From the Guidelines
A comprehensive physical examination for a patient with minor stroke should prioritize a detailed neurological assessment, cardiovascular evaluation, and identification of stroke risk factors to guide immediate management decisions and inform secondary prevention strategies. When performing the physical examination, it is essential to begin with vital signs, including blood pressure, heart rate, respiratory rate, temperature, and oxygen saturation, as outlined in the guidelines for the early management of patients with acute ischemic stroke 1.
The examination should include a thorough neurological assessment using the National Institutes of Health Stroke Scale (NIHSS) to evaluate level of consciousness, language function, visual fields, facial symmetry, motor strength in all extremities, sensory function, coordination, and presence of neglect. Cranial nerves should be evaluated, particularly for signs of facial droop, dysarthria, and visual field defects. If the patient can safely ambulate, gait should be assessed.
A cardiovascular examination is also crucial, including heart auscultation to detect arrhythmias or murmurs suggestive of atrial fibrillation or valvular disease, and carotid auscultation to identify bruits indicating stenosis, as these findings can significantly impact management decisions 1. Peripheral pulses should be checked, and signs of peripheral vascular disease should be looked for. Additionally, examining for signs of other stroke risk factors such as xanthelasma or xanthomas suggesting hyperlipidemia is important.
Given the high risk of recurrent stroke after a minor stroke, with estimates suggesting up to 10% recurrence within the first week of symptom onset 1, a thorough and timely physical examination is critical to identify potential causes of the stroke, coexisting comorbidities, and issues that may impact management. This approach helps determine stroke severity, identify the likely etiology, and inform immediate and long-term management strategies to reduce the risk of future vascular events.
From the Research
Physical Examination of a Patient with Minor Stroke
- The physical examination of a patient with minor stroke is crucial in determining the etiology of the ischemic stroke 2
- Key findings in the physical examination, including vital signs and classic components of the physical exam, can indicate the etiology of the infarct and help choose the use of ancillary tests 2
- The physical examination can help identify signs of the disease, starting with primary vital signs and continuing with careful observation of the patient 2
- A systematic search of articles published in English related to the physical examination of patients with stroke identified key findings that have shown clinical significance when determining ischemic stroke etiology 2
Role of Antiplatelet Therapy
- Antiplatelet therapy, including aspirin, clopidogrel, or a combination of aspirin with dipyridamole, is a first-line option for secondary stroke prevention in the absence of atrial fibrillation 3
- Dual antiplatelet therapy has a benefit in the first three weeks after stroke, but patients should change to a single antiplatelet drug after this time 3
- The addition of clopidogrel to aspirin for patients with transient ischemic attack (TIA) or minor ischemic stroke (IS) appeared to significantly reduce the risk of IS recurrence with a possible increase in the risk of bleeding compared with aspirin alone 4
- Dual antiplatelet therapy with aspirin and clopidogrel is recommended for patients with high-risk TIA or minor ischemic stroke, started within 24 hours of the onset of symptoms and continued for 10-21 days 5
Management of Minor Stroke
- Patients with minor stroke or TIA should be started on dual antiplatelet therapy with aspirin and clopidogrel within 24 hours of the ischemic event and continued for a maximum of 21 days 6
- Statins and antihypertensives are also recommended for secondary stroke prevention 3
- Anticoagulants are indicated if the patient has atrial fibrillation, but combinations of anticoagulants and antiplatelet drugs should be avoided 3