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of an organized protocol and stroke team should speed the clinical assessment, the performance of diagnostic studies, and decisions for early management. The clinical assessment (history, general examination, and neurological examination) remains the cornerstone of the evaluation. This evaluation should be performed by the physicians in the ED. The goals are to determine whether the patient has had a stroke and to establish potential contraindications for emergency treatment with agents such as rtPA. A stroke rating scale, such as the NIHSS, provides important information about the severity of stroke. It provides prognostic information, and the score may influence decisions about acute treatment. Some of the recommendations included in the present statement are influenced by the NIHSS. This scale can be performed with a reasonable degree of accuracy by practitioners in a broad range of specialties. Education in the nuances of NIHSS can improve the accuracy of this scale. Because time is critical, a limited number of diagnostic tests are recommended. These tests should be available on a 24-hours-per-day, 7-days-per-week basis. These tests are used to screen for ischemic stroke, to exclude important alternative diagnoses (especially intracerebral hemorrhage), to assess for serious comorbid diseases, and to search for acute medical or neurological complications of the stroke (Table 9). Examination of the cerebrospinal fluid has a limited role in the evaluation of patients with suspected stroke. Additional diagnostic studies, including cardiac and vascular imaging, often are time consuming and may delay emergency treatment. Thus, most of these tests are not done until after the acute treatment or after the patient is admitted to the hospital. The recommendations that follow are similar to those included in previous statements except recommendation 1 under Class III. Class I Recommendations 1.An organized protocol for the emergency evaluation of patients with suspected stroke is recommended (Class I, Level of Evidence B). The goal is to complete an evaluation and to decide treatment within 60 minutes of the patient’s arrival in an ED. Designation of an acute stroke team that includes physicians, nurses, and laboratory/radiology personnel is encouraged. Patients with stroke should have a careful clinical assessment, including neurological examination. 2. The use of a stroke rating scale, preferably the NIHSS, is recommended (Class I, Level of Evidence B). Hospitals (ie, administration) must provide the necessary resources to use such a scale. 3. A limited number of hematologic, coagulation, and biochemistry tests are recommended during the initial emergency evaluation ( Table 9 ) (Class I, Level of Evidence B). 4. Patients with clinical or other evidence of acute cardiac or pulmonary disease may warrant chest x-ray (Class I, Level of Evidence B). 5. An ECG is recommended because of the high incidence of heart disease in patients with stroke (Class I, Level of Evidence B). Class III Recommendations 1. Most patients with stroke do not need a chest x-ray as part of their initial evaluation (Class III, Level of Evidence B). This is a change from the previous guideline. 2. Most patients with stroke do not need an examination of the cerebrospinal fluid (Class III, Level of Evidence B). The yield of brain imaging is very high for detection of intracranial hemorrhage. The clinical course of subarachnoid hemorrhage or acute central nervous system infections usually is distinct from that of ischemic stroke. Examination of the cerebrospinal fluid may be indicated for evaluation of a patient with a stroke that may be secondary to an infectious illness. IV. EARLY DIAGNOSIS: BRAIN AND VASCULAR IMAGING A. Brain Imaging As therapeutic options evolve, brain imaging strategies are playing an increasingly important role in the initial evaluation of patients with acute stroke Brain imaging findings, including the size, location, and vascular distribution of the infarction, as well as the presence of bleeding, affect both short-term and long-term treatment decisions. In addition, information about the possible degree of reversibility of ischemic injury, intracranial vessel status, and cerebral
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