Sometimes, this can be obtained only from someone other than the patient, especially for patients who present with aphasia or who are obtunded at presentation. Similarly, the extent of neurologic deficit, presence of associated impairment of consciousness, and evidence of meningeal irritation from presumed subarachnoid hemorrhage may be useful. Most patients with ischemic infarction are not initially obtunded, whereas those with hemorrhagic stroke often show varying impairment of consciousness and may present in a coma. A history of sudden or apoplectic onset of neurologic deficit without headache suggests an embolic source for the stroke. Evolution over minutes to a maximum deficit with headache and altered consciousness strongly suggests a hemorrhagic event.
Time is precious when considering existing therapeutic options.
Tests such as those for immune complex disorders and hypercoagulable states should be dictated by the clinical picture. Frequent monitoring of vital signs and neurologic status is mandatory because symptoms and signs may fluctuate rapidly over the first few hours and days after a stroke. Often, this is best accomplished in an intensive care setting or a specialized stroke center. Patients with a neurologic deficit on presentation require urgent neuroimaging. Of the existing modalities, CT scans are generally more rapidly available and require less patient compliance to provide diagnostically useful images.