How do you evaluate a patient for stroke symptoms?

Evaluation of Stroke Symptoms

Immediately assess airway, breathing, and circulation, then perform a rapid neurological examination using the National Institutes of Health Stroke Scale (NIHSS) within the first 10 minutes of patient arrival, while simultaneously establishing the exact time the patient was last known to be at their normal baseline. 1, 2

Immediate Triage and Initial Assessment

Stroke patients must be triaged at the highest priority level (Emergency Severity Index level 2)—equivalent to unstable trauma or critical cardiac patients—requiring immediate assessment. 1, 3

Primary Survey (First 10 Minutes)

• Assess ABCs (airway, breathing, circulation) to identify any life-threatening conditions requiring immediate intervention 1, 2
• Establish time of symptom onset by determining when the patient was last known to be at their previous baseline or symptom-free state—this is the single most critical piece of information for treatment eligibility 1, 2
  • If exact time cannot be determined, document as morning (6:00 AM-11:59 AM), afternoon (noon-5:59 PM), evening (6:00 PM-11:59 PM), or overnight (midnight-5:59 AM) 1
• Measure blood glucose immediately using fingerstick testing to rule out hypoglycemia, a common stroke mimic 1, 4

Neurological Examination and Stroke Severity Assessment

Use the NIHSS to quantify stroke severity—this standardized 11-item scale ranges from 0-42 points and must be completed within the first 24 hours, ideally at presentation. 1

The NIHSS evaluates 1:

• Level of consciousness (alertness, orientation, commands)
• Visual fields (confrontation testing)
• Extraocular movements (horizontal gaze)
• Facial symmetry (smile, grimace)
• Motor function (arm drift at 90°/45° for 10 seconds; leg drift at 30° for 5 seconds)
• Limb ataxia (finger-to-nose, heel-to-shin)
• Sensory function (pinprick testing)
• Language (naming, comprehension, repetition)
• Dysarthria (speech clarity)
• Extinction/inattention (simultaneous bilateral stimulation)

Interpretation of NIHSS scores: 0-6 points indicates minor stroke, 7-15 points indicates moderate stroke, and ≥16 points indicates severe stroke with higher mortality risk 5, 6

Vital Signs and Physiological Monitoring

Check vital signs every 30 minutes minimum while in the emergency department. 3 Specifically assess:

• Heart rate and rhythm with continuous cardiac monitoring, as cardiac abnormalities frequently accompany stroke 1, 3
• Blood pressure in both arms—critical for treatment decisions 1
  • For non-thrombolytic candidates: only treat if SBP >220 mmHg or DBP >120 mmHg 1
  • For thrombolytic candidates: BP must be <185/110 mmHg before treatment 2
• Temperature every 4 hours for first 48 hours; initiate cooling measures if >37.5°C 2
• Oxygen saturation to ensure adequate oxygenation 1
• Hydration status to assess volume status 1
• Seizure activity monitoring—treat new-onset seizures with short-acting medications (e.g., lorazepam IV) if not self-limited, but do not use prophylactic anticonvulsants 1, 2

Essential Laboratory Investigations

Obtain acute blood work immediately, but do not delay imaging or treatment decisions. 1 Required tests include:

• Complete blood count (CBC) to assess for anemia, thrombocytopenia, or infection 1, 4
• Electrolytes and glucose to identify metabolic derangements 1, 4
• Coagulation studies (INR, aPTT) essential for thrombolytic eligibility 1, 4
• Renal function (creatinine, eGFR) to assess kidney function before contrast studies 1, 4
• Troponin to evaluate for concurrent cardiac ischemia 1, 4
• Electrocardiogram to identify atrial fibrillation or acute coronary syndrome 1, 4

Immediate Neuroimaging

Non-contrast CT or MRI must be completed within 25 minutes of hospital arrival for potential thrombolysis candidates, with interpretation within 45 minutes. 3 This is the critical time benchmark for organized stroke care 1.

• CT scan without contrast is the primary imaging modality to differentiate ischemic from hemorrhagic stroke 2, 4, 3
• CT angiography (CTA) from aortic arch to vertex should be performed simultaneously with initial brain CT when possible to assess for large vessel occlusion 2, 4
• Chest X-ray only if evidence of acute heart or pulmonary disease; can be deferred until after treatment decision 1

Swallowing Assessment

Complete swallowing screening using a validated tool as early as possible, ideally within 24 hours, but do not delay acute stroke treatment decisions. 1, 2

• Keep patient NPO (nil per os) until swallowing screen is completed 1
• Do not administer oral medications until normal swallowing is confirmed; use IV or rectal routes instead 1
• Refer patients with abnormal screening to a healthcare professional with swallowing expertise for comprehensive assessment 1

Special Considerations and Common Pitfalls

For patients with cerebellar symptoms (dizziness, ataxia, visual disturbances), perform the HINTS examination (head-impulse, nystagmus, test of skew)—this is more sensitive for cerebellar stroke than early MRI. 7

For suspected subarachnoid hemorrhage (rapid onset severe headache), if CT is negative but clinical suspicion remains high, perform lumbar puncture for further evaluation 7

For patients beyond 6 hours from symptom onset, CT or MR perfusion scanning can demonstrate perfusion mismatch and determine ischemic core extent for potential endovascular therapy eligibility 3

Critical time targets for organized stroke care 1:

• Door-to-physician: 10 minutes
• Door-to-CT completion: 25 minutes
• Door-to-CT interpretation: 45 minutes
• Door-to-thrombolytic therapy: 60 minutes

Document all findings immediately and share assessment results with the patient and family members to facilitate informed decision-making regarding acute interventions 1