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(NIHSS). The scale may be used by a broad spectrum of non-neurological healthcare providers (Table 8).24,68,69 Use of a standardized examination helps to ensure that the major components of a neurological examination are performed in a timely fashion. These scores not only help to quantify the degree of neurological deficit but also facilitate communication between healthcare professionals, identify the possible location of vessel occlusion, provide early prognosis, and help to identify patient eligibility for various interventions and the potential for complications.42,70–72 Several studies have demonstrated that emergency physicians committed to stroke care may correctly identify and safely treat stroke patients, especially with the use of such standardized scales.73,74 All hospital systems should ensure access to neurological expertise when required.75TABLE 8. National Institutes of Health Stroke Scale Several tests should be performed routinely in patients with suspected ischemic stroke to identify systemic conditions that may mimic or cause stroke or that may influence therapeutic options (Table 9). These tests include blood glucose, electrolytes, complete blood count with platelet count, prothrombin time, activated partial thromboplastin time, international normalized ratio, and renal function studies. Hypoglycemia may cause focal symptoms and signs that mimic stroke, and hyperglycemia is associated with unfavorable outcomes. Determination of the platelet count and, in patients taking warfarin or with liver dysfunction, the prothrombin time/international normalized ratio is important. Because time is critical, thrombolytic therapy should not be delayed while waiting for the results of the prothrombin time, activated partial thromboplastin time, or platelet count unless a bleeding abnormality or thrombocytopenia is suspected, the patient has been taking warfarin and heparin, or anticoagulation use is uncertain.. Immediate Diagnostic Studies: Evaluation of a Patient With Suspected Acute Ischemic Stroke 5. Cardiac Tests A clinical cardiovascular examination, cardiac enzyme tests, and a 12-lead ECG should be performed in all stroke patients (Table 9).76 Cardiac abnormalities are prevalent among patients with stroke, and the patient can have an acute cardiac condition that mandates urgent treatment. For example, acute myocardial infarction can lead to stroke, and acute stroke can lead to myocardial ischemia.77–79 In addition, cardiac arrhythmias can occur among patients with acute ischemic stroke.77,78,80,81 Atrial fibrillation, an important potential cause of stroke, can be detected in the acute setting.82 Cardiac monitoring should be conducted routinely after an acute cerebrovascular event to screen for serious cardiac arrhythmias.83 Chest radiography was previously recommended for the evaluation of all patients with acute ischemic stroke.1 A subsequent study found that clinical management was altered in only 3.8% of patients who had routine chest radiographs at the time of admission for stroke, which suggests that the test is of modest, but not nil, value.83 Examination of the cerebrospinal fluid is indicated if the patient has symptoms suggestive of subarachnoid hemorrhage and a CT scan does not demonstrate blood. Fortunately, the clinical features of subarachnoid hemorrhage differ considerably from those of ischemic stroke. Electroencephalography may be helpful for evaluating patients in whom seizures are suspected as the cause of the neurological deficits or in whom seizures could have been a complication of the stroke.84 Seizure in the absence of imaging confirmation of acute ischemia is a relative contraindication for the use of rtPA in acute ischemic stroke. Additional tests may be performed as indicated by the patient’s history, symptoms, physical findings, or comorbidities). A toxicology screen, blood alcohol level, arterial blood gas, and pregnancy test should be obtained if the physician is uncertain about the patient’s history or as suggested by findings on examination. B. Conclusions and Recommendations The evaluation and initial treatment of patients with stroke should be performed as a priority in the hospital ED. The development
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