Medical History Information From the Family of a Suspected Stroke Patient
Diagnosis of Acute Stroke
Am Fam Physician. 2015 Apr 15;91(8):528-536.
Patient data: See related handout on stroke, written by the authors of this article.
This clinical content conforms to AAFP criteria for continuing medical teaching (CME). See the CME Quiz Questions.
Writer disclosure: No relevant financial affiliations.
Article Sections
- Abstract
- Classifying Stroke
- Risk Factors
- Clinical Diagnosis
- Diagnostic Tests and Imaging
- Training Patients to Recognize Stroke Symptoms
- References
Stroke can be categorized as ischemic stroke, intracerebral hemorrhage, or subarachnoid hemorrhage. Awakening with or experiencing the abrupt onset of focal neurologic deficits is the hallmark of the diagnosis of ischemic stroke. The most mutual presenting symptoms of ischemic stroke are speech disturbance and weakness on ane-half of the body. The well-nigh common conditions that can mimic a stroke are seizure, conversion disorder, migraine headache, and hypoglycemia. Taking a patient history and performing diagnostic studies volition usually exclude stroke mimics. Neuroimaging is required to differentiate ischemic stroke from intracerebral hemorrhage, likewise as to diagnose entities other than stroke. The choice of neuroimaging depends on availability of the method, the patient's eligibility for thrombolysis, and presence of contraindications. Subarachnoid hemorrhage presents nigh commonly with sudden onset of a severe headache, and noncontrast caput computed tomography is the imaging exam of pick. Cerebrospinal fluid inspection for bilirubin is recommended if subarachnoid hemorrhage is suspected in a patient with a normal computed tomography effect. Public teaching near common presenting stroke symptoms may improve patient knowledge and clinical outcomes.
The symptoms of acute stroke can be misleading and misinterpreted past clinicians and patients. Family physicians are on the forepart line to recognize and manage acute cerebrovascular diseases. Rapid, accurate examination of persons with stroke symptoms can reduce disability and help prevent recurrences.
SORT: Key RECOMMENDATIONS FOR PRACTICE
| Clinical recommendation | Prove rating | References |
|---|---|---|
| All patients with stroke symptoms should undergo urgent neuroimaging with CT or MRI. | C | nine, 37 |
| Patients presenting with acute vestibular syndrome or suspected posterior infarction should undergo acute diffusion-weighted MRI. A negative MRI result should be followed by repeat MRI in three to seven days or bedside oculomotor testing to exclude a simulated-negative result. | C | eighteen, 37 |
| Lumbar puncture should be performed in persons with suspected subarachnoid hemorrhage and a normal noncontrast head CT result. | C | 22, 23 |
| Patients and family unit members should be educated near stroke symptoms and the need for urgent evaluation. | C | nine |
Classifying Stroke
- Abstract
- Classifying Stroke
- Run a risk Factors
- Clinical Diagnosis
- Diagnostic Tests and Imaging
- Training Patients to Recognize Stroke Symptoms
- References
Stroke can be classified past pathologic procedure and vascular distribution affected. Defining the overall pathologic process is critical for decisions on thrombolysis, antithrombotic therapy, and prognosis. Hemorrhagic stroke has a college mortality charge per unit than ischemic stroke.one In the Us, 87% of all strokes are ischemic secondary to big-artery atherosclerosis, cardioembolism, minor-vessel occlusion, or other and undetermined causes.1,two The remaining 13% of strokes are hemorrhagic in intracerebral or subarachnoid locations.1
Hazard Factors
- Abstruse
- Classifying Stroke
- Risk Factors
- Clinical Diagnosis
- Diagnostic Tests and Imaging
- Preparation Patients to Recognize Stroke Symptoms
- References
Although in that location are many risk factors for stroke, such every bit age, family unit history, diabetes mellitus, chronic kidney disease, and sleep apnea, the major modifiable risk factors include hypertension, atrial fibrillation, smoking, symptomatic carotid artery disease, and sickle cell disease.one Physical inactivity; regular consumption of sweetened beverages; and low daily consumption of fish, fruits, or vegetables are too associated with an increased take a chance of stroke.1 In women, current use of oral contraceptives, migraine with aureola, the immediate postpartum period, and preeclampsia confer small absolute increases in take a chance of stroke.1
Clinical Diagnosis
- Abstract
- Classifying Stroke
- Risk Factors
- Clinical Diagnosis
- Diagnostic Tests and Imaging
- Training Patients to Recognize Stroke Symptoms
- References
HISTORY AND Concrete Test
In a community-based study, primary care physicians practicing in an emergency setting had a 92% sensitivity for diagnosing stroke and transient ischemic attack based on history and test.iii The overall reliability of a clinician's diagnosis of stroke is moderate to good, with lower reliability in less experienced or less confident examiners.four The about common historical feature of an ischemic stroke is awakening with or acute onset of symptoms, whereas the well-nigh mutual concrete findings are unilateral weakness and speech disturbance.5 The well-nigh common and reliable symptoms and signs of ischemic stroke are listed in Tabular array 1.4–7 The most common symptoms and signs of posterior circulation stroke are listed in Tabular array 2.8
Figure i provides an algorithm for stroke diagnosis. A critical slice of information is the fourth dimension of onset. This value does non assist in diagnosing stroke, but it determines whether a patient meets the 3- or 4.five-hour eligibility windows for thrombolysis among persons with a diagnosis of ischemic stroke.9
Tabular array 1.
Well-nigh Common Symptoms and Signs of Ischemic Stroke
| Symptom or sign | Prevalence (%) 5 | Agreement betwixt examiners (kappa) 4 |
|---|---|---|
| Symptoms | ||
| Acute onset | 96 | Proficient (0.63)4 |
| Subjective arm weakness* | 63 | Moderate (0.59)4 |
| Subjective leg weakness* | 54 | Moderate (0.59)4 |
| Cocky-reported speech disturbance | 53 | Expert (0.64)4 |
| Subjective facial weakness | 23 | — |
| Arm paresthesia† | xx | Good (0.62)iv |
| Leg paresthesia† | 17 | Good (0.62)four |
| Headache | 14 | Skilful (0.65)4 |
| Nonorthostatic dizziness | 13 | — |
| Signs | ||
| Arm paresis | 69 | Moderate to excellent (0.42 to 1.00)4,6 |
| Leg paresis | 61 | Off-white to fantabulous (0.40 to 0.84)4,6 |
| Dysphasia or dysarthria | 57 | Moderate to excellent (0.54 to 0.84)iv,6 |
| Off-white to excellent (0.29 to 1.00)iv,6 | ||
| Hemiparetic/ataxic gait | 53 | Excellent (0.91)6 |
| Facial paresis | 45 | Poor to excellent (0.xiii to 1.00)4,vi |
| Eye movement aberration | 27 | Fair to excellent (0.33 to 1.00)half-dozen |
| Visual field defect | 24 | Poor to first-class (0.16 to 0.81)4,half dozen |
Table ii.
Nigh Common Symptoms and Signs of Posterior Circulation Stroke
| Symptom or sign | Prevalence (%) eight |
|---|---|
| Symptoms | |
| Dizziness | 47 |
| Unilateral limb weakness | 41 |
| Dysarthria | 31 |
| Headache | 28 |
| Nausea or vomiting | 27 |
| Signs | |
| Unilateral limb weakness | 38 |
| Gait ataxia | 31 |
| Unilateral limb ataxia | 30 |
| Dysarthria | 28 |
| Nystagmus | 24 |
Diagnosis of Acute Stroke
Effigy ane.
Algorithm for the diagnosis of acute stroke.
Physicians managing acute stroke should become familiar with the National Institutes of Health Stroke Calibration (NIHSS). The NIHSS is a xv-item calibration that can be performed in about 5 minutes. Although it can help distinguish stroke from stroke mimics,10 its chief use is to reliably evaluate stroke severity to determine whether tissue plasminogen activator administration is appropriate. It is also used to predict prognosis. Reliable employ of the NIHSS requires training,11 which can produce fantabulous inter-rater reliability of scoring beyond physicians and nurses.12 Free online training is bachelor from the National Stroke Clan at http://www.stroke.org/site/PageServer?pagename=nihss.13
Studies of missed stroke diagnosis have establish weakness and fatigue, altered mental status, syncope, altered gait and dizziness, and hypertensive urgency to exist the most common presenting symptoms in patients admitted for a diagnosis other than stroke who were after confirmed to have had a stroke.14,15 However, such nonspecific symptoms are not usual presentations of stroke. The history and physical examination for common stroke symptoms should uncover the diagnosis of stroke even in uncommon presentations.
Posterior circulation strokes may be challenging to diagnose. One potential area of confusion is when patients present with dizziness, which is a mutual concern in general but an uncommon presentation for stroke. In a population-based study of adults older than 44 years presenting to the emergency department or straight admitted to the hospital with a main business organization of dizziness, simply 0.7% of patients with isolated dizziness symptoms had an ultimate diagnosis of stroke or transient ischemic attack, although their stroke was missed by the initial examiner 44% of the fourth dimension.xvi
However, in patients presenting with acute vestibular syndrome17 defined by 1 hr or more of astute, persistent, continuous vertigo or dizziness with spontaneous or gaze-evoked nystagmus, plus nausea or vomiting, head movement intolerance, and new gait unsteadiness, one-fourth or more accept a posterior circulation stroke.18,19 Equally many every bit 2-thirds of patients with acute vestibular syndrome caused by stroke accept no obvious neurologic findings.19 A bombardment of three bedside tests of eye movement is more sensitive than early magnetic resonance imaging (MRI) for diagnosing posterior stroke in this setting and is highly specific.18,xx Table 3 describes the behave and operating characteristics of each examination and the battery.18–20 A video demonstrating these tests is available at http://content.lib.utah.edu/cdm/singleitem/collection/ehsl-dent/id/6/rec/5.
Tabular array 3.
Bedside Predictors of Stroke and Other Central Etiologies in Patients with Acute Vestibular Syndrome
| Bedside diagnostic predictor | Test description | Sensitivity (95% CI) | Specificity (95% CI) | LR+(95% CI) | LR−(95% CI) |
|---|---|---|---|---|---|
| Normal consequence on horizontal head impulse exam | Plow the patient'southward head laterally 10 to xx degrees while observing his or her eyes. A normal result is for the optics to stay fixed on a target. An abnormal result is for the eyes to rapidly move back to the target once caput movement stops. The test also may exist performed by turning the patient's head dorsum to center from 10 to twenty degrees off-center.20 | 0.85 (0.79 to 0.91) | 0.95 (0.90 to 1.00) | 18.39 (half dozen.08 to 55.64) | 0.16 (0.11 to 0.23) |
| Direction-irresolute nystagmus | Nystagmus in the setting of acute vertiginous syndrome is normally unidirectional, with the fast beat of nystagmus abroad from the affected side and a slow return toward the afflicted side. Nystagmus is enhanced when the centre moves toward the side of the fast beat and decreases or disappears when the eye moves toward the side of ho-hum beat. With central lesions, the fast beat of nystagmus may change directions toward the direction the eyes are moving, hence the term "direction-changing nystagmus."20 | 0.38 (0.32 to 0.44) | 0.92 (0.86 to 0.98) | 4.51 (2.xviii to ix.34) | 0.68 (0.threescore to 0.76) |
| Skew deviation | Usually during the cover-uncover examination in that location is no heart move. Upwardly or downwards movement on the encompass-uncover test (refixation) indicates skew deviation and is associated with a primal lesion.20 | 0.30 (0.22 to 0.39) | 0.98 (0.95 to 1.00) | 19.66 (2.76 to 140.15) | 0.71 (0.63 to 0.80) |
| HINTS positive | HINTS positive is a normal head impulse examination result, management-changing nystagmus, refixation on cover test (skew deviation), or any combination of these findings.18 | 96.8 (92.four to 99.0) | 98.v (92.8 to 99.9) | 63.9 (9.13 to 446.85) | 0.03 (0.01 to 0.09) |
Reliably distinguishing between hemorrhagic and ischemic stroke can be washed only through neuroimaging. Patients with hemorrhagic stroke are more than likely to accept headache, airsickness, diastolic blood force per unit area greater than 110 mm Hg, meningismus, or coma, simply none of these findings lone or in combination is reliable enough to define a diagnosis.21
Subarachnoid hemorrhage (SAH) presents differently from intracerebral hemorrhage or ischemic stroke. Near 80% of patients with aneurysmal SAH study a sudden onset of what they describe as the worst headache of their life.22 A previous sentinel headache 2 to eight weeks before aneurysmal rupture is a critical historical finding present in upwards to xl% of patients with SAH.22 Findings accompanying the headache tin include vomiting, photophobia, seizures, meningismus, focal neurologic signs, and decreased level of consciousness.22,23 Funduscopy should be performed because intraocular hemorrhages are present in 1 in seven patients with aneurysmal SAH.24 Because the bleeding occurs outside the brain, persons with SAH may not have focal neurologic signs.
STROKE MIMICS AND DIFFERENTIAL DIAGNOSIS
Clinicians should consider a broad differential diagnosis when evaluating suspected stroke (Table 47,ix,10,16,xix,25–34). Seizure, conversion or somatoform disorder, migraine headache, and hypoglycemia are the about common stroke mimics.10,25–30 Checklists to ascertain eligibility for intravenous thrombolysis explicitly include detection of hypoglycemia, hyperglycemia, and recent seizures.
Tabular array 4.
Stroke Mimics and Distinguishing Features
| Condition | Distinguishing features |
|---|---|
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The rates of misdiagnosis of stroke in studies of consecutive patients not treated with thrombolysis vary from 25% to 31%.10,25,35 Of patients receiving thrombolysis, one.4% to sixteen.7% are constitute to have a stroke mimic.26–31 Factors associated with greater risk of a stroke mimic are younger age, lower baseline NIHSS scores, history of cerebral impairment, and nonneurologic abnormal physical findings.10,26–31 Patients with a stroke mimic are more likely to present with global aphasia without hemiparesis than patients demonstrated to accept a stroke.26,31
Diagnostic Tests and Imaging
- Abstract
- Classifying Stroke
- Hazard Factors
- Clinical Diagnosis
- Diagnostic Tests and Imaging
- Training Patients to Recognize Stroke Symptoms
- References
Tabular array 5 lists initial diagnostic studies recommended by current guidelines for patients with suspected stroke.9 The purpose of these studies is to uncover stroke mimics, diagnose critical comorbidities such as myocardial ischemia, and observe contraindications to thrombolytic therapy. No combination of stroke biomarkers has been shown to give additional diagnostic certainty over that of clinical history and examination lonely.36
Table 5.
Immediate Diagnostic Studies: Evaluation of a Patient with Suspected Acute Ischemic Stroke
| All patients |
| Noncontrast brain CT or encephalon MRI |
| Blood glucose |
| Oxygen saturation |
| Serum electrolytes/renal function tests* |
| Complete blood count, including platelet count* |
| Markers of cardiac ischemia* |
| Prothrombin time/INR* |
| Activated partial thromboplastin time* |
| ECG* |
| Selected patients |
| TT and/or ECT if it is suspected the patient is taking directly thrombin inhibitors or direct gene Xa inhibitors |
| Hepatic function tests |
| Toxicology screen |
| Blood booze level |
| Pregnancy examination |
| Arterial claret gas tests (if hypoxemia suspected) |
| Breast radiography (if lung disease suspected) |
| Lumbar puncture (if subarachnoid hemorrhage is suspected and CT scan is negative for blood) |
| Electroencephalogram (if seizures are suspected) |
All patients with stroke symptoms should undergo urgent neuroimaging with noncontrast computed tomography (CT) or MRI.ix,37 The principal purpose of neuroimaging in a patient with suspected ischemic stroke is to rule out the presence of nonischemic fundamental nervous system lesions and to distinguish between ischemic and hemorrhagic stroke. Figures 2 and 3 evidence examples of intracerebral and subarachnoid hemorrhages on non-contrast CT.7 Noncontrast CT is considered sufficiently sensitive for detecting mass lesions, such as a brain mass or abscess, every bit well as for detecting acute hemorrhage. However, less than two-thirds of strokes are detected by noncontrast CT at three hours postinfarction.38 Noncontrast CT has fifty-fifty lower sensitivity for small or posterior fossa strokes.9
Effigy ii.
Caput computed tomography showing intracerebral hemorrhages (arrows).
Reprinted with permission from Yew KS, Cheng Eastward. Astute stroke diagnosis. Am Fam Physician. 2009;80(1):38.
Effigy three.
Caput computed tomography showing subarachnoid hemorrhages (arrows). Note that acute hemorrhage appears hyperdense (white) on computed tomography.
Reprinted with permission from Yew KS, Cheng Due east. Acute stroke diagnosis. Am Fam Medico. 2009;80(i):38.
Multimodal MRI sequences, particularly improvidence-weighted images, have meliorate resolution than noncontrast CT, and therefore have a greater sensitivity for detecting acute ischemic stroke.37,38 MRI sequences (particularly slope recalled echo and diffusion-weighted sequences) are as sensitive as noncontrast CT for detecting intracerebral hemorrhagic stroke.ix,37,38 Figure 4 shows the head noncontrast CT and diffusion-weighted MRI of a patient with a previous stroke and a new acute stroke.
Figure 4.
(A) Noncontrast computed tomography showing two hypodense regions indicating old infarctions in the distribution of the left-middle cerebral (long pointer) and posterior cerebral arteries (short arrow). (B) Improvidence-weighted magnetic resonance imaging obtained shortly afterward the computed tomography reveals a new extensive infarction (arrow) in the right-middle cerebral artery distribution not axiomatic on the computed tomography.
Reprinted with permission from MedPix. Retrieved from http://rad.usuhs.edu/medpix.
MRI has better resolution than noncontrast CT, but noncontrast CT is faster, more bachelor, less expensive, and can be performed in persons with implanted devices (e.yard., pacemakers) and in persons with claustrophobia. If a patient is within the fourth dimension window of intravenous thrombolytic therapy, guidelines recommend that noncontrast CT or MRI exist performed to exclude intracerebral hemorrhage and evaluate for ischemic changes.ix In patients younger than 55 years presenting with stroke-like symptoms, MRI yields a lower rate of misdiagnosis than noncontrast CT considering of a lower prevalence of vascular risk factors and a higher prevalence of cardinal nervous system stroke mimics in this age grouping.39,40 Patients presenting with acute vestibular syndrome or suspected posterior infarction should undergo acute diffusion-weighted MRI.37 Considering MRI may miss upward to xv% of posterior strokes in the commencement 48 hours,18 a negative MRI result should be followed past a repeat MRI in three to vii days or bedside oculomotor testing to exclude a false-negative result.
Although acute neuroimaging is essential, information technology may exist possible to efficiently obtain imaging of the carotid arteries to observe carotid stenosis, such every bit when MRI of the brain is combined with magnetic resonance angiography of the cervix. Current guidelines practise non accost acute imaging of cervical vessels, just it is recommended as part of the subsequent evaluation of patients with confirmed stroke or transient ischemic attack,ix which is beyond the scope of this commodity. Astute intracranial vascular imaging is recommended if intravascular therapy is being considered, as long as it does non filibuster intravenous thrombolysis.9
Dissimilar ischemic stroke and intracerebral hemorrhage, diagnosing SAH requires a different diagnostic approach. The frequency of misdiagnosis of SAH is nigh 12%.22 Noncontrast CT is the imaging exam of choice for persons with suspected SAH.22 Noncontrast CT has a sensitivity of most 100% for detecting subarachnoid blood in the first 72 hours.22 The sensitivity of noncontrast CT to detect subarachnoid claret declines over time, whereas MRI remains highly sensitive to intracranial blood for upwardly to xxx days, making information technology the preferred test for delayed presentations.22,23
Persons with suspected SAH and a normal noncontrast CT result should undergo a lumbar puncture to notice bilirubin, a breakup product of red claret cells in the cerebrospinal fluid.23 Considering red blood prison cell breakup tin can have up to 12 hours, the lumbar puncture should exist delayed until 12 hours after the initial onset of symptoms to accurately distinguish SAH from a traumatic tap.23,41 The yellow color acquired by bilirubin, which is called xanthochromia, tin can be detected by visual inspection or spectrophotometry.23,41 Spectrophotometry is more sensitive than visual inspection, merely is not widely available.23,41 Bilirubin tin exist detected up to two weeks after the initial onset of symptoms. If SAH is detected, persons should immediately undergo CT, MRI, or catheter angiography to look for an aneurysm.
Training Patients to Recognize Stroke Symptoms
- Abstract
- Classifying Stroke
- Risk Factors
- Clinical Diagnosis
- Diagnostic Tests and Imaging
- Preparation Patients to Recognize Stroke Symptoms
- References
Patients and family members should be educated about stroke symptoms and the need for urgent evaluation.9 Consistent data testify considerable room for improvement in stroke knowledge in the general population.42 However, at that place are limited data to support the effectiveness of public media campaigns to meliorate stroke knowledge and to link improved cognition of stroke symptoms to beliefs or clinical outcomes.43,44 A recent study showed that noesis of two warning signs of stroke was associated with activation of emergency medical services, which suggests a goal for public teaching campaigns.45 The American Stroke Clan is promoting the F.A.Southward.T. (face drooping, arm weakness, speech difficulty, time to call ix–ane–1) entrada to better patient knowledge about stroke and to expedite activation of ix–1–1 services.46
Data Sources: A PubMed search using a filter for diagnostic studies detailed in the Cochrane Database of Systematic Reviews (Beynon R, Leeflang MM, McDonald Due south, et al. Search strategies to identify diagnostic accuracy studies in Medline and Embase. Cochrane Database Syst Rev. 2013;(nine):MR000022) was performed using the MeSH stroke terms stroke; stroke, lacunar; infarction, posterior cognitive avenue; brain stem infarctions; infarction, middle cerebral avenue; infarction, anterior cerebral artery; inductive spinal artery stroke crossed with sensitivity and specificity#[MESH] OR diagnos* OR predict* OR accura* with limits of human being, English, developed and publication engagement afterward June 1, 2008 (the end date of the literature search for the previous AFP article on this topic). Also searched were Essential Evidence Plus, the National Guideline Clearinghouse, the Institute for Clinical Systems Comeback "Diagnosis and Initial Treatment of Ischemic Stroke" guideline, tenth ed., and commodity bibliographies. Search dates: July 10, 2014, and Feb 13, 2015.
annotation: This review updates a previous article on this topic past the authors.7
The authors thank Dr. James Smirniotopoulos for assistance with MedPix, and Mrs. Robin Yew for editorial assist.
The views expressed in this article are those of the authors and do non necessarily reverberate the official position of the Department of Defence force or the U.S. government.
Dr. Cheng received funding from Cooperative Agreement Honor U54 NS08164 from the National Establish of Neurological Disorders and Stroke.
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REFERENCES
show all references
1. Get As, Mozaffarian D, Roger VL, et al.; American Heart Association Statistics Commission and Stroke Statistics Subcommittee. Center illness and stroke statistics—2014 update: a written report from the American Heart Association. Circulation. 2014;129(3):e28–e292. ...
2. Adams HP Jr, Bendixen BH, Kappelle LJ, et al. Classification of subtype of acute ischemic stroke. Definitions for employ in a multicenter clinical trial. TOAST. Trial of Org 10172 in Acute Stroke Handling. Stroke. 1993;24(ane):35–41.
3. Morgenstern LB, Lisabeth LD, Mecozzi Ac, et al. A population-based report of astute stroke and TIA diagnosis. Neurology. 2004;62(vi):895–900.
iv. Manus PJ, Haisma JA, Kwan J, et al. Interobserver agreement for the bedside clinical assessment of suspected stroke. Stroke. 2006;37(3):776–780.
5. Nor AM, Davis J, Sen B, et al. The Recognition of Stroke in the Emergency Room (ROSIER) scale: development and validation of a stroke recognition instrument. Lancet Neurol. 2005;4(xi):727–734.
6. Goldstein LB, Simel DL. Is this patient having a stroke? JAMA. 2005; 293(nineteen):2391–2402.
7. Yew KS, Cheng Due east. Astute stroke diagnosis. Am Fam Physician. 2009;80(one):33–40.
eight. Searls DE, Pazdera L, Korbel E, Vysata O, Caplan LR. Symptoms and signs of posterior apportionment ischemia in the New England Medical Center Posterior Circulation Registry. Arch Neurol. 2012;69(3):346–351.
9. Jauch EC, Saver JL, Adams HP Jr, et al.; American Eye Association Stroke Council; Quango on Cardiovascular Nursing; Council on Peripheral Vascular Disease; Quango on Clinical Cardiology. Guidelines for the early direction of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2013;44(3):870–947.
10. Manus PJ, Kwan J, Lindley RI, Dennis MS, Wardlaw JM. Distinguishing between stroke and mimic at the bedside: the encephalon attack study. Stroke. 2006;37(iii):769–775.
11. Schmülling S, Grond M, Rudolf J, Kiencke P. Training as a prerequisite for reliable use of NIH Stroke Scale. Stroke. 1998;29(half-dozen):1258–1259.
12. Josephson SA, Hills NK, Johnston SC. NIH Stroke Calibration reliability in ratings from a large sample of clinicians. Cerebrovasc Dis. 2006;22(5–six):389–395.
xiii. National Stroke Association. NIH Stroke Calibration. 2014; NIHSS online instruction. http://www.stroke.org/site/PageServer?pagename=nihss. Accessed October 21, 2014.
xiv. Lever NM, Nyström KV, Schindler JL, Halliday J, Wira C 3, Funk M. Missed opportunities for recognition of ischemic stroke in the emergency department. J Emerg Nurs. 2013;39(5):434–439.
15. Dupre CM, Libman R, Dupre SI, Katz JM, Rybinnik I, Kwiatkowski T. Stroke chameleons. J Stroke Cerebrovasc Dis. 2014;23(two):374–378.
16. Kerber KA, Brown DL, Lisabeth LD, Smith MA, Morgenstern LB. Stroke among patients with dizziness, vertigo, and imbalance in the emergency department: a population-based study. Stroke. 2006;37(x):2484–2487.
17. Hotson JR, Baloh RW. Astute vestibular syndrome. N Engl J Med. 1998;339(ten):680–685.
18. Newman-Toker DE, Kerber KA, Hsieh YH, et al. HINTS outperforms ABCD2 to screen for stroke in acute continuous vertigo and dizziness. Acad Emerg Med. 2013;20(10):986–996.
19. Tarnutzer AA, Berkowitz AL, Robinson KA, Hsieh YH, Newman-Toker DE. Does my giddy patient accept a stroke? A systematic review of bedside diagnosis in acute vestibular syndrome. CMAJ. 2011;183(9):E571–E592.
xx. Newman-Toker DE. 3-Component H.I.Northward.T.South. bombardment. http://content.lib.utah.edu/cdm/singleitem/drove/ehsl-dent/id/half dozen/rec/v. Accessed July 20, 2014.
21. Runchey S, McGee S. Does this patient have a hemorrhagic stroke?: clinical findings distinguishing hemorrhagic stroke from ischemic stroke. JAMA. 2010;303(22):2280–2286.
22. Connolly ES Jr, Rabinstein AA, Carhuapoma JR, et al.; American Heart Assoication Stroke Council; Quango on Cardiovascular Radiology and Intervention; Couincil on Cardiovascular Nursing; Council on Cardiovascular Surgery and Anesthesia; Council on Clinical Cardiology. Guidelines for the management of aneurysmal subarachnoid hemorrhage: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2012;43(vi):1711–1737.
23. Moore SA, Rabinstein AA, Stewart MW, Freeman WD. Recognizing the signs and symptoms of aneurysmal subarachnoid hemorrhage. Good Rev Neurother. 2014;fourteen(7):757–768.
24. van Gijn J, Kerr RS, Rinkel GJ. Subarachnoid haemorrhage. Lancet. 2007;369(9558):306–318.
25. Hemmen TM, Meyer BC, McClean TL, Lyden PD. Identification of non-ischemic stroke mimics amidst 411 code strokes at the University of California, San Diego, Stroke Center. J Stroke Cerebrovasc Dis. 2008;17(i):23–25.
26. Förster A, Griebe M, Wolf ME, Szabo Thou, Hennerici MG, Kern R. How to identify stroke mimics in patients eligible for intravenous thrombolysis? J Neurol. 2012;259(7):1347–1353.
27. Artto V, Putaala J, Strbian D, et al.; Helsinki Stroke Thrombolysis Registry Group. Stroke mimics and intravenous thrombolysis. Ann Emerg Med. 2012;59(one):27–32.
28. Tsivgoulis G, Alexandrov AV, Chang J, et al. Rubber and outcomes of intravenous thrombolysis in stroke mimics: a 6-year, single-intendance middle study and a pooled analysis of reported serial. Stroke. 2011;42(6):1771–1774.
29. Vroomen PC, Buddingh MK, Luijckx GJ, De Keyser J. The incidence of stroke mimics amidst stroke department admissions in relation to age group. J Stroke Cerebrovasc Dis. 2008;17(6):418–422.
thirty. Mehta Southward, Vora Northward, Edgell RC, et al. Stroke mimics under the drip-and-send epitome. J Stroke Cerebrovasc Dis. 2014;23(5):844–849.
31. Guillan 1000, Alonso-Canovas A, Gonzalez-Valcarcel J, et al. Stroke mimics treated with thrombolysis: further evidence on safety and distinctive clinical features. Cerebrovasc Dis. 2012;34(two):115–120.
32. Qureshi AI, Ezzeddine MA, Nasar A, et al. Prevalence of elevated blood pressure in 563,704 adult patients with stroke presenting to the ED in the United States. Am J Emerg Med. 2007;25(1):32–38.
33. Headache Nomenclature Subcommittee of the International Headache Lodge. The International Classification of Headache Disorders. 2nd edition. Cephalalgia. 2004;24(suppl ane):9–160.
34. Liou KC, Chen LA, Lin YJ. Cervical spinal epidural hematoma mimics acute ischemic stroke. Am J Emerg Med. 2012;30(7):1322.e1–e3.
35. Merino JG, Luby M, Benson RT, et al. Predictors of acute stroke mimics in 8187 patients referred to a stroke service. J Stroke Cerebrovasc Dis. 2013;22(8):e397–e403.
36. An SA, Kim J, Kim OJ, et al. Limited clinical value of multiple claret markers in the diagnosis of ischemic stroke. Clin Biochem. 2013;46(9):710–715.
37. Wintermark M, Sanelli PC, Albers GW, et al. Imaging recommendations for acute stroke and transient ischemic assail patients: A joint statement by the American Society of Neuroradiology, the American College of Radiology, and the Social club of NeuroInterventional Surgery. AJNR Am J Neuroradiol. 2013;34(11):E117–E127.
38. Latchaw RE, Alberts MJ, Lev MH, et al.; American Eye Association Quango on Cardiovascular Radiology and Intervention, Stroke Council, and the Interdisciplinary Council on Peripheral Vascular Illness. Recommendations for imaging of acute ischemic stroke: a scientific statement from the American Middle Clan. Stroke. 2009;40(11):3646–3678.
39. Ferro JM, Massaro AR, Mas JL. Aetiological diagnosis of ischaemic stroke in young adults. Lancet Neurol. 2010;nine(11):1085–1096.
40. Bhattacharya P, Nagaraja N, Rajamani K, Madhavan R, Santhakumar S, Chaturvedi S. Early use of MRI improves diagnostic accuracy in immature adults with stroke. J Neurol Sci. 2013;324(1–2):62–64.
41. Cruickshank A, Auld P, Beetham R, et al.; Britain NEQAS Specialist Advisory Group for External Quality Assurance of CSF Proteins and Biochemistry. Revised national guidelines for analysis of cerebrospinal fluid for biliru-bin in suspected subarachnoid bleeding. Ann Clin Biochem. 2008; 45(pt 3):238–244.
42. Kleindorfer D, Khoury J, Broderick JP, et al. Temporal trends in public awareness of stroke: warning signs, chance factors, and handling. Stroke. 2009;40(7):2502–2506.
43. Lecouturier J, Rodgers H, Murtagh MJ, White Thou, Ford GA, Thomson RG. Systematic review of mass media interventions designed to meliorate public recognition of stroke symptoms, emergency response and early treatment. BMC Public Health. 2010;x:784.
44. Reeves MJ. Reducing the delay between stroke onset and hospital arrival: is it an achievable goal? J Am Middle Assoc. 2012;1(3):e002477.
45. Mosley I, Nicol M, Donnan Thousand, Thrift AG, Dewey HM. What is stroke symptom noesis? Int J Stroke. 2014;nine(one):48–52.
46. American Heart Clan; American Stroke Association. Stroke alarm signs and symptoms. http://strokeassociation.org/STROKEORG/WarningSigns/Stroke-Alert-Signs-and-Symptoms_UCM_308528_SubHomePage.jsp. Accessed July 24, 2014.
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