Jordan Ellis
Diagnosing a stroke in hospital involves a series of tests to determine the type, cause, location, and severity of the stroke. Doctors will assess symptoms, medical history, and risk factors through a physical exam, neurological exam, and questioning of the patient or their family members. Imaging tests such as computed tomography (CT) scans and magnetic resonance imaging (MRI) are commonly used to visualise the brain and detect issues like bleeding, blood vessel problems, or brain cell damage. Other tests include electrocardiograms (ECG or EKG) to assess heart function, blood tests to check for problems like clotting or infection, and lumbar punctures to detect substances from damaged blood cells. The prompt diagnosis of stroke type is crucial, as it dictates treatment, which may include clot-busting drugs, blood-thinning medications, or surgery.
| Characteristics | Values |
|---|---|
| Symptoms | Numbness, weakness, trouble speaking, seeing, or walking, etc. |
| Medical History | Family history of stroke, risk factors, etc. |
| Physical Exam | Blood pressure, reflexes, simple actions, etc. |
| Neurological Exam | Checks the nervous system to determine the severity and location of the stroke |
| Imaging Tests | Computed tomography (CT) scan, Magnetic resonance imaging (MRI), digital subtraction angiography (DSA), positron emission tomography (PET), CT or MR angiogram |
| Blood Tests | Complete blood count (CBC), serum electrolytes, C-reactive protein test, blood protein test |
| Other Tests | Electrocardiogram (ECG or EKG), carotid ultrasound, echocardiography, cerebral angiography, lumbar puncture (spinal tap) |
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What You'll Learn
Neurological exams
A neurological examination is crucial in diagnosing a stroke and determining the severity of neurological impairment. The purpose of the examination is to localise the lesion and evaluate the various neurological functions affected. The level of detail in the examination will depend on the setting, the patient's history, and the symptoms presented.
Several components make up the neurological examination, including auditory and vestibular function assessments. For example, the patient's ability to discern words or sentences at a low volume may be tested, or fingers may be rubbed close to the ear to assess hearing. If a hearing deficit is detected, further tests such as the Weber and Rinne tests can differentiate between conductive and sensorineural hearing loss. The Head Impulse Test (HIT) is another important tool used to assess the horizontal vestibulo-ocular reflex (VOR) and diagnose acute unilateral vestibular lesions.
In addition to auditory and vestibular assessments, a neurological exam may also include sensory testing to evaluate light touch, pain, and temperature sensation in different areas of the face. This involves testing the three divisions of the trigeminal nerve: ophthalmic, maxillary, and mandibular. It is important to avoid the angle of the mandible during this test, as it is innervated by C2/C3. Another aspect of the neurological exam is the evaluation of the patient's eyes, which can provide important information about the location of the lesion. For instance, in a contralateral cortical lesion, the patient's eyes will deviate towards the lesion, while in a contralateral brainstem lesion, the eyes will deviate away from it.
Further tests that may be included as part of a neurological examination are the Dix-Hallpike test, MMSE, brainstem reflexes, and tests for thoracic outlet syndrome. These additional tests can aid in diagnosing specific conditions related to the stroke, such as trigeminal neuralgia or tumours affecting the cerebellopontine angle.
The results of the neurological examination, along with other assessments and imaging scans, help healthcare providers determine the type of stroke, its cause, the affected area of the brain, and the severity of the stroke's impact. This information is crucial for developing an effective treatment plan for the patient.
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Imaging tests
Computed Tomography (CT) Scan
CT scanning is often one of the first imaging tests performed after a suspected stroke. It uses X-rays to capture clear, detailed images of the brain. CT scans can reveal bleeding in the brain, damage to brain cells, and other issues that might be causing stroke-like symptoms. This test is typically performed immediately after a suspected stroke to assess the situation.
Magnetic Resonance Imaging (MRI)
MRI scans utilise strong magnets and radio waves to create images of the brain. They can identify changes in brain tissue and damage to brain cells caused by a stroke. MRI scans may be used in conjunction with or as an alternative to CT scans. MRIs can detect brain changes caused by a stroke earlier than CT scans and can also identify bleeding and blood flow problems. Additionally, they help rule out other conditions like tumours that might be causing similar symptoms.
CT or MR Angiogram
An angiogram is an imaging technique that focuses on the blood vessels and blood flow. In a CT angiogram, a dye is injected into the veins to provide a detailed visualisation of the blood vessels, while an MR angiogram is used in conjunction with an MRI scan. Angiograms can help doctors understand blood flow issues and identify problems like narrowed blood vessels in the neck, aneurysms, or tangled blood vessels (arteriovenous malformations).
Digital Subtraction Angiography (DSA) and Positron Emission Tomography (PET)
DSA and PET scans are additional imaging tests that can be used to examine the blood vessels. These techniques help detect narrowed blood vessels, aneurysms, or arteriovenous malformations in the brain.
Lumbar Puncture (Spinal Tap)
In cases where a stroke is suspected but imaging scans do not reveal any bleeding in the brain, a lumbar puncture may be performed. This test involves using a needle to collect fluid from the spine, which is then tested for substances that indicate the presence of damaged blood cells.
The information gathered from these imaging tests plays a vital role in diagnosing a stroke, determining its type, location, and severity, and guiding the subsequent treatment plan.
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Electrocardiogram (ECG or EKG)
An electrocardiogram (ECG or EKG) is a test that measures the electrical activity of the heartbeat. It can help find heart problems that may have led to a stroke. For example, this test can help diagnose atrial fibrillation or a previous heart attack. There is no pain or risk associated with having an EKG. The test requires small stickers to be placed on the chest to record the electrical activity of the heart. It doesn't send electricity into the body.
In the investigator-initiated multicenter MonDAFIS study, 3,465 patients with acute ischemic stroke or transient ischemic attack and without known atrial fibrillation were randomised to receive Holter-ECG for up to 7 days in-hospital with systematic evaluation in a core cardiology laboratory (intervention group) or standard diagnostic care (control group). Abnormal ECG findings were detected in 19.3% of patients in the intervention group.
Systematic in-hospital Holter ECG reveals abnormal findings in 1 in 5 patients with acute stroke, and mortality was lower at 24 months in patients with systematic ECG recording in the hospital. Further studies are needed to determine the potential impact of medical management of abnormal ECG findings.
In addition to ECG, there are several other tests used to diagnose a stroke. Computed tomography (CT) uses X-rays to take clear, detailed pictures of the brain and can show whether there is bleeding or damage to the brain cells. Magnetic resonance imaging (MRI) uses magnets and radio waves to create images of the brain and can be used to identify changes in brain tissue and damage to brain cells. Other imaging tests may include digital subtraction angiography (DSA) and positron emission tomography (PET) to look for narrowed blood vessels in the neck, an aneurysm, or an arteriovenous malformation (AVM) in the brain.
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Physical exams
A physical examination is an important part of diagnosing a stroke in the hospital. It helps the doctor determine the severity of the stroke and plan the treatment approach. During the physical exam, the doctor will check for vital signs and symptoms indicative of a stroke. This includes taking the patient's blood pressure and assessing their mental alertness. The doctor will also check for any numbness, weakness, or paralysis on one side of the body, as well as any difficulties with speech, vision, or walking.
In addition to these general assessments, the doctor will also perform a neurological exam to evaluate the nervous system's functioning. This involves asking the patient questions, testing their reflexes, and instructing them to perform simple actions. Each part of the neurological exam targets a different part of the brain, aiding in localising the stroke and gauging its severity.
Furthermore, the doctor will use a stethoscope to listen to the carotid arteries as part of the physical exam. This examination is crucial in detecting signs of carotid artery disease, a common cause of ischemic stroke.
While a physical exam is a crucial aspect of stroke diagnosis, it is often complemented by other tests and imaging techniques, such as computed tomography (CT) scans, magnetic resonance imaging (MRI), and blood tests, to confirm the diagnosis and rule out other potential causes of similar symptoms.
It is important to note that the physical exam for stroke diagnosis begins even before the patient reaches the hospital. Ambulance workers are often the first responders and start the initial stroke examination, which is then continued and expanded upon by the doctor in the hospital setting.
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Medical history
A patient's medical history is an important factor in diagnosing a stroke. Doctors will ask the patient or their family members about their symptoms, risk factors, and medical history. This includes questions about any personal or family history of stroke, as well as the presence of other risk factors such as atrial fibrillation, a previous heart attack, or carotid artery disease.
The medical history will also help determine the type of stroke the patient may have had. Ischemic strokes, the most common type, occur when a blood vessel carrying blood to the brain is blocked or restricted by severely narrowed arteries or a blood clot. Risk factors for ischemic strokes include clogged arteries due to fat, cholesterol, and other substances that harden over time to form plaque, as well as existing heart conditions. On the other hand, hemorrhagic strokes happen when a blood vessel in the brain ruptures or breaks, allowing blood to leak into the brain. Understanding the patient's medical history and any existing conditions can help doctors determine the likelihood of each type of stroke and inform the diagnostic process.
Additionally, the medical history can provide insights into any previous transient ischemic attacks (TIAs) or mini-strokes. TIAs are short episodes of stroke-like symptoms that usually last from a few minutes to up to 24 hours and often serve as a warning sign of an impending stroke. Information about any previous TIAs, their frequency, and their duration can help doctors assess the patient's risk factors and determine the urgency of further diagnostic tests and treatments.
The patient's medical history will also guide the selection of specific diagnostic tests. For example, if there is a history of heart problems or atrial fibrillation, an electrocardiogram (ECG or EKG) may be prioritized to assess the heart's electrical activity and determine if atrial fibrillation could have caused the stroke. Blood tests, such as a complete blood count (CBC) and serum electrolyte test, may also be ordered based on the patient's medical history to rule out other health problems with similar symptoms or identify underlying conditions that increase stroke risk.
Overall, the patient's medical history plays a crucial role in diagnosing a stroke, guiding doctors in understanding the patient's risk factors, determining the type of stroke, evaluating the urgency of the situation, and selecting the most appropriate diagnostic tests.
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Frequently asked questions
The first step in diagnosing a stroke is to determine whether the patient is experiencing an ischemic or hemorrhagic stroke. This can be done by asking the patient or their family about their symptoms and medical history. The patient will then undergo a physical exam, which includes taking their blood pressure and checking for mental alertness, numbness or weakness, or trouble speaking, seeing, or walking.
The next step is to perform a neurological exam, which tests how well the nervous system is working and can show how serious the stroke was and where in the brain it occurred. At least one imaging test will also be performed to allow doctors to see inside the brain, assess the damage, and determine the location and type of stroke.
Imaging tests used to diagnose a stroke include computed tomography (CT) scans, which use X-rays to take clear, detailed pictures of the brain and can show bleeding or damage to brain cells. Magnetic resonance imaging (MRI) may also be used, which employs magnets and radio waves to create pictures of the brain and can identify changes in brain tissue. Other imaging tests include digital subtraction angiography (DSA) and positron emission tomography (PET) to look for narrowed blood vessels in the neck, aneurysms, or tangled blood vessels (AVM) in the brain.
Other tests used to diagnose a stroke include blood tests such as a complete blood count (CBC) to measure overall blood health and serum electrolyte tests to check for electrolyte problems, which can cause stroke-like symptoms. An electrocardiogram (ECG or EKG) can also be used to detect heart problems that may have led to the stroke, such as atrial fibrillation or a previous heart attack.
