Is this a vascular event

The diagnosis depends crucially on an accurate history, taken from the patient and/or carer. We ask ourselves the following questions to help decide whether it was a vascular event.

• Are the neurological symptoms focal rather than non-focal?

• Are the focal neurological symptoms negative (that is, loss of function) rather than positive (for example, pins and needles rather than numbness)?

• Was the onset of the focal symptoms sudden?

• Were the focal symptoms maximal at onset (that is, coming on over minutes to hours) rather than progressive (that is, evolving over hours to days)?

If the answer to all these questions is yes, then a vascular cause (either cerebral ischaemia or haemorrhage) is very likely. Of course, presentations vary. Occasional patients have symptoms or signs which are not easily localised (for example, memory impairment, confusion, or a reduced conscious level), symptoms may be positive (for example, movement disorders), and many patients describe symptoms evolving over hours or even days. These exceptions simply make the clinical diagnosis less certain and should lead to early investigation to exclude alternative diagnoses which require different urgent treatment (for example, hypoglycaemia, non-convulsive seizures, cerebral infection, or subdural haematoma). When one sees a patient within the first few hours of symptom onset, it is often difficult to know whether one is witnessing a transient ischaemic attack (TIA) or stroke (or a stroke mimic), and increasingly we refer to the concept of a "brain attack" - that is, the acute onset of focal brain symptoms which are likely to be due to a vascular cause.

In addition, we consider the context in which the event has occurred. Strokes are uncommon in the young and as about 80% of stroke patients have at least one vascular risk factor at presentation,21 the absence of risk factors should lead one to be slightly more sceptical about a diagnosis of stroke. Accurate diagnosis in the hyperacute phase (less than six hours from onset) is often difficult because symptoms and signs may be changing rapidly. The introduction of acute therapies which need to be administered within this time window suggests that early and accurate diagnoses will become increasingly important.

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