroke are seizure, conversion disorder, migraine headache, and hypoglycemia. Taking a patient history and performing diagnostic studies will usually exclude stroke mimics. Neuroimaging is required to differentiate ischemic stroke from intracerebral hemorrhage, as well as to diagnose entities other than stroke. The choice of neuroimaging depends on availability of the method, the patient's eligibility for thrombolysis, and presence of contraindications. Subarachnoid hemorrhage presents most commonly with sudden onset of a severe headache, and noncontrast head computed tomography is the imaging test of choice. Cerebrospinal fluid inspection for bilirubin is recommended if subarachnoid hemorrhage is suspected in a patient with a normal computed tomography result. Public education about common presenting stroke symptoms may improve patient knowledge and clinical outcomes.

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Phillip Sirota

1. Know the appropriate imaging tests to order in the patient with acute stroke.
2. Know the evidence for IV-TPA in the management of acute ischemic stroke and the guidelines for its administration.
3. Know the evidence for aspirin therapy in the management of acute ischemic stroke (dose, time of initiation).
4. Know the appropriate management of acute stroke in a patient who presents with atrial fibrillation.
5. Know the appropriate management of a patient with acute ischemic stroke who presents outside the window for IV-TPA. Identify the circumstances in which catheter directed clot retrieval indicated and when it is contraindicated.


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