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Essentials of Diagnosis

  • Stroke presents as a neurologic deficit or headache of abrupt onset.

  • Hemorrhagic strokes can be intracerebral or subarachnoid.

  • Urgent neuroimaging studies are essential for diagnosis.

General Principles in Older Adults

Stroke recently declined from the third to the fourth leading cause of death in the United States, which is testament to a half century of progress in cerebrovascular disease prevention and acute care. It remains, however, a leading cause of disability, with up to half of all patients who survive a stroke failing to regain independence and needing long-term health care. Stroke primarily affects the elderly, and for each successive decade after the age of 55 years, the stroke rate doubles for both men and women.

The majority of strokes (80% of cases) result from insufficient blood flow to the brain (ischemic stroke), whereas bleeding that destroys and compresses the brain parenchyma accounts for 15% (intracerebral hemorrhage [ICH]). Bleeding that occurs in the subarachnoid space (subarachnoid hemorrhage) accounts for 5% of strokes.

Clinical Findings

Signs & Symptoms

A stroke presents as an acute neurologic deficit. The neurologic impairment reflects the area of the brain affected. Although the presenting focal neurologic symptoms are variable, 80% of patients present with unilateral weakness; 90% have a speech and/or motor deficit. In addition, deficits in sensation, vision, language, cognition and balance may occur.

Older patients have more severe stroke deficits at presentation than do younger patients. After the onset of symptoms, timely evaluation and diagnosis are paramount. This is because the effect of thrombolysis is time dependent. Thus, neurologic screening tools like the Cincinnati Stroke Scale (Table 23–1) can be useful in early triage.

Table 23–1.Cincinnati stroke scale.

Special Tests

In patients suspected of stroke, diagnostics occur in 2 phases: (a) acute triage and (b) investigations into etiology after stroke is established as the diagnosis.

In the acute triage phase, several tests should be performed routinely in all patients with suspected stroke. This is to establish a diagnosis, identify systemic conditions that may mimic or cause stroke, and identify conditions that influence therapeutic options. Immediate diagnostic studies in all patients should include noncontrast brain CT, blood glucose, serum electrolytes/renal function tests, electrocardiogram (ECG) markers of cardiac ischemia, ...

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