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Stroke

Make the Diagnosis: Stroke

Prior Probability

Among emergency patients with nontraumatic, noncomatose, neurologically relevant complaints, the prevalence of stroke or transient ischemic attack is roughly 10%.

Population for Whom Stroke Should Be Considered

Stroke can be considered in patients with a variety of symptoms and signs. Patient with acute neurologic findings, especially those associated with acute focal sensory deficits, focal weakness, change in mentation or level of consciousness, or sudden loss of ability to communicate effectively, should be evaluated for a stroke. Headache, seizure, and syncope are also important symptoms that can identify a patient with a stroke.

Detecting the Likelihood of Stroke

Typically, the physician can rely on just a few findings for identifying the patient with a stroke (Table 48-10).

Table 48-10Likelihood Ratios for Stroke From Summing Up Combinations of Findings
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Table 48-10 Likelihood Ratios for Stroke From Summing Up Combinations of Findings
Combination of Findings Findings Present LR+ (95% CI)
Cincinnati Prehospital Stroke Scale1

Facial paresis

 3 Present 14 (1.6-121)
Arm drift 2 Present 4.2 (1.4-13)
Abnormal speech 1 Present 5.2 (2.6-11)
0 Present 0.39 (0.25-0.61)
Hospital Evaluation2

Persistent neurologic deficit

 4 Present 40 (29-55)
Focal neurologic deficit 1-3 Present Uncertain LR, but probability of stroke ≥10%
Acute onset of symptoms during the previous week 0 Present 0.14 (0.10-0.20)

Abbreviations: CI, confidence interval; LR, likelihood ratio; LR+, positive likelihood ratio.

aThe findings should be applied to patients who have no head trauma.

Reference Standard Tests

Combination of clinical findings with neuroimaging results.

Original Article: Is This Patient Having a Stroke?

Clinical Scenario

The wife of a 58-year-old right-handed man calls emergency medical services because her husband abruptly developed difficulty speaking and moving his right arm. Figure 48-1 presents the diagnostic flow of a patient who experiences neurologic symptoms that suggest a stroke.

Figure 48-1

Diagnostic Flow of a Patient Who Experiences Neurologic Symptoms That Suggest a Stroke

aCincinnati Prehospital Stroke Scale (CPSS); facial droop, arm drift, and abnormal speech. bLos Angeles Prehospital Stroke Scale (LAPSS); medical history (age >45 y, no history of seizures, symptoms < 24 h, not wheelchair bound), blood glucose 60-400 mg/dL (3.3-22 mmol/L), and examination showing unilateral facial weakness, grip weakness, and arm weakness. Abbreviations: LR, likelihood ratio; NIH, National Institutes of Health.

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Why Is the Clinical Examination of Patients With Suspected Stroke Important?

Since the original review of stroke published as part of The Rational Clinical Examination series more than a decade ago, much has changed.1 What has not changed ...

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