What is the correct way to document a stroke diagnosis, including type, vascular territory, onset time, neurological deficits, NIH Stroke Scale score, imaging findings, patient demographics, relevant past medical history, current antithrombotic therapy, and presumed etiology?

How to Document a Stroke Diagnosis

A complete stroke diagnosis must include: (1) stroke type (ischemic vs. hemorrhagic), (2) exact symptom onset time (last known well), (3) NIHSS score at presentation, (4) vascular territory and imaging findings, (5) stroke severity classification, (6) relevant exclusion criteria for reperfusion therapy, and (7) presumed etiology using a standardized classification system. 1

Essential Components of Stroke Documentation

Patient Demographics and Timing

• Document the patient's age because age >80 years excludes patients from the 3–4.5 hour thrombolysis window (though not the 0–3 hour window). 1
• Record the exact time of symptom onset or last known well time, as this determines all reperfusion therapy eligibility. 1
• For wake-up strokes, the onset time is defined as the last moment the patient was awake and symptom-free, not when the deficit was discovered. 2
• Use time anchors (TV programs, phone calls, bathroom visits) and witness accounts to establish timing when the patient cannot provide history. 2

Neurological Assessment and Severity Grading

• Calculate and document the NIHSS score at the time of stroke diagnosis to quantify deficit severity, guide treatment eligibility, and predict prognosis. 3, 1
• Classify acute stroke severity using standardized categories: mild (NIHSS 0–5), moderate (NIHSS 6–14), or severe (NIHSS ≥15). 3
• Document specific focal neurological deficits including impairment of language, motor function, cognition, gaze, vision, or neglect. 4
• Record the pre-stroke Modified Rankin Scale (mRS) score, as only patients with mRS 0–1 are clearly eligible for endovascular thrombectomy in the 0–6 hour window. 2

Stroke Type Classification

• Distinguish between ischemic stroke, hemorrhagic stroke (intracerebral or subarachnoid), and stroke mimics based on clinical presentation and imaging. 3

Ischemic Stroke Documentation

• Define ischemic stroke as acute onset of focal neurological signs or symptoms conforming to a focal or multifocal vascular territory with either: (a) signs/symptoms lasting ≥24 hours or until death with neuroimaging evidence of CNS infarction, or (b) symptoms lasting <24 hours with neuroimaging confirmation of CNS infarction in the corresponding vascular territory. 3
• Document the vascular territory involved (anterior circulation, posterior circulation, specific arterial distribution). 4
• When symptoms last <24 hours without imaging evidence of infarction, classify as TIA (NeuroARC Type 3a), not stroke. 3

Hemorrhagic Stroke Documentation

• For intracerebral hemorrhage, document location (deep, lobar, brainstem, cerebellar, primary intraventricular, single vs. multiple). 5
• Record hemorrhage size using the ABC/2 method and note presence/absence of intraventricular extension. 5
• For subarachnoid hemorrhage, classify etiology (aneurysmal rupture, intracranial dissection, perimesencephalic, cortical). 5

Imaging Findings

• Document non-contrast CT findings, specifically noting presence or absence of intracranial hemorrhage, extent of early ischemic changes, and whether changes exceed >1/3 of the middle-cerebral-artery territory. 1
• Record CT angiography findings to identify large-vessel occlusions qualifying for mechanical thrombectomy. 1
• Note any covert CNS injury (neuroimaging evidence of focal or multifocal ischemia without acute neurological symptoms). 3

Vital Signs and Laboratory Values

• Record specific blood pressure values (systolic/diastolic), as BP must be <185/110 mmHg before thrombolysis and maintained <180/105 mmHg for 24 hours after. 1
• Document point-of-care glucose, as values <50 mg/dL or >400 mg/dL exclude NINDS-window thrombolysis. 1
• Record INR (>1.7 excludes ECASS III thrombolysis; >1.6 excludes NINDS-window thrombolysis), platelet count (<100×10⁹/L is an absolute contraindication), and other relevant laboratory values. 1

Medication History and Contraindications

• Document current anticoagulant use (warfarin, direct oral anticoagulants, heparin) and timing of last dose, as this directly determines thrombolysis eligibility. 2
• Record antiplatelet therapy (aspirin, clopidogrel, dual antiplatelet) when assessing for reperfusion treatment. 2
• Note any oral anticoagulant use, which excludes patients from ECASS III-window thrombolysis regardless of INR. 1

Past Medical History Relevant to Exclusion Criteria

• Document prior stroke or serious head trauma within 3 months (absolute contraindication to thrombolysis). 2, 1
• Record major surgery within 14 days, recent hemorrhage (GI/GU bleeding within 21 days), myocardial infarction within 3 months, and history of intracranial hemorrhage. 2, 1
• Note the combination of diabetes mellitus plus prior stroke, which excludes patients from the 3–4.5 hour treatment window. 2, 1
• Document arterial puncture at a non-compressible site within 7 days, recent intracranial/intraspinal surgery, known intracranial neoplasm, arteriovenous malformation, or aneurysm. 2

Stroke Etiology Classification

• Use a standardized classification system such as TOAST (minimum requirement) or more stringent mechanistic systems like the Causative Classification System (CCS) for prospective studies. 5
• Document potential etiologies including atherothrombotic, small vessel disease, cardioembolic, or other causes. 5
• Record cardiac rhythm findings (atrial fibrillation suggests cardioembolic source and guides post-stroke anticoagulation). 2, 1
• Note vascular imaging findings (carotid stenosis, large-vessel occlusion) that influence management. 1

Disability and Functional Outcome

• Assess stroke disability using the mRS between 30 and 90 days (90 days optimal), classifying as: fatal stroke (death from stroke), stroke with disability (mRS ≥2 at 90 days and increase ≥1 from baseline), or stroke without disability (mRS 0–1 at 90 days or no increase from baseline). 3

Timing Classification

• Classify neurological events by timing: periprocedural (≤30 days after index procedure), acute (≤24 hours), sub-acute (>24 hours and ≤30 days), early (>30 days and ≤1 year), or late (>1 year). 3

Common Documentation Pitfalls to Avoid

• Never accept "onset unknown" without exhaustive questioning using time anchors and witness accounts. 2
• Do not delay imaging or thrombolysis while awaiting complete laboratory results unless a specific contraindication (e.g., INR for warfarin patients) is suspected. 1
• Do not rely on a single ECG to rule out atrial fibrillation; prolonged monitoring up to 30 days is necessary. 1
• Severe headache, vomiting, or coma on arrival roughly doubles the likelihood of intracerebral hemorrhage rather than ischemic stroke and warrants urgent imaging. 2
• When CNS infarction location does not match transient (<24 hours) symptoms, classify as both covert CNS infarction (NeuroARC Type 2a) and TIA (NeuroARC Type 3a), not as ischemic stroke. 3