Initial Management and History Taking for Suspected Stroke Localization

Emergency Triage and Initial Evaluation

The American Heart Association recommends that patients with suspected stroke should be triaged with the same priority as those with acute myocardial infarction or serious trauma, regardless of deficit severity 2, 3
Implement stroke pathways and notify the stroke team immediately upon suspicion of stroke, as recommended by the American Stroke Association 3
Perform initial stabilization of airway, breathing, and circulation (ABCs), followed by assessment of neurological deficits and comorbidities, as suggested by the American College of Emergency Physicians 3
Monitor cardiac rhythm as cardiac abnormalities may accompany stroke, according to the American Heart Association 4
Check vital signs at least every 30 minutes while in the emergency department, as recommended by the Joint Commission 5
Treat fever >99.6°F as hyperthermia is associated with poor stroke outcomes, as suggested by the Society of Critical Care Medicine 5

The time of symptom onset is the single most important historical information, defined as when the patient was last at baseline or symptom-free, as emphasized by the American Academy of Neurology 3
Document specific symptoms to help localize the lesion, including anterior circulation symptoms (contralateral hemiparesis, hemisensory loss, aphasia) and posterior circulation symptoms (vertigo, ataxia, diplopia), as recommended by the American Stroke Association 5
Note if symptoms were preceded by similar symptoms that resolved (TIA), as suggested by the American Heart Association 3

Order urgent brain imaging, such as CT or MRI, within 24 hours, but ideally immediately, as recommended by the American College of Radiology 6, 7
Non-contrast CT can exclude hemorrhage and assess for early ischemic changes, according to the American Stroke Association 4
Consider CTA from aortic arch to vertex to assess extracranial and intracranial circulation, as suggested by the Society of NeuroInterventional Surgery 7
Order laboratory tests immediately, but do not delay imaging, including complete blood count, electrolytes, renal function, coagulation studies, and blood glucose, as recommended by the American Association for Clinical Chemistry 6, 7

Be aware of conditions that can mimic stroke presentation, including psychogenic, seizures, hypoglycemia, migraine with aura, hypertensive encephalopathy, Wernicke's encephalopathy, and CNS abscess or tumor, as emphasized by the American Academy of Neurology 1, 2, 3
Use clinical judgment and diagnostic tests to differentiate stroke from mimics, as suggested by the American Stroke Association 1, 2, 3

Position the head of bed at 25-30° unless contraindicated, as recommended by the American Heart Association 5
Provide supplemental oxygen for hypoxic patients, as suggested by the American Thoracic Society 5
For patients receiving thrombolysis, check vital signs every 15 minutes during infusion, as recommended by the American College of Emergency Physicians 5
Perform swallowing screening as early as possible using a validated tool, as suggested by the American Speech-Language-Hearing Association 7

Failure to establish accurate symptom onset time can exclude patients from time-sensitive interventions, as emphasized by the American Stroke Association 3
Posterior circulation strokes may present with atypical symptoms and require special attention to airway management, as suggested by the American Academy of Neurology 5
Avoid delays in imaging - CT scan should be completed within 25 minutes for rtPA-eligible patients, as recommended by the American College of Radiology 5