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Examinations to Be Done for a Stroke Patient

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1. History Taking

• Time of symptom onset - this is the most critical piece of information for determining thrombolytic eligibility (within 4.5 hours for IV tPA)
• Nature of onset: Sudden onset suggests embolic or hemorrhagic stroke; stuttering/waxing-waning course suggests thrombotic or hypoperfusion
• Preceding events: Thunderclap headache / Valsalva maneuver (ruptured aneurysm); recent neck trauma/manipulation (cervical artery dissection)
• Risk factors: Hypertension, diabetes mellitus, hyperlipidemia, coronary artery disease (suggest thrombotic stroke)
• Cardiac history: Atrial fibrillation, valvular replacement, recent MI (suggest embolic stroke)
• Prior TIAs: Same vascular distribution = thrombotic; different distributions = embolic
• Medications: Anticoagulants, antiplatelets, contraceptive pills
• Family history of stroke, coagulopathy, or connective tissue disorders

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2. General Physical Examination

A. Airway, Breathing, Circulation (ABCs) - FIRST PRIORITY

• Ensure patent airway (especially if consciousness is impaired)
• Check breathing rate, oxygen saturation
• Check pulse, blood pressure (in both arms), heart rate

B. Vital Signs

• Blood pressure: Hypertension (hemorrhagic/hypertensive stroke), hypotension (cardiogenic cause)
• Temperature: Fever prompts search for CNS infection (meningitis, encephalitis) or aspiration pneumonia / UTI as a complication
• Heart rate and rhythm: Irregular pulse suggests atrial fibrillation (embolic source)
• Blood glucose: Hypoglycemia is a common stroke mimic

C. Cardiovascular Examination

• Cardiac auscultation: Murmurs (valvular disease, endocarditis), S3 gallop (heart failure, embolic source)
• Carotid bruit: Suggests ipsilateral carotid stenosis
• Peripheral pulses: Decreased pulses (Takayasu arteritis); all four limb BP comparison for aortic dissection
• Ocular bruit: Can reflect intracranial carotid stenosis

D. Skin and General Examination

E. Fundoscopy (Ophthalmoscopy)

• Papilledema: Mass lesion, cerebral venous thrombosis, hypertensive crisis
• Preretinal hemorrhage: Subarachnoid hemorrhage
• Hollenhorst plaques (cholesterol emboli) in retinal arteries: Carotid atherosclerotic disease
• Retinal hemorrhages: Trauma, bleeding diathesis, ruptured aneurysm, collagen vascular disease

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3. Neurological Examination

A. Level of Consciousness (GCS / AVPU)

• Assess alertness, orientation (time, place, person)
• Look for subtle altered mental status

B. Mental Status

• Orientation, memory, attention
• Use MoCA (Montreal Cognitive Assessment) - superior for detecting mild deficits
• Assess behavior, mood, signs of delirium

C. Speech and Language

• Aphasia: Expressive (Broca's - frontal lobe) vs. receptive (Wernicke's - temporal lobe) vs. global
• Dysarthria: Slurred speech (motor - corticobulbar/cerebellar)
• Dysphasia

D. Cranial Nerve Examination

E. Motor Examination

• Tone (spasticity/flaccidity), power (0-5 MRC scale) in all four limbs
• Pronator drift (arms outstretched, eyes closed): drifting/pronation = contralateral upper motor neuron weakness
• Look for hemiparesis, monoparesis (rarely quadriparesis)

F. Sensory Examination

• Light touch, pinprick, vibration, proprioception
• Hemisensory loss (contralateral)
• Two-point discrimination, graphesthesia (parietal lobe)
• Sensory neglect / extinction on double simultaneous stimulation

G. Cerebellar Examination

• Finger-nose test (dysmetria)
• Heel-shin test
• Dysdiadochokinesia (rapid alternating movements)
• Romberg test

H. Reflexes

• Deep tendon reflexes (biceps, triceps, knee, ankle) - hyperreflexia in UMN lesion
• Plantar response: Upgoing (Babinski sign) = corticospinal tract involvement
• Check for clonus
• Hoffman's sign

I. Gait and Coordination

• Gait (hemiplegic, ataxic, foot drop)
• Tandem gait (cerebellar)

J. Signs of Meningeal Irritation

• Neck stiffness (nuchal rigidity)
• Kernig's sign, Brudzinski's sign - if subarachnoid hemorrhage or meningitis is suspected

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4. Stroke Severity Scales

NIHSS (NIH Stroke Scale) - Most widely used

1. Level of consciousness
2. Gaze (horizontal eye movement)
3. Visual fields
4. Facial palsy
5. Motor - arm (left and right)
6. Motor - leg (left and right)
7. Limb ataxia
8. Sensory
9. Best language
10. Dysarthria
11. Extinction / inattention

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5. Investigations

Immediate / Bedside

Urgent Blood Tests

Imaging

Cardiac Investigations

Other Investigations (as indicated)

• Lumbar puncture (LP): If subarachnoid hemorrhage suspected with negative CT (xanthochromia)
• EEG: If seizures suspected as stroke mimic or complication
• Chest X-ray: Aspiration pneumonia, cardiomegaly, aortic arch
• Urine analysis / culture: UTI (fever, infection complication)
• Dysphagia screening: Bedside water swallow test before oral feeding/medications

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6. Prehospital Screening Tools (for quick identification)

• Cincinnati Prehospital Stroke Scale (CPSS): Facial droop + Arm drift + Speech abnormality (any one abnormal = 66% sensitivity)
• FAST: Face, Arm, Speech, Time

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Summary Approach

Airway-Breathing-Circulation → Vital Signs + Blood Glucose
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History (TIME OF ONSET is #1 priority)
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General + Neurological Examination (NIHSS)
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URGENT: CT brain (non-contrast) → r/o hemorrhage
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Blood tests + ECG + CTA/CTP (if LVO suspected)
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Cardiac workup (Echo, Holter) + Vascular imaging

Sources: Tintinalli's Emergency Medicine, Ch. 167, pp. 1162-1163 | Adams and Victor's Principles of Neurology, 12th Ed., p. 2081-2120 | Bradley and Daroff's Neurology in Clinical Practice, Table 68.2, p. 1475