Standardized Format for Writing Stroke Diagnosis
The proper format for writing a stroke diagnosis should include stroke type, etiology, location, and severity using standardized classification systems such as TOAST, CCS, or A-S-C-O for ischemic stroke. 1
Stroke Type Classification
First, clearly identify the major stroke category:
- Ischemic Stroke (88%) - Caused by arterial occlusion
- Intracerebral Hemorrhage (2%) - Bleeding within brain parenchyma
- Subarachnoid Hemorrhage (10%) - Bleeding into subarachnoid space 1
Ischemic Stroke Subtyping
For ischemic stroke, specify the subtype using one of these classification systems:
TOAST Classification (Minimum Requirement)
- Large artery atherosclerosis (>50% stenosis/occlusion)
- Cardioembolic
- Small vessel occlusion (lacunar)
- Stroke of other determined etiology
- Stroke of undetermined etiology 1
Causative Classification System (CCS) (Preferred)
- More mechanistic approach
- Provides graded certainty
- Limits "undetermined" assignments
- Identifies most likely source when multiple etiologies exist 1
A-S-C-O Phenotypic System (Alternative)
- Provides graded certainty
- Mechanistic approach 1
Location and Distribution
Specify the anatomical location:
- Vascular territory - e.g., "left middle cerebral artery territory"
- Brain structures affected - e.g., "involving left basal ganglia and corona radiata"
- For lacunar stroke: Subcortical location measuring <1.5 cm in diameter 1
- For ICH: Specify location as deep, lobar, brainstem, cerebellum, or intraventricular 1
Severity Assessment
Include a standardized severity score:
- For ischemic stroke: National Institutes of Health Stroke Scale (NIHSS) or Scandinavian Stroke Scale 1
- For ICH: Glasgow Coma Scale (minimum), FUNC score, or ICH score (preferred) 1
- For SAH: Hunt and Hess scale or World Federation of Neurosurgical Societies (WFNS) grading scale 1
Timing and Onset
Document the timing information:
- Date and time of symptom onset or "last known well"
- For TIA: Note that symptoms resolved within 24 hours 1
Example Format
[Stroke Type] due to [Etiology] involving [Location/Distribution], [Severity Score]Examples:
"Ischemic stroke due to large artery atherosclerosis (70% left ICA stenosis) involving left MCA territory, NIHSS 8"
"Lacunar ischemic stroke due to small vessel disease involving right internal capsule, NIHSS 3"
"Intracerebral hemorrhage, deep location (left basal ganglia), ICH score 2, GCS 14"
Important Considerations
- Avoid combining stroke and TIA cases in documentation unless specifically noting the distinction 1
- Document hemorrhage volume for ICH using the ABC/2 method 1
- Note presence/absence of intraventricular hemorrhage and "spot sign" for ICH 1
- Document Fisher or Hijdra scales for initial hemorrhage volume in SAH 1
- Avoid assigning patients to "other" categories - instead categorize by specific etiologies 1
Common Pitfalls to Avoid
- Failing to differentiate between stroke types (ischemic vs. hemorrhagic)
- Omitting severity scores which are essential for prognosis and treatment decisions
- Using vague terminology instead of standardized classification systems
- Not documenting the time of symptom onset or "last known well"
- Overlooking stroke mimics such as seizures, migraines, or hypoglycemia 2
By following this standardized format, you will ensure comprehensive documentation that facilitates appropriate treatment decisions, accurate communication between healthcare providers, and proper coding for administrative purposes.