HISTORY. Determine if the patient is on any medications or abuses intravenous drugs. Elicit a history of neurological deficits (Table 4). Determine if the patient has experienced an inability to recognize familiar objects or persons through sensory stimuli (agnosia) or any memory loss (amnesia). Elicit a history of speech difficulties such as an inability to understand language or express language (aphasia), poorly articulated speech (dysarthria), or any other form of speech impairment (dysphasia). Determine if the patient has lost the ability to comprehend written words (alexia), read written words (dyslexia), or write (agraphia). Establish a history of visual difficulties such as double vision (diplopia), defective vision, or blindness in the right or left halves of the visual fields of both eyes (homonymous hemianopia), lack of depth perception, color blindness, blindness, blurring on the affected side, or drooping eyelids (ptosis).
Stroke Sites and Neurological Deficits
|STROKE SITE||SIGNS AND SYMPTOMS|
|Posterior cerebral artery||Visual field deficits, sensory impairments; reading difficulty (dyslexia); coma; cortical blindness resulting from ischemia in the occipital area; paralysis (rarely)|
|Vertebral or basilar artery||Numbness around the lips and mouth; dizziness; weakness on the affected side; vision deficits (color blindness; lack of depth perception; double vision [diplopia]); poor coordination; difficulty swallowing (dysphagia); slurred speech; amnesia; staggering gait (ataxia)|
|Internal carotid artery||Headache; weakness; paralysis; numbness; sensory changes; vision disturbances (blurring on the affected side or blindness); altered level of consciousness; bruits over the carotid artery; defective language function (aphasia); speech impairment (dysphasia); eyelid drooping (ptosis)|
|Middle cerebral artery||Defective language function (aphasia); speech impairment (dysphasia); reading difficulty (dyslexia); visual field deficits; hemiparesis on the affected side (more severe in the face and arm than in the leg)|
Elicit a history of motor difficulties such as the inability to move the muscles (akinesia), inability to perform purposeful acts or manipulate objects (apraxia), poor coordination, impairment of voluntary movement (dyskinesia), muscular weakness or partial paralysis affecting one side of the body (hemiparesis), or paralysis of one side of the body (hemiplegia). Ask if the patient has experienced numbness and ascertain the specific location. Determine if the patient has experienced headaches. Establish a history of personality changes such as flat affect or distractibility.PHYSICAL EXAM
. If the patient appears unconscious, quickly determine his or her airway status and level of consciousness. If the patient is conscious, he or she may be experiencing a TIA or a stroke in evolution. Determine the level of orientation; ability to respond to questions of intellectual functioning; and speech, hearing, and vision ability. Lightly touch the patient's skin on various parts of the body and ask the patient to identify the location. Apply firm pressure to various parts of the body and observe the patient's responses. Be sure to test skin sensations sensed in both hemispheres of the body and compare the responses.
Begin your assessment by determining the patient's understanding of your commands and the appropriateness of her or his verbal and nonverbal responses. In left-hemisphere stroke, there is likely to be loss of language ability, although memory may be intact. In right-hemisphere stroke, patients are often confused and disoriented, but the ability to speak remains. Determine the presence of hemiplegia or hemiparesis and the patient's muscle strength, gait, and balance. Assess the patient's cranial nerves (V, VII, IX, X, and XII) to determine tongue movement and ability to chew and swallow, as well as the presence of a gag reflex. Assess the patient for the presence of hemianopia by observing whether he or she sees objects on either side of the midvisual field. If the patient is disoriented or has lost the ability to understand language (receptive aphasia), assessing hemianopia is difficult. Try handing the patient a fork on the affected side, and ask the patient to tell you what it is you are holding or ask the patient to pick up the fork.PSYCHOSOCIAL
. During the early stages of their condition, many patients with stroke experience great despair and frustration trying to communicate their needs. The inability to communicate causes profound depression. Although patients may laugh or cry or display outbursts of anger and frustration at unusual times, it is impossible to know with any certainty if these responses are inappropriate for the patient.Diagnostic Highlights
|Test||Normal Result||Abnormality with Condition||Explanation|
|Computed tomography (CT)||Intact cerebral anatomy||Identification of size and location of site of hemorrhage or infarction||Shows anterior to posterior slices of the brain to highlight abnormalities|
Magnetic resonance imaging is more sensitive than CT if the stroke is small and/or in the brain stem. Carotid duplex scanning is used in patients with acute ischemic stroke when carotid artery stenosis or occlusion is suspected. Transcranial Doppler ultrasound is used to evaluate the middle cerebral, intracranial carotid, and vertebrobasilar arteries. Echocardiography is used for patients with acute ischemic stroke when cardiogenic embolism is suspected. Continuous oximetry and electrocardiographic monitoring provides surveillance. Laboratory tests include complete blood count with differential, platelet count, prothrombin time, activated partial thromboplastin time, electrolytes, creatinine, glucose. Other diagnostic tests that help evaluate cerebral blood flow, identify abnormalities, or locate the stroke include positron emission tomography, cerebral blood flow studies, and transthoracic two-dimensional echocardiography to identify intracardiac sites for thrombi.
Stroke has been found in Diseases and Disorders
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