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severity of the deficits. Roughly half of all acute stroke patients access the ED through 9-1-1 and EMS. Prehospital notification of the arrival of a patient with a potential stroke expedites evaluation and diagnosis, and therefore hospitals should request notification from local EMS providers.63,64 For the remaining 50% of stroke patients, the ED staff should maintain a high level of suspicion for stroke in patients presenting through the ED lobby to minimize delays in triage. Early implementation of stroke pathways and stroke team notification should occur in parallel with the ED evaluation and management. A. Immediate Evaluation The initial evaluation of a potential stroke patient is similar to that of other critically ill patients: stabilization of the ABCs. This is quickly followed by a secondary assessment of neurological deficits and possible comorbidities. The overall goal is not only to identify patients with possible stroke but also to exclude stroke mimics (conditions with stroke-like symptoms), identify other conditions requiring immediate intervention, and determine potential causes of the stroke for early secondary prevention. Stroke Mimics and Clinical Features 1. History The single most important piece of historical information is the time of symptom onset. The current definition of the time of stroke onset is when patients were at their previous baseline or symptom-free state. For patients unable to provide this information or who awaken with stroke symptoms, the time of onset is defined as when the patient was last awake and symptom free or known to be “normal.” Often a patient’s current symptoms were preceded by similar symptoms that subsequently resolved. Currently, for patients who had neurological symptoms that completely resolved, the therapeutic clock is reset, and the time of symptom onset begins anew. It is important to note, however, that the longer the transient neurological deficits last, the greater is the chance of detecting neuroanatomically relevant focal abnormalities on diffusion-weighted and apparent diffusion coefficient imaging.65 Whether this represents an increased risk of hemorrhage with thrombolysis remains to be determined. Additional historical items include circumstances around the development of the neurological symptoms and features that may point to other potential causes of the symptoms. Although not absolutely accurate, some early historical data and clinical findings may direct the physician toward a diagnosis of another cause for the patient’s symptoms (Table 7). It is important to ask about risk factors for arteriosclerosis and cardiac disease in all patients, as well as any history of drug abuse, migraine, seizure, infection, trauma, or pregnancy. Historical data related to eligibility for therapeutic interventions in acute ischemic stroke are equally important.66 Bystanders or family witnesses should be asked for information about onset time and historical issues, and therefore EMS personnel should be encouraged to identify witnesses and bring them in the ambulance when patients are unable to speak or provide history. Validated tools for identification of stroke patients within an ED are available.67 2. Physical Examination The general physical examination continues from the original assessment of the ABCs and should include pulse oximetry and body temperature. Examination of the head and neck may reveal signs of trauma or seizure activity (eg, contusions, tongue lacerations), carotid disease (bruits), or congestive heart failure (jugular venous distention). The cardiac examination focuses on identifying concurrent myocardial ischemia, valvular conditions, irregular rhythm, and, in rare cases, aortic dissection, which could precipitate a cardioembolic event. Similarly, the respiratory and abdominal examinations seek to identify other comorbidities. Examination of the skin and extremities may also provide insight into important systemic conditions such as hepatic dysfunction, coagulopathies, or platelet disorders (eg, jaundice, purpura, petechia) 3. Neurological Examination and Stroke Scale Scores The emergency physician’s neurological examination should be brief but thorough. It is enhanced by use of a formal stroke score or scale, such as the NIH Stroke Scale
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