a. Acuity? When did symptoms start?

b. Badness? How severe are they?

c. Bleeding? Intracranial blood is an absolute contraindication for tPA

d. Anterior vs. posterior? I.e., carotid vs. vertebrobasilar territory.

a. Anterior circulation: Acute usually defined as sx beginning <3 h ago, but rx now available for anterior circulation strokes up to 9 h (or more if sx fluctuate, esp. with BP).

b. Posterior circulation: Up to 24 h for posterior circulation strokes.

a. Level of consciousness: 0 = alert and responsive; 1 = arousable to minor stimuli; 2 = arousable only to pain; 3 = reflex responses or unarousable.

b. Orientation: Ask pt.’s name and month. Must be exact. 0 = both correct; 1 = one correct (or dysarthria, intubated, foreign language); 2 = neither correct.

c. Commands: Open/close eyes, grip and release nonparetic hand (mimicry or another 1-step command okay). 0 = both correct (okay if impaired by weakness); 1 = one correct; 2 = neither correct.

d. Best gaze: Horizontal EOM by voluntary or Doll’s test. 0 = normal; 1 = partial palsy (abnormal in one or both eyes); 2 = forced eye deviation or total paresis that cannot be overcome by Doll’s.

e. Visual field: Use visual threat if necessary. If monocular, score field of good eye. 0 = normal; 1 = quadrantanopia, partial hemianopia, or extinction; 2 = complete hemianopia; 3 = blindness.

f. Facial palsy: If stuporous, check grimace to pain. 0 = normal; 1 = minor paralysis (flat nasolabial fold, asymmetric smile); 2 = partial paralysis (lower face); 3 = complete paralysis (lower and upper face).

g. Motor arms: Arms outstretched 90 degrees (sitting) or 45 degrees (supine) for 10 sec. Encourage best effort. 0 = no drift × 10 sec; 1 = drift but does not hit bed; 2 = some antigravity effort, but cannot sustain; 3 = no antigravity effort, but even minimal movement counts; 4 = no movement at all; X = cannot assess due to amputation, fracture, etc.

h. Motor legs: Score like motor arms (see above).

i. Limb ataxia: Check finger-nose and heel-shin; score only if out of proportion to paresis. 0 = no ataxia (or aphasia, hemiplegic); 1 = ataxia in arm or leg; 2 = ataxia in arm AND leg; X = unable to assess, as above.

j. Sensory: Use pin. Check grimace or withdrawal if stuporous. Score only stroke-related losses. 0 = normal; 1 = mild-moderate unilateral loss but pt. aware of touch (or aphasic or confused); 2 = total unilateral loss, pt. unaware of touch; 3 = bilateral loss or coma.

k. Best language: Describe cookie jar or picture; name objects; read sentences. May use repeating, writing, stereognosis. 0 = normal; 1 = mild-mod aphasia (but comprehensible); 2 = severe aphasia (almost no info exchanged); 3 = mute, no one-step commands, coma.

l. Dysarthria: Read list of words. 0 = normal; 1 = mild-mod slurring; 2 = severe, unintelligible, or mute; X = intubation or mechanical barrier.

m. Extinction/neglect: Simultaneously touch pt on both hands, show fingers in both visual fields, ask about deficit, left hand. 0 = normal; 1 = neglects or extinguishes to double stimulation in any modality; 2 = profound neglect in more than one modality.

a. Anterior: Preserved alertness, aphasia; neglect; both weak and numb in face + arm without leg OR in leg without face + arm; horizontal gaze palsy in which pt. looks away from paretic side.

b. Posterior: Ataxia; vertigo, N/V; cranial nerve deficits; altered consciousness; bilateral or crossed sensory and motor deficits; crossed dissociation of proprioception from pain sensation, horizontal gaze palsy in which pt looks towards paretic side.

a. Other causes and complications: LOC, seizure-like activity, previous strokes and their deficits, etc.

b. Vascular risk factors: HTN, smoking, obesity, DM, hyperlipidemia, male sex, age, angina, MIs, PVD, pregnancy, oral contraceptive use, family history of early MIs or strokes.

c. Detailed exam: See sx of specific stroke syndromes, p. 26.

a. General: Glucose, BUN/Cr, CBC, PTT (q6h on heparin until in range), PT, INR, ESR, Hgb A1c, RPR, homocysteine.

b. Lipids: Total cholesterol, LDL, HDL, triglycerides.

c. Hypercoagulability panel for pts <60 (lupus anticoagulant and anticardiolipin Ab, D-dimer, fibrinogen, Lp(a), protein C&S, factor V Leiden, prothrombin gene mutation, antithrombin III Ab).

a. Emergent head CT: To rule out bleed. Best to do head and neck CTA at same time; it may detect persistent clot or arterial stenosis (contraindications: confirmed contrast allergy, Cr >1.7). Consider CT perfusion scan to assess area at risk for further ischemia.

b. Follow-up scan: To assess stroke territory, e.g., MRI with diffusion-weighted image (DWI), or repeat CT in 6-12 h. Consider diffusion-perfusion MRI to look for territory at risk in pts whose exam fluctuates or iron-susceptibility sequence to rule out small bleeds from amyloid angiopathy.

c. Vascular studies: Carotid ultrasound, anterior and posterior transcranial Doppler (TCD), MRA (time-of-flight or with gadolinium), or CT angiogram. Consider conventional angiogram [diagnostic or therapeutic (IA tPA)].

a. Large artery: (∼15% of strokes) Arterial dissection, atherosclerosis.

b. Penetrating artery: (∼25%) Lacunar, from hypertensive lipohyalinosis.

c. Venous thrombosis: (see p. 126.)

a. Cardiac: About 20% of all ischemic strokes. Causes: A fib, sustained A flutter, rheumatic valve dz/mechanical valves, LV clot (recent MI, dilated cardiomyopathy), endocarditis, myxoma, hypercoagulable state (see p. 192).

b. Paradoxical embolus: Via patent foramen ovale, atrial septal aneurysm, atrial or ventricular septal defect; or clot from lung.

c. Artery-to-artery embolus: E.g., from carotid plaque.

d. Other: Fat, air, or septic embolus.