Stroke timeline: Stroke On Call, by Ahmed Koriesh Last seen normal:

First time seen with stroke:

Paged: Past medical history: DM – HTN – Cardiac – Hepatic - Other:
Bedside: Past surgical history: any recent surgery?
Exam: Medications: Antiplatelets? Anticoagulants? Other home meds:
CT: Allergy to contrast? To drugs?
IV tPA:
1a. Level of Consciousness(LOC) Alert (or awakens easily and stays awake) 0 ICH Scale
Drowsy (Responds to minor stim. but falls back asleep) 1 GCS: Volume: IVH: Infratentorial: Age:
Obtunded (Responds only to deep pain or vigorous stim) 2 3-4: 2 points ≥30: 1 point Yes: 1 point Yes: 1 point ≥80: 1 point
Comatose 3 5-12: 1 point <30: 0 points No: 0 points No: 0 points <80: 0 point
1b. LOC- Questions Month? Age? Both correct 0 - One answer correct 1 - Neither question answered correctly 2 13-15: 0 points
Mortality: 1 point: 13% 4 points: 97% 6 points: 100%
1c. LOC– Commands Both correct 0 - One correct 1 - Neither performed correctly 2 0 points: 0% 2 points: 26% 3 points: 72% 5 points: 100%
Opens/closes eyes - Opens/closes hands
2. Eye Movements: Normal 0 - Mild gaze paralysis (can bring eyes only over to midline) 1 - Complete 2
Horizontal eye movements Hunt and Hess scale Survival
3. Visual fields: Normal 0 - Partial (quadrant) 1 - Complete hemianopia 2 - Bilateral hemianopia 3 1 Asymptomatic, mild headache, slight nuchal rigidity 70%
2 Moderate to severe headache, nuchal rigidity, no neurologic deficit other than CN palsy 60%
3 Drowsiness / confusion, mild focal neurologic deficit 50%
4. Facial: Normal 0
4 Stupor, moderate-severe hemiparesis 20%
Minor paralysis (flattening of nasolabial folds) 1
5 Coma, decerebrate posturing 10%
Partial paralysis (near or total paralysis lower face) 2
Complete paralysis (Of upper and lower face) 3 Fischer Grade score
5a. Motor – Left Arm Normal (No drift at all) 0 Grade 1: No blood
Hold arm straight out from chest Drift (Drifts downward but NOT to bed before 10 sec.) 1 Grade 2: Diffuse or thin layer of blood less than 1 mm thick
Amputation or joint fusion (N/A) Drifts to bed within 10 sec 2 Grade 3: Localized clots and/or layers of blood greater than 1 mm thick in the vertical plane
Movement, but not against gravity 3 Grade 4: Intracerebral or intraventricular clots with diffuse or absent blood in basal cisterns
Complete paralysis (No movement at all) 4
tPA
5b. Motor – Right Arm Normal (No drift at all) 0
Inclusion Criteria:
Hold arm straight out from chest Drift (Drifts downward but NOT to bed before 10 sec.) 1
- Onset of symptoms <3 hours - ischemic stroke causing measurable neurological deficit - Aged ≥18 years
Amputation or joint fusion (N/A) Drifts to bed within 10 sec 2
Exclusion Criteria
Movement, but not against gravity 3
 Significant head trauma or prior stroke in previous 3 months
Complete paralysis (No movement at all) 4
 Symptoms suggest subarachnoid hemorrhage
6a. Motor – Left leg Normal (No drift at all) 0
 History of previous intracranial hemorrhage
Drift (Drifts downward but NOT to bed before 5 sec.) 1
Keep leg off bed
 Intracranial neoplasm, AVM, or aneurysm
Amputation or joint fusion (N/A) Drifts to bed within 5 sec 2
 Recent intracranial or intraspinal surgery
Movement, but not against gravity 3
 Arterial puncture at noncompressible site in previous 7 days
Complete paralysis (No movement at all) 4
 Elevated blood pressure (systolic >185 mm Hg or diastolic >110 mm Hg)
6b. Motor – Right leg Normal (No drift at all) 0  Active internal bleeding
Keep leg off bed Drift (Drifts downward but NOT to bed before 5 sec.) 1  Blood glucose concentration <50mg/dl (2.7mmol/L)
Amputation or joint fusion (N/A) Drifts to bed within 5 sec 2  Acute bleeding diathesis, including but not limited to: Platelet count <100 000/mm³
Movement, but not against gravity 3  Heparin received within 48 hours, resulting in abnormally elevated aPTT
Complete paralysis (No movement at all) 4  Current use of anticoagulant with INR >1.7 or PT >15 seconds
7. Limb Ataxia: Finger-Nose - Heel-Knee Absent (OR pt cannot move arm/leg) 0 - in one limb 1 - in two limbs 2  Current use of direct thrombin inhibitors or direct factor Xa inhibitors
 CT demonstrates multilobar infarction (hypodensity >1/3 cerebral hemisphere)
8. Sensory : (Test on face, arm & thigh) Normal 0 - Mild to moderate loss 1 - Severe (unaware of being touched) 2 Relative Exclusion Criteria
 Only minor or rapidly improving stroke symptoms (clearing spontaneously)
9. Language/Aphasia Normal ability use words and follow commands 0  Seizure at onset with postictal residual neurological impairments
Repetition & Comprehension Mild to Moderate (Repeats / names with some difficulty) 1  Major surgery or serious trauma within previous 14 days
“Today is a bright sunny day” Severe Aphasia (very few words correct or understood) 2  Recent gastrointestinal or urinary tract hemorrhage (within previous 21 days)
Mute (no ability to speak or understand at all) 3  Pregnancy
10. Dysarthria (slurred) Normal 0 Mild to moderate 1 Severe (none understandable) 2 To extend IV tPA to 4.5 hours, the following additional criteria MUST be met:
Intubated or other physical barrier (N/A)  Patient is < 80 years of age
11. Neglect : Ignores touch or vision Normal 0 - Mild (partial) 1 - Profound (Visual and tactile – complete) 2  Patient does not have a history of both diabetes AND stroke
 Patient is not taking Warfarin (Coumadin) or any other anticoagulant regardless of INR/coagulation results
Total Score 0 = Best, 42 = Worst  NIHSS is < 25
 Written informed consent obtained from patient and/or family – required