Initial assessment and management of stroke
Abstract
This second article, in a two-part series on stroke, will review and outline the importance of the initial assessment and management of patients with stroke in hospital. Stroke affects over 111 000 individuals per year, with almost 1 million individuals managing daily with its after-effects in England. The management of patients with stroke has rapidly developed in recent years, with widespread access to intravenous thrombolytic therapy for the preponderance (85%) of acute ischaemic stroke, while the remaining haemorrhagic strokes (15%) can potentially be managed with a decompressive hemicraniectomy procedure. Further developments include mechanical thrombectomy that treats large-vessel occlusive stroke using an interventional neuroradiology procedure called mechanical thrombectomy. Ensuring delivery of appropriate stroke treatments relies on the accurate assessment of the patient, with particular attention to their past medical history, cardiovascular risk factors and access to hyperacute stroke care. The key risks factors for stroke will also be discussed, as many of these may only present at stroke diagnosis. A range of stroke assessment tools, including their effectiveness, will be discussed in addition to differential stroke diagnosis and stroke mimics.
References
- Seizures and strokes. In: Bogousslasky JCaplan L, eds. Stroke Syndromes. 2nd edn. Cambridge: Cambridge University Press; 2001: 182–191. Google Scholar .
-
Association of Ambulance Service Chief Executives . UK Ambulance Services Clinical Practice Guidelines Bridgwater: Class Professional Publishing: 2016. Google Scholar - A Randomized Trial of Intraarterial Treatment for Acute Ischemic Stroke. New Engl J Med. 2015:372(1):11–20. Crossref, Google Scholar .
- Safety of tPA in stroke mimics and neuroimaging-negative cerebral ischemia. Neurology. 2010;74(17): 1340–1345. Crossref, Google Scholar .
- Seizures after cerebrovascular events: risk factors and clinical features. Seizure. 2013;22(4):275–282. Crossref, Google Scholar .
- Stroke mimic diagnoses presenting to a hyperacute stroke unit. Clinical Medicine. 2016;16(5):423–426. Crossref, Google Scholar .
-
Department of Health and Social Care . ASSET 2—Action on Stroke Services: an Evaluation Toolkit for commissioners. London: HMSO; 2006. Google Scholar - Emergency department presentation of patients with conversion disorder. Acad Emerg Med. 1995;2:120–123. Crossref, Google Scholar .
- How to identify stroke mimics in patients eligible for intravenous thrombolysis? J Neurol. 2012;259(7):1347–1353. Crossref, Google Scholar .
- Does Use of the Recognition Of Stroke In the Emergency Room Stroke Assessment Tool Enhance Stroke Recognition by Ambulance Clinicians? Stroke. 2013:44. Google Scholar .
- The differential diagnosis of suspected stroke: a systematic review. J R Coll Physicians Edinb. 2013. 43:114–118. http://tinyurl.com/yb4k9jcc (
accessed 13 February 2018 ) Google Scholar . - Distinguishing Between Stroke and Mimic at the Bedside The Brain Attack Study. Stroke. 2016;37(3):769–775. Crossref, Google Scholar .
- Impact of treatment of people with transient ischaemic attack on stroke incidence and public health. Cerebrovasc Dis. 1996: 6(Suppl 1):26–33. Crossref, Google Scholar .
- Experience from a multicentre stroke register: a preliminary report. Bulletin of the World Health Organization. 1976;54(5):541–553. Google Scholar .
- Stroke and conditions that mimic it: a protocol secures a safe early recognition. Hippokratia. 2008;12(2):98–102. Google Scholar .
- Stroke Differential Diagnosis—Mimics and Chameleons. Foundation for Education and Research in Neurological Emergencies. 2014. http://tinyurl.com/y9mwlcnx (
accessed 13 February 2018 ) Google Scholar . - Frequency and accuracy of prehospital diagnosis of acute stroke. Stroke. 1995. 26:937–941. Crossref, Google Scholar .
- The Atlas of Heart Disease and Stroke. WHO: Geneva; 2014. http://tinyurl.com/nx7pk (
accessed 13 February 2018 ) Google Scholar . - Risk and cumulative risk of stroke recurrence: a systematic review and meta-analysis. Stroke. 2011;42:1489–1494. Crossref, Google Scholar .
-
National Audit Office . Progress in improving stroke care. 2010. http://tinyurl.com/yde3mfjy (accessed 13 February 2018 ) Google Scholar -
NHS England . News: Stroke patients in England set to receive revolutionary new treatment. 2017. http://tinyurl.com/yb5u8lu6 (accessed 13 February 2018 ) Google Scholar -
National Institute for Health and Care Excellence . Stroke and transient ischaemic attack in over 16s: diagnosis and initial management. 2008. https://www.nice.org.uk/Guidance/CG68 (accessed 13 February 2018 ) Google Scholar -
National Institute for Health and Care Excellence . Mechanical clot retrieval for treating acute ischaemic stroke. 2016. http://tinyurl.com/y8cgy2yf (accessed 13 February 2018 ) Google Scholar - The Recognition of Stroke in the Emergency Room (ROSIER) scale: development and validation of a stroke recognition instrument. Lancet Neurol. 2005;4:727–734. Crossref, Google Scholar .
-
Royal College of Physicians . National clinical guideline for stroke. 5th edn. 2016. http://tinyurl.com/y95gwlwc (accessed 13 February 2018 ) Google Scholar - The benefits and harms of intravenous thrombolysis with recombinant tissue plasminogen activator within 6 h of acute ischaemic stroke (the third international stroke trial [IST-3]): a randomised controlled trial. Lancet. 2012. 379:2352–63. https://doi.org/https://doi.org/10.1016/S0140-6736(12)60768-5 Crossref, Google Scholar .
- Time is Brain—Quantified. Stroke. 2006;37:263–266. Crossref, Google Scholar .
- Is it a mimic or stroke? Key indicators to help your staff. Dallas: American Heart Association & American Stroke Association; 2015. http://tinyurl.com/y967x9z6 (
accessed 13 February 2018 ) Google Scholar . - Stroke and migraine is there a possible comorbidity? Ital J Pediatr. 2016:42.41 Crossref, Google Scholar .
- Use of the Barthel Index and Modified Rankin Scale in Acute Stroke Trials. Stroke. 1999;30:1538–1541. Crossref, Google Scholar .
- Safety and outcomes of intravenous thrombolysis in stroke mimics: a 6-year, single-care center study and a pooled analysis of reported series. Stroke. 2011;42(6):1771–1774. Crossref, Google Scholar .
- Identifying disease that mimic stroke. JEMS. 2011;36:3. Google Scholar .
- Thrombolysis in Stroke Mimics. Frequency, Clinical Characteristics, and Outcome. Stroke. 2009;40:1522–1525. Crossref, Google Scholar .
- Acute symptomatic hypoglycaemia mimicking ischaemic stroke on imaging: a systemic review. BMC Neurol. 2013;12:139 Crossref, Google Scholar .