What is the diagnosis and treatment for a patient (Pt.) symptomatic of stroke upon arrival at the emergency department?

Diagnosis and Initial Management of Acute Stroke

A patient presenting with stroke symptoms requires immediate brain imaging with non-contrast CT to differentiate ischemic stroke from hemorrhagic stroke, followed by rapid assessment for time-sensitive reperfusion therapies. 1

Immediate Diagnostic Approach

Priority Triage and Assessment

• Triage stroke patients with the same urgency as acute myocardial infarction or major trauma, regardless of symptom severity 1
• Assign high-severity triage category to be evaluated within 10 minutes of emergency department arrival 1
• Use validated stroke screening tools (FAST: Face drooping, Arm weakness, Speech difficulty, Time) for rapid recognition 1, 2

Critical Time Documentation

• The single most important piece of information is establishing when the patient was last known to be at baseline or symptom-free 1
• For patients who awaken with symptoms, time of onset is when they were last awake and symptom-free 1
• Creative questioning using time anchors (phone call timestamps, TV programming times) may help establish onset time for initially unclear cases 1

Immediate Brain Imaging

• All patients with suspected acute stroke must undergo immediate brain imaging with non-contrast CT or MRI 1
• For patients arriving within 4.5 hours: perform non-contrast CT immediately without delay to determine thrombolysis eligibility 1
• For patients arriving within 6 hours: perform non-contrast CT plus CT angiography (arch-to-vertex) to identify large vessel occlusions eligible for endovascular thrombectomy 1
• Target door-to-imaging time of 25 minutes or less 1

Differential Diagnosis Considerations

Stroke Mimics to Exclude

The following conditions can present with stroke-like symptoms and must be ruled out 1:

• Hypoglycemia (check serum glucose immediately in all patients) 1
• Seizures (history of witnessed seizure activity, postictal period) 1
• Migraine with aura (history of similar events, preceding aura) 1
• Hypertensive encephalopathy (severe hypertension, headache, delirium) 1
• CNS abscess (fever, history of drug abuse or endocarditis) 1
• Psychogenic causes (inconsistent examination, non-vascular distribution) 1

Stroke Type Differentiation

• Ischemic stroke (approximately 85-88% of cases): requires consideration for thrombolysis and/or thrombectomy 1, 3
• Intracerebral hemorrhage (approximately 12-15% of cases): requires blood pressure management and coagulopathy reversal 1
• Subarachnoid hemorrhage: consider with sudden severe headache; may require lumbar puncture if imaging negative 3

Initial Severity Assessment

Neurological Scoring

• Perform National Institutes of Health Stroke Scale (NIHSS) on arrival and before/after any treatment 1
• Use Glasgow Coma Scale for obtunded or comatose patients 1
• Repeat validated neurological assessments hourly for first 24 hours 1

Immediate Supportive Care

Airway and Oxygenation

• Administer supplementary oxygen if oxygen saturation <94% 1, 2
• Patients with acute stroke are at risk for respiratory compromise, which exacerbates ischemic brain injury 1

Blood Pressure Management

• Do NOT treat blood pressure in the prehospital setting unless systolic BP <90 mmHg (hypotensive) 1
• For thrombolysis candidates: lower BP to <185/110 mmHg before treatment and maintain <180/105 mmHg for 24 hours post-treatment 1
• For non-thrombolysis candidates: avoid precipitous BP drops; ideal targets remain uncertain 1

Laboratory Evaluation

• Obtain blood glucose immediately (treat if >8 mmol/L) 4
• For hemorrhagic stroke: measure platelet count, PTT, INR, and obtain medication history 1

Time-Sensitive Treatment Decisions

Ischemic Stroke Treatment Windows

• Intravenous thrombolysis (alteplase or tenecteplase): within 4.5 hours of symptom onset 1, 5
• Endovascular thrombectomy for large vessel occlusion: up to 24 hours in selected patients with salvageable tissue on advanced imaging 1, 5
• Target door-to-needle time of <60 minutes for thrombolysis 1

Hemorrhagic Stroke Management

• Intracerebral hemorrhage is a medical emergency requiring immediate blood pressure control and coagulopathy reversal 1
• Contact neurosurgery immediately for potential hematoma evacuation or external ventricular drainage 1

Critical Pitfalls to Avoid

• Do not delay imaging for extensive history-taking or laboratory results 1
• Do not assume mild symptoms mean low urgency—early deterioration occurs in >20% of patients 1
• Do not treat blood pressure aggressively in the prehospital setting unless hypotensive 1
• Do not miss the therapeutic window by failing to establish accurate time of symptom onset 1
• For cerebellar symptoms, perform HINTS examination (more sensitive than early MRI for cerebellar stroke) 3