During the initial clinical assessment of this patient, how likely are you to perform the following?
Definitely Probably Probably Definitely Would Not Would Not Would Would
1. A full neurologic examination (ie, detailed evaluation of
mental status, sensation, etc) ❍ ❍ ❍ ❍
2. A focused neurologic examination using a standardized
assessment tool ❍ ❍ ❍ ❍
Examination: Temperature 37.1°C, blood pressure 179/89 mm Hg, pulse 91 and irregular, respirations 16.
He is awake, alert, and in no distress. The neck is supple. No cervical bruits or cardiac murmurs are present. He is unable to state his age or the current month. He is able to close his eyes to command but protrudes his tongue when asked to make a fist with his left hand. He is unable to read or name objects.
There is a left gaze preference that can be overcome with vigorous stimulation from the right side. No appreciable visual field deficit is present. The motor examination demonstrates dense hemiparesis involving the right lower face, arm, and leg. There are trace distal movements in the right hand and foot. The sensory examination is remarkable for decreased pin sensation in the right face, arm, and leg. There is no evidence of ataxia or hemispatial neglect.
How likely are you to order the following tests in the evaluation of this patient?
Definitely Probably Probably Definitely Would Not Would Not Would Would
3. Finger-stick glucose ❍ ❍ ❍ ❍
4. Complete blood count ❍ ❍ ❍ ❍
5. Lumbar puncture ❍ ❍ ❍ ❍
6. Coagulation profile (activated partial thromboplastin time [aPTT],
international normalized ratio) ❍ ❍ ❍ ❍
7. Chest radiograph ❍ ❍ ❍ ❍
8. Noncontrast head CT ❍ ❍ ❍ ❍
After obtaining normal laboratory and noncontrast head CT results, how likely are you to administer the following medications to this patient 100 minutes after symptom onset?
Definitely Probably Probably Definitely Would Not Would Not Would Would
9. IV unfractionated heparin infusion to achieve aPTT 2.5 times
the baseline value ❍ ❍ ❍ ❍
10. IV recombinant tissue-type plasminogen activator (rt-PA) ❍ ❍ ❍ ❍
How likely are you to administer IV rt-PA to an otherwise eligible patient with the following findings on noncontrast head CT?
Definitely Probably Probably Definitely Would Not Would Not Would Would
11. Intraparenchymal hyperintensity in a clinically relevant area ❍ ❍ ❍ ❍
12. Loss of gray-white differentiation in the insular cortex
or lentiform nucleus ❍ ❍ ❍ ❍
13. Well-demarcated area of hypodensity with mass effect
involving greater than one-third of the middle cerebral artery ❍ ❍ ❍ ❍
Prior to administration of IV rt-PA to an eligible patient with stroke, how likely are you to obtain the following?
Definitely Probably Probably Definitely Would Not Would Not Would Would
14. Testing for stool guaiac ❍ ❍ ❍ ❍
15. Written informed consent ❍ ❍ ❍ ❍
Case 2
History: A 53-year-old man arrives in the emergency department by ambulance 1 hour after he suddenly developed slurred speech and difficulty walking. His son was with him when the symptoms began, and he reports that his father was “staggering” and appeared “sweaty.” The patient reports no headache, visual changes, or loss of feeling. There was no witnessed loss of consciousness and no prior history of stroke or TIA.
Past Medical History: Coronary artery disease, peripheral vascular disease, hypertension, non–insulin-dependent diabetes, hyperlipidemia.
Past Surgical History: Percutaneous coronary angioplasty and two stents.
Medications: Aspirin 325 mg daily, clopidogrel 75 mg daily, amlodipine 10 mg daily, hydrochlorothiazide 25 mg daily, lisinopril 10 mg daily, simvastatin 20 mg daily.
Family History: Mother with diabetes. Father deceased with stroke. Two “healthy” brothers.
Social History: Smokes 1.5 packs of cigarettes daily. Drinks two to three beers nightly.
Examination: Temperature 37.6°C, blood pressure 200/99 mm Hg, pulse 95 and regular, respirations 18. The general physical examination is remarkable for a left cervical bruit and a 2/6 systolic ejection murmur heard best at the right upper sternal border with radiation to the suprasternal notch. He is able to correctly state his age and the current month. There is no evidence of aphasia or neglect. There is no gaze preference or visual field deficit. Ocular motility is full with persistent nystagmus on left lateral gaze. Speech is markedly dysarthric.
The motor examination is normal without evidence of drift. The sensory examination shows no evidence of sensory asymmetry to pin or hemispatial neglect. There is marked ataxia on finger-to-nose testing of the left arm and heel-to-shin testing of the left leg.
Management: The patient undergoes a noncontrast head CT that shows no evidence of acute intracranial hemorrhage. The finger-stick glucose level is 121. The remainder of the laboratory evaluation is within normal limits. There is no past history of intracranial hemorrhage, recent head trauma, recent surgical procedures, gastrointestinal or genitourinary hemorrhage, or recent arterial puncture. A bolus of IV labetalol 20 mg is administered, and the blood pressure 5 minutes later is 176/78 mm Hg. The risks, benefits, and alternatives of IV rt-PA are discussed with the patient and his family. Alteplase 0.9 mg/kg is ordered; 10% of the dose is given as a bolus over 1 minute, and the remainder of the dose is started as a continuous infusion over the next hour.
How likely are you to recommend continued care for this patient in the following setting?
Definitely Probably Probably Definitely Would Not Would Not Would Would
16. A monitored bed on a general medical ward ❍ ❍ ❍ ❍
17. A medical or neurologic intensive care unit ❍ ❍ ❍ ❍
PART 1—BASELINE QUESTIONNAIRE CONTINUED
Following transfer to an appropriate unit, how likely are you to recommend the following for this patient?
Definitely Probably Probably Definitely Would Not Would Not Would Would
18. Intraarterial blood pressure monitoring ❍ ❍ ❍ ❍
19. Unfractionated heparin 5000 international units 3 times daily ❍ ❍ ❍ ❍
20. Lower extremity sequential pneumatic compression devices ❍ ❍ ❍ ❍
Investigations: Thirty minutes after initiation of rt-PA therapy a blood pressure of 235/110 mm Hg is obtained.
How likely are you to administer the following agents to this patient?
Definitely Probably Probably Definitely Would Not Would Not Would Would
21. Sodium nitroprusside ❍ ❍ ❍ ❍
22. IV nicardipine infusion at 5 mg/h ❍ ❍ ❍ ❍
Interval Case History: Shortly after the elevated blood pressure measurement, a change occurs in the patient’s neurologic condition. The patient reports a severe occipital headache, and his speech is more dysarthric. He vomits once, and the headache continues to worsen.
In response to the change in the patient’s clinical condition, how likely would you be to perform the following?
Definitely Probably Probably Definitely Would Not Would Not Would Would
23. Administer oxycodone + acetaminophen 5/100 two tablets
by mouth ❍ ❍ ❍ ❍
24. Discontinue rt-PA infusion ❍ ❍ ❍ ❍
25. Order an urgent noncontrast head CT ❍ ❍ ❍ ❍
Investigations Continued: The noncontrast head CT reveals a cerebellar hemorrhage.
How likely are you to perform the following?
Definitely Probably Probably Definitely Would Not Would Not Would Would
26. Administer antithrombin III ❍ ❍ ❍ ❍
27. Administer cryoprecipitate and platelets ❍ ❍ ❍ ❍
28. Obtain neurosurgical consultation ❍ ❍ ❍ ❍
Thank you for your time.
Please send your completed survey by fax to (651) 361- 4806 or by mail to:
Lori Strachota
American Academy of Neurology 1080 Montreal Avenue
St. Paul MN 55116
Please review the preferred answers, which follow this questionnaire.