Narrative Review: Stroke
|
Narrative Review |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mehrian Jafarizade, M.D [2]
| Site | Patient | AE | Complication | Event date | AE code |
|---|---|---|---|---|---|
| XXX | XXX | X | ... | MM/DD/YYYY | XXX |
Diagnosis
Addmission date: MM/DD/YYYY
Symptoms:
O Loss of consciousness
O New focal neurological deficits [scale based on the NIH table]
O Presence of hypoglycemia
O Presence of AF (or other arrhythmia)
National Institutes of Health Stroke Scale: [Write the score of stroke]
| Class | Title | Responses and Scores |
|---|---|---|
| 1A | Level of consciousness | 0—Alert
1—Drowsy 2—Obtunded 3—Coma/unresponsive |
| 1B | Orientation questions | 0—Answers both correctly
1—Answers 1 correctly 2—Answers neither correctly |
| 1C | Response to commands | 0—Performs both tasks correctly
1—Performs 1 task correctly 2—Performs neither |
| 2 | Gaze | 0—Normal horizontal movements
1—Partial gaze palsy 2—Complete gaze palsy |
| 3 | Visual fields | 0—No visual field defect
1—Partial hemianopia 2—Complete hemianopia 3—Bilateral hemianopia |
| 4 | Facial movement | 0—Normal
1—Minor facial weakness 2—Partial facial weakness 3—Complete unilateral palsy |
| 5 | Motor function (arm)a. Leftb. Right | 0—No drift
1—Drift before 5 seconds 2—Falls before 10 seconds 3—No effort against gravity 4—No movement |
| 6 | Motor function (leg)a. Leftb. Right | 0—No drift
1—Drift before 5 seconds 2—Falls before 5 seconds 3—No effort against gravity 4—No movement |
| 7 | Limb ataxia | 0—No ataxia
1—Ataxia in 1 limb 2—Ataxia in 2 limbs |
| 8 | Sensory | 0—No sensory loss
1—Mild sensory loss 2—Severe sensory loss |
| 9 | Language | 0—Normal
1—Mild aphasia 2—Severe aphasia 3—Mute or global aphasia |
| 10 | Articulation | 0—Normal
1—Mild dysarthria 2—Severe dysarthria |
| 11 | Extinction or inattention | 0—Absent
1—Mild (loss 1 sensory modality lost) 2—Severe (loss 2 modalities lost) |
Imaging:
- MM/DD/YYYY at xx:xx on brain MRI : [Write the MRI findings, mention the site of stroke here]
- MM/DD/YYYY at xx:xx on brain CT : [Write the CT findings, mention the site of stroke here]
- MM/DD/YYYY at xx:xx on EEG:
- MM/DD/YYYY at xx:xx on Carotid US:
Type of stroke/TIA:
O Ischemic Stroke
O Hemorrhagic Stroke
O Undetermined Stroke
O TIA
Stroke/TIA definitions
Stroke:
Each of:
- Duration of a focal or global neurological deficit 24 h
- < 24 h if available neuroimaging procedure (CT scan or brain MRI) documents a new intracranial or subarachnoid hemorrhage (hemorrhagic stroke) or central nervous system infarction (ischemic stroke)
- The neurological deficit results in death
- There is confirmation of a stroke diagnosis by a neurologist or neurosurgical specialist.
Ischemic:
- An acute episode of focal cerebral, spinal, or retinal dysfunction caused by infarction of the central nervous system tissue.
Hemorrhagic:
- An acute episode of focal or global cerebral or spinal dysfunction caused by intraparenchymal, intraventricular, or subarachnoid hemorrhage.
Undetermined:
- If there is insufficient information to allow categorization as ischemic or hemorrhagic.
TIA:
Each of:
- Duration of a focal or global neurological deficit <24 h and neuroimaging procedure (CT scan or brain MRI) does not demonstrate a new hemorrhage or infarct.
- There is confirmation of a TIA diagnosis by a neurologist or neurosurgical specialist.
Event
Demographic: [age] year old [gender]
Site Reported Event Onset Date: MM/DD/YYYY
Event (1) summary:
- Symptoms and sign:
- Subject presented with [sign and symptom] on MM/DD/YYYY.
- Important characteristics of the chief complaint such as severity, site, and duration.
- Other important symptoms related to the chief complaint.
- Past Medical History: [eg. CAD, Severe mitral stenosis, former tobacco use, dyslipidemia, ...]
- Past Surgical History: [including date]
- Medications: [relevant to the event not all]
- Physical assessment:
- Vital signs
- Positive physical examinations or related negative examinations.
Event (2) summary: [If there is more than 1 event]
- Symptoms and sign:
- Subject presented with [sign and symptom] on MM/DD/YYYY.
- Important characteristics of the chief complaint such as severity, site, and duration.
- Other important symptoms related to the chief complaint.
- Past Medical History: [eg. CAD, Severe mitral stenosis, former tobacco use, dyslipidemia, ...]
- Past Surgical History: [including date]
- Medications: [relevant to the event not all]
- Physical assessment:
- Vital signs
- Positive physical examinations or related negative examinations.
Procedure
- Index Procedure Date/Time:
- MM/DD/YYYY at xx:xx [insert date and time]
- Index Procedure Detail:
- On MM/DD/YYYY at xx:xx [insert date and time] the subject underwent a [select surgical correction] for [select etiology].
- Access site details
- The site reported that there were/were not procedural complication(s).
Laboratory data
- Lab studies list: (Date/ name/ value)
Other Diagnostic tests
- MM/DD/YYYY at xx:xx on MRA: [write the most important findings]
- MM/DD/YYYY at xx:xx on ECG: [write the most important findings]
- MM/DD/YYYY at xx:xx on ECHO: [write the most important findings]
- MM/DD/YYYY at xx:xx on Ultrasound: [write the most important findings]
- MM/DD/YYYY at xx:xx on Endoscopy: [write the most important findings]
- MM/DD/YYYY at xx:xx ... (Other relevant imaging and diagnostic tests)
Consults
- Date and time of consult
- Suggested treatments
Clinical course
- Date and time of events,
- Patient condition got worse or better.
Treatment and outcome
- List of relevant medical treatments
- Outcome [Discharge / Hospice / Death]