What is the initial management and history taking approach for a patient with a suspected stroke to localize the site of the lesion?

Initial Management and History Taking for Suspected Stroke Localization

The most critical initial step in managing a suspected stroke patient is to stabilize the airway, breathing, and circulation (ABCs), followed by a rapid neurological assessment using a validated stroke scale like the NIHSS, while simultaneously establishing the exact time of symptom onset to determine eligibility for time-sensitive interventions. 1

Emergency Triage and Initial Evaluation

• Patients with suspected stroke should be triaged with the same priority as those with acute myocardial infarction or serious trauma, regardless of deficit severity 1
• Implement stroke pathways and notify the stroke team immediately upon suspicion of stroke 1
• Perform initial stabilization of ABCs, followed by assessment of neurological deficits and comorbidities 1
• Monitor cardiac rhythm as cardiac abnormalities may accompany stroke 1
• Check vital signs at least every 30 minutes while in the emergency department 1
• Treat fever >99.6°F as hyperthermia is associated with poor stroke outcomes 1

Critical History Elements for Lesion Localization

• Time of symptom onset: The single most important historical information - defined as when the patient was last at baseline or symptom-free 1

  • For patients unable to provide this information or who awaken with symptoms, use the time last known to be normal 1
  • Use creative questioning to establish time anchors (phone calls, TV programs, etc.) 1

• Pattern of neurological deficits: Document specific symptoms to help localize the lesion 1

  • Anterior circulation symptoms: Contralateral hemiparesis, hemisensory loss, aphasia (left), neglect (right) 1
  • Posterior circulation symptoms: Vertigo, ataxia, diplopia, bilateral weakness, decreased consciousness 1

• Progression of symptoms: Note if symptoms were preceded by similar symptoms that resolved (TIA) 1

• Risk factors and medical history: Identify potential stroke mechanisms 1, 2

  • Hypertension (most important modifiable risk factor) 2
  • Atrial fibrillation or other cardiac conditions 1
  • Diabetes, hyperlipidemia, smoking status 3
  • Prior stroke or TIA 3
  • Family history of stroke or vascular disease 3

Diagnostic Workup

• Brain imaging: Order urgent CT or MRI (within 24 hours, but ideally immediately) 1, 4

  • Non-contrast CT can exclude hemorrhage and assess for early ischemic changes 1
  • Consider CTA from aortic arch to vertex to assess extracranial and intracranial circulation 4

• Laboratory tests: Order immediately but do not delay imaging 1, 4

  • Complete blood count, electrolytes, renal function 1
  • Coagulation studies (INR, aPTT) 4
  • Blood glucose (to rule out hypoglycemia mimicking stroke) 1
  • Cardiac biomarkers (troponin preferred over CPK) 1

• Cardiac evaluation: ECG to identify concurrent myocardial ischemia or arrhythmias 1

Differentiating Stroke from Mimics

• Be aware of conditions that can mimic stroke presentation 1:
  • Psychogenic: Lack of objective cranial nerve findings, inconsistent exam
  • Seizures: History of seizures, witnessed seizure activity, postictal period
  • Hypoglycemia: History of diabetes, low serum glucose, decreased consciousness
  • Migraine with aura: History of similar events, preceding aura, headache
  • Hypertensive encephalopathy: Headache, delirium, significant hypertension
  • Wernicke's encephalopathy: History of alcohol abuse, ataxia, ophthalmoplegia
  • CNS abscess or tumor: Gradual progression, fever, history of malignancy

Early Management Considerations

• Position the head of bed at 25-30° unless contraindicated 1
• Provide supplemental oxygen for hypoxic patients 1
• For patients receiving thrombolysis, check vital signs every 15 minutes during infusion 1
• For non-thrombolysis patients, check neurological status and vital signs at least every 4 hours 1
• Perform swallowing screening as early as possible using a validated tool 4

Pitfalls and Caveats

• Failure to establish accurate symptom onset time can exclude patients from time-sensitive interventions 1
• Posterior circulation strokes may present with atypical symptoms and require special attention to airway management 1
• For patients with cerebellar symptoms, consider HINTS examination (head-impulse, nystagmus, test of skew) as it's more sensitive for cerebellar stroke than early MRI 5
• Avoid delays in imaging - CT scan should be completed within 25 minutes for rtPA-eligible patients 1
• Recognize that up to 39% of stroke patients may not know a single sign or symptom of stroke, with elderly patients (≥65 years) being less knowledgeable 3