Bedside Evaluation of the Acute Stroke Patient

Emanating from the results of the original National Institute of Neurological Disorders and Stroke recombinant tissue plasminogen activator (NINDS rt-PA) trial [1], the management of acute stroke has evolved as a cornerstone of emergency medical care, hospital medicine, and clinical neurology. While the only treatment for acute ischemic stroke approved by the US Food and Drug Administration (FDA) remains intravenous (IV) rt-PA administered within 3 hours of symptom onset, the field continues to expand with a focus on more timely treatment, expanding the pool of patients eligible for treatment, and optimization of methods of reperfusion. These advances include the use of IV rt-PA beyond the 3-hour window, the direct administration of intra-arterial rt-PA, and implementation of a variety of devices aimed at mechanical thrombectomy and other interventional means of cerebrovascular recanalization. However, integrating all of the scientific evidence guiding the acute stroke paradigm is daunting, even for the most seasoned vascular neurologist. According to the National Guideline Clearinghouse, an initiative of the Agency for Healthcare Research and Quality in the De partment of Health and Human Services, there are currently 225 published guidelines related to “acute stroke” from various organizations and societies around the world [2]. The current standard of stroke care in the US is guided by the American Heart Association/American Stroke Association’s (AHA/ASA) Get With the Guidelines (GWTG) program [3]. While stroke therapeutics will be discussed in detail elsewhere in this book, the aim of this chapter is to offer a simple, practical approach to the bedside evaluation of the acute stroke patient. As the opinions and recommendations herein draw on experience treating acute stroke, they also reflect the literature and guiding evidence. The chapter will broadly highlight seminal studies, published AHA/ASA guidelines, FDA regulations, and The Joint Commission (TJC) certification requirements for primary/comprehensive stroke centers – links to further resources can be found in the Appendix, Chapter 9. Explored in detail will be the various issues facing neurologists or other physicians in acute stroke scenarios, including an accurate gathering of history, essentials of the acute stroke physical exam, radiological diagnosis, and potential hurdles precluding a treatment decision. While these necessary steps are very much protocol driven, the reality of the acute stroke setting dictates a somewhat simultaneous process in order to achieve the efficient delivery of treatment. Ultimately, the aim of the chapter is to further promote rapid diagnosis and timely management for all acute stroke patients, as the medical community continues to strive for the best possible outcomes from this disabling and deadly disease.