What are the key components of taking a history from a patient with a cerebrovascular accident (CVA) and why are they important?

Cerebrovascular Accident (CVA) History Taking: Key Components and Rationale

A thorough and structured history taking for stroke patients is essential for accurate diagnosis, determining treatment eligibility, and improving patient outcomes through targeted interventions.

Time of Symptom Onset

• Exact time of symptom onset: This is the most critical piece of information to obtain as it determines eligibility for time-sensitive treatments like thrombolysis and thrombectomy 1
  • Ask: "When did you first notice something was wrong?"
  • Use creative questioning with time anchors: "What TV show were you watching?" "Who were you with?" "What were you doing when symptoms started?"
  • For patients who woke up with symptoms, determine "last known well" time
  • Rationale: Treatment windows are strict (typically 4.5 hours for IV thrombolysis, up to 24 hours for certain thrombectomy candidates)

Symptom Characterization

• Primary neurological deficits: Document specific symptoms 1

  • Ask about sudden onset of:
    • Weakness or numbness (which side of body?)
    • Speech difficulties (slurred speech vs. language problems)
    • Vision changes (complete or partial loss, one or both eyes)
    • Balance/coordination problems
    • Severe headache (especially with hemorrhagic stroke)
  • Rationale: Helps localize the lesion and determine vascular territory involved

• Symptom progression:

  • Ask: "Have the symptoms gotten better, worse, or stayed the same?"
  • Rationale: Helps distinguish between stroke types and identify patients with ongoing ischemia

Medical History

• Vascular risk factors: These significantly impact stroke risk and guide secondary prevention 2

  • Hypertension (most important modifiable risk factor)
  • Atrial fibrillation (increases stroke risk 5-fold)
  • Diabetes mellitus (doubles stroke risk)
  • Hyperlipidemia
  • Coronary artery disease
  • Carotid stenosis
  • Rationale: Identifies underlying etiology and guides secondary prevention

• Previous cerebrovascular events: 2

  • Prior stroke or TIA (increases risk of recurrent events)
  • Level of disability from previous stroke
  • Rationale: Prior CVA is an independent predictor of recurrent stroke 3

• Cardiovascular history: 2

  • Heart failure
  • Myocardial infarction
  • Valvular heart disease
  • Rationale: Cardiac conditions can cause cardioembolic strokes

Medication History

• Current medications: 1
  • Anticoagulants (warfarin, DOACs) - affects treatment decisions and bleeding risk
  • Antiplatelet agents (aspirin, clopidogrel) - affects treatment decisions
  • Antihypertensives - helps assess BP control
  • Statins - helps assess lipid management
  • Rationale: Impacts acute management decisions and identifies medication non-adherence

Family History

• Family history of stroke or vascular disease: 1
  • First-degree relatives with early stroke
  • Hereditary conditions (CADASIL, Fabry disease)
  • Rationale: May suggest genetic predisposition or hereditary stroke syndromes

Social History

• Lifestyle factors: 1
  • Smoking status (current, former, never)
  • Alcohol consumption (amount and frequency)
  • Drug use (particularly cocaine, amphetamines)
  • Physical activity level
  • Diet
  • Rationale: Identifies modifiable risk factors for primary and secondary prevention

For Specific Patient Populations

• Women: 2

  • Oral contraceptive use
  • Hormone replacement therapy
  • Pregnancy status and history
  • Migraine with aura
  • Rationale: These factors specifically increase stroke risk in women

• Young adults: 1

  • Hypercoagulable states
  • Recreational drug use
  • Migraine history
  • Oral contraceptive use
  • Rationale: Different etiologies are more common in young stroke patients

Assessment of Stroke Severity

• NIH Stroke Scale components: 1
  • Level of consciousness
  • Gaze
  • Visual fields
  • Facial palsy
  • Motor function (arms and legs)
  • Limb ataxia
  • Sensory function
  • Language and speech
  • Extinction/inattention
  • Rationale: Quantifies deficit severity, facilitates communication among providers, and helps predict outcomes

Screening for Dysphagia

• Swallowing difficulties: 2
  • Ask about coughing while eating/drinking
  • Difficulty managing secretions
  • Voice changes after swallowing
  • Rationale: Dysphagia increases risk of aspiration pneumonia, a common complication after stroke

Common Pitfalls in CVA History Taking

1. Failing to establish precise symptom onset time - This is the most critical information for treatment eligibility
2. Not distinguishing between true stroke and stroke mimics (seizures, migraines, hypoglycemia)
3. Missing atypical presentations in posterior circulation strokes (dizziness, nausea)
4. Overlooking medication non-adherence as a cause for recurrent stroke
5. Not asking about recent procedures that might increase stroke risk (cardiac procedures, AF ablation) 3

Algorithmic Approach to CVA History Taking

1. Establish time of symptom onset (most critical)
2. Document specific neurological deficits and their progression
3. Assess vascular risk factors and previous cerebrovascular events
4. Review medication history (focus on antithrombotics)
5. Evaluate for stroke complications (dysphagia, seizures)
6. Screen for modifiable risk factors for secondary prevention

By following this structured approach to history taking in stroke patients, clinicians can efficiently gather the information needed for diagnosis, acute management decisions, and development of secondary prevention strategies to reduce morbidity and mortality.