Diagnosis

To determine the stroke mechanism or mechanisms, the following clinical bedside data should be obtained through careful history taking: (1) ecology--past and present personal and family illnesses; (2) the presence and nature of past strokes and TIAs; (3) the time of onset of the symptoms; (4) activity at onset; (5) the temporal course and progression of the findings; and (6) accompanying symptoms. A general physical examination should then be done to add more data that can be used for diagnosis of the stroke mechanism. Elevated blood pressure, cardiac enlargement or murmurs, bruits in the carotid and supraclavicular region, and symmetry of blood pressure and pulses in the arms are important check points during physical examination of stroke patients y (see Chap.te.r22 ).

The presence of some findings, such as headache, vomiting, loss of consciousness, and seizures, is helpful in diagnosing subtypes of strokes. Headache at onset is an invariable feature of SAH and is also common in patients with large ICHs and large cerebral infarcts due to large artery occlusive disease and brain embolism. Headache unusual for the patient is rare in patients with lacunar infarction due to penetrating artery disease. Some patients with large artery occlusive disease and those with severe hypertension often have unaccustomed headaches in the days and weeks preceding a stroke or TIA.

Vomiting is very common in patients with SAH and ICH and in those with brain stem and cerebellar infarcts. Vomiting is very rare in patients with hemispherical brain infarction due to large artery occlusive disease or embolism. Seizures at or shortly after the onset of the stroke are relatively common in patients with lobar hemorrhages and those with brain embolism, but do not occur in patients with lacunar infarcts. Loss of consciousness at onset is common in patients with large SAHs and in those with embolism to the basilar artery but is rare in strokes due to other mechanisms. Patients with large ICHs often have headache, vomiting, and progressive loss of alertness as the hematoma enlarges and intracranial pressure rises.

Neuroimaging studies include CT scan, MRI, single-photon emission computed tomography (SPECT), and positron emission tomography (PET). CT and MRI scans image brain structure. CT scans are best for differentiating ischemic stroke from hemorrhagic stroke. MRI can detect an acute ischemic stroke earlier than CT and is the preferred technique for identifying brain stem and cerebellar infarctions. SPECT and pEt scans image the perfusion and metabolic state of the brain and can quantify cerebrovascular reserve capacity. y

_TABLE 45-1 -- LABORATORY STUDIES FOR STROKE PATIENTS

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