What imaging can disclose about suspected stroke and its Tx

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doi:10.12788/jfp.0093

Applied Evidence

What imaging can disclose about suspected stroke and its Tx

J Fam Pract. 2020 November;69(9):438-446 | 10.12788/jfp.0093

By

Brian Ford, MD

Vijay Hegde, MD

Michael Dore, MD

Selecting useful modalities is key in early and later management of an acute ischemic event. This review—augmented by an at-a-glance table—can inform your care.

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References

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Stroke ranks second behind heart disease as the leading cause of mortality worldwide, accounting for 1 of every 19 deaths,¹ and remains a serious cause of morbidity. Best practices in stroke diagnosis and management can seem elusive to front-line clinicians, for 2 reasons: the rate of proliferation and nuance in stroke medicine and the fact that the typical scope of primary care practice exists apart from much of the diagnostic tools and management schema provided in stroke centers.²In this article, we describe and update the diagnosis of stroke and review imaging modalities, their nuances, and their application in practice.

Diagnosis of acute stroke

Acute stroke is diagnosed upon observation of new neurologic deficits and congruent neuroimaging. Some updated definitions favor a silent form of cerebral ischemia manifested by imaging pathology only; this form is not discussed in this article. Although there are several characteristically distinct stroke syndromes, there is no way to clinically distinguish ischemic pathology from hemorrhagic pathology.

Some common symptoms that should prompt evaluation for stroke are part of the American Stroke Association FAST mnemonic designed to promote public health awareness^3-5:

face drooping
arm weakness
speech difficulty
time to call 911.

There are several characteristically distinct stroke syndromes, but no way to differentiate ischemic and hemorrhagic pathologies clinically.

Other commonly reported stroke symptoms include unilateral weakness or numbness, confusion, word-finding difficulty, visual problems, difficulty ambulating, dizziness, loss of balance or coordination, and thunderclap headache. A stroke should also be considered in the presence of any new focal neurologic deficit.^3,4

Stroke patients should be triaged by emergency medical services using a stroke screening scale, such as BE-FAST⁵ (a modification of FAST that adds balance and eye assessments); the Los Angeles Prehospital Stroke Screen (LAPSS)^6,7; the Rapid Arterial oCclusion Evaluation (RACE)⁸; and the Cincinnati Prehospital Stroke Severity Scale (CP-SSS)^9,10 (see “Stroke screening scales for early identification and triage"). Studies have not found that any single prehospital stroke scale is superior to the others for reliably predicting large-vessel occlusion; therefore, prehospital assessment is typically based on practice patterns in a given locale.¹¹ A patient (or family member or caregiver) who seeks your care for stroke symptoms should be told to call 911 and get emergency transport to a health care facility that can capably administer intravenous (IV) thrombolysis.^a

SIDEBAR
Stroke screening scales for early identification and triage

National Institutes of Health Stroke Scale
www.stroke.nih.gov/resources/scale.htm

FAST
www.stroke.org/en/help-and-support/resource-library/fast-materials

BE-FAST
www.ahajournals.org/doi/10.1161/STROKEAHA.116.015169

Los Angeles Prehospital Stroke Screen (LAPSS)
http://stroke.ucla.edu/workfiles/prehospital-screen.pdf

Rapid Artery Occlusion Evaluation (RACE)
www.mdcalc.com/rapid-arterial-occlusion-evaluation-race-scale-stroke

Cincinnati Prehospital Stroke Severity Scale (CP-SSS)
https://www.mdcalc.com/cincinnati-prehospital-stroke-severity-scale-cp-sss

First responders should elicit “last-known-normal” time; this critical information can aid in diagnosis and drive therapeutic options, especially if patients are unaccompanied at time of transport to a higher echelon of care. A point-of-care blood glucose test should be performed by emergency medical staff, with dextrose administered for a level < 45 mg/dL. Establishing IV access for fluids, medications, and contrast can be considered if it does not delay transport. A 12-lead electrocardiogram can also be considered, again, as long as it does not delay transport to a facility capable of providing definitive therapy. Notification by emergency services staff before arrival and transport of the patient to such a facility is the essential element of prehospital care, and should be prioritized above ancillary testing beyond the stroke assessment.¹⁴

Guidelines recommend use of the National Institutes of Health Stroke Scale (NIHSS; www.stroke.nih.gov/resources/scale.htm) for clinical evaluation upon arrival at the ED.¹⁵ Although no scale has been identified that can reliably predict large-vessel occlusion amenable to endovascular therapy (EVT), no other score has been found to outperform the NIHSS in achieving meaningful patient outcomes.¹⁶ Furthermore, NIHSS has been validated to track clinical changes in response to therapy, is widely utilized, and is free.

Continue to: A criticism of the NIHSS...