1 = Present in one limb. 2 = Present in two limbs. ensure testing is done in intact visual field. The finger-nose-finger and heel-shin tests UN = Amputation or joint fusion, explain:________________ are performed on both sides, and ataxia is scored only if present out of proportion to weakness. Ataxia is absent in the patient https://www.uptodate.com/contents/early-antithrombotic-treatment-of-acute-ischemic-stroke-and-transient-ischemic-attack/print 38/49 7/5/23, 12:10 PM Early antithrombotic treatment of acute ischemic stroke and transient ischemic attack - UpToDate who cannot understand or is paralyzed. Only in the case of amputation or joint fusion, the examiner should record the score as untestable (UN), and clearly write the explanation for this choice. In case of blindness, test by having the patient touch nose from extended arm position. 8. Sensory: Sensation or grimace to pinprick 0 = Normal; no sensory loss. when tested, or withdrawal from noxious stimulus in the obtunded or aphasic patient. 1 = Mild-to-moderate sensory loss; patient feels pinprick is less sharp or is dull on the affected side; or there is a loss of superficial Only sensory loss attributed to stroke is scored as abnormal and the examiner pain with pinprick, but patient is aware of being touched. should test as many body areas (arms [not hands], legs, trunk, face) as needed to 2 = Severe to total sensory loss; patient is not aware of being touched in the face, arm, accurately check for hemisensory loss. A score of 2, "severe or total sensory loss," should only be given when a severe or total loss of sensation can be clearly and leg. _____ demonstrated. Stuporous and aphasic patients will, therefore, probably score 1 or 0. The patient with brainstem stroke who has bilateral loss of sensation is scored 2. If the patient does not respond and is quadriplegic, score 2. Patients in a coma (item 1a=3) are automatically given a 2 on this item. 9. Best language: A great deal of 0 = No aphasia; normal. _____ information about comprehension will be obtained during the preceding sections of the examination. For this scale item, the patient is asked to describe what is happening in the attached picture, to name 1 = Mild-to-moderate aphasia; some obvious loss of fluency or facility of comprehension, without significant limitation on ideas expressed or form of expression. Reduction of speech and/or comprehension, however, makes the items on the attached naming sheet and to read from the attached list of sentences. conversation about provided materials Comprehension is judged from responses here, as well as to all of the commands in difficult or impossible. For example, in conversation about provided materials, the preceding general neurological exam. If examiner can identify picture or naming card content from patient's response. visual loss interferes with the tests, ask the patient to identify objects placed in the 2 = Severe aphasia; all communication is through fragmentary expression; great need hand, repeat, and produce speech. The intubated patient should be asked to write. for inference, questioning, and guessing by the listener. Range of information that can The patient in a coma (item 1a=3) will automatically score 3 on this item. The be exchanged is limited; listener carries burden of communication. Examiner cannot examiner must choose a score for the patient with stupor or limited cooperation, but a score of 3 should be used only if the https://www.uptodate.com/contents/early-antithrombotic-treatment-of-acute-ischemic-stroke-and-transient-ischemic-attack/print 39/49 7/5/23, 12:10 PM Early antithrombotic treatment of acute ischemic stroke and transient ischemic attack - UpToDate patient is mute and follows no one-step identify materials provided from patient commands. response. 3 = Mute, global aphasia; no usable speech or auditory comprehension. 10. Dysarthria: If patient is thought to be normal, an adequate sample of speech must 0 = Normal. 1 = Mild-to-moderate dysarthria; patient be obtained by asking patient to read or slurs at least some words and, at worst, can be understood with some difficulty. repeat words from the attached list. If the patient has severe aphasia, the clarity of 2 = Severe dysarthria; patient's speech is so slurred as to be unintelligible in the absence articulation of spontaneous speech can be rated. Only if the patient is intubated or has _____ of or out of proportion to any dysphasia, or is mute/anarthric. other physical barriers to producing speech, the examiner should record the score as untestable (UN), and clearly write an UN = Intubated or other physical barrier, explanation for this choice. Do not tell the patient why he or she is being tested. explain:________________ 11. Extinction and inattention (formerly 0 = No abnormality. neglect): Sufficient information to identify neglect may be obtained during the prior testing. If the patient has a severe visual loss preventing visual double simultaneous stimulation, and the cutaneous stimuli are normal, the score is normal. If the patient has aphasia but does appear to attend to 1 = Visual, tactile, auditory, spatial, or personal inattention or extinction to bilateral simultaneous stimulation in one of the sensory modalities. 2 = Profound hemi-inattention or extinction to more than one modality; does not recognize own hand or orients to only one side of space. _____ both sides, the score is normal. The presence of visual spatial neglect or anosognosia may also be taken as evidence of abnormality. Since the abnormality is scored only if present, the item is never untestable. _____ Adapted from: Goldstein LB, Samsa GP. Reliability of the National Institutes of Health Stroke Scale. Extension to non- neurologists in the context of a clinical trial. Stroke 1997; 28:307. Graphic 61698 Version 8.0 https://www.uptodate.com/contents/early-antithrombotic-treatment-of-acute-ischemic-stroke-and-transient-ischemic-attack/print 40/49 7/5/23, 12:10 PM Early antithrombotic treatment of acute ischemic stroke and transient ischemic attack - UpToDate Barthel Index Activity Score Feeding 0 = Unable 5 = Needs help cutting, spreading butter, etc, or requires modified diet 10 = Independent Bathing 0 = Dependent 5 = Independent (or in shower) Grooming 0 = Needs to help with personal care 5 = Independent face/hair/teeth/shaving (implements provided) Dressing 0 = Dependent 5 = Needs help but can do about half unaided 10 = Independent (including buttons, zips, laces, etc) Bowels 0 = Incontinent (or needs to be given enemas) 5 = Occasional accident 10 = Continent Bladder 0 = Incontinent, or catheterized and unable to manage alone 5 = Occasional accident 10 = Continent Toilet use 0 = Dependent 5 = Needs some help, but can do something alone 10 = Independent (on and off, dressing, wiping) Transfers (bed to chair and back) https://www.uptodate.com/contents/early-antithrombotic-treatment-of-acute-ischemic-stroke-and-transient-ischemic-attack/print 41/49 7/5/23, 12:10 PM Early antithrombotic treatment of acute ischemic stroke and transient ischemic attack - UpToDate 0 = Unable, no sitting balance 5 = Major help (one or two people, physical), can sit 10 = Minor help (verbal or physical) 15 = Independent Mobility (on level surfaces) 0 = Immobile or <50 yards 5 = Wheelchair independent, including corners, >50 yards 10 = Walks with help of one person (verbal or physical) >50 yards 15 = Independent (but may use any aid; for example, stick) >50 yards Stairs 0 = Unable 5 = Needs help (verbal, physical, carrying aid) 10 = Independent Total (0-100): The Barthel ADL Index: Guidelines The index should be used as a record of what a patient does, not as a record of what a patient could do The main aim is to establish degree of independence from any help, physical or verbal, however minor and for whatever reason The need for supervision renders the patient not independent Patient performance should be established using the best available evidence provided by the patient, family, friends and caregivers; direct observation and common sense are also important, but direct testing is not needed Usually the patient's performance over the preceding 24 to 48 hours is important, but occasionally longer periods will be relevant Middle categories imply that the patient supplies over 50 percent of the effort Use of aids to be independent is allowed ADL: activities of daily living. References: 1. Mahoney FI, Barthel D. Functional evaluation: The Barthel Index. Maryland State Medical Journal 1965; 14:56. Used with permission. 2. Loewen SC, Anderson BA. Predictors of stroke outcome using objective measurement scales. Stroke 1990; 21:78. 3. Gresham GE, Phillips TF, Labi ML. ADL status in stroke: Relative merits of three standard indexes. Arch Phys Med Rehabil 1980; 61:355. 4. Collin C, Wade DT, Davies S, Horne V. The Barthel ADL Index: A reliability study. Int Disability Study 1988; 10:61. https://www.uptodate.com/contents/early-antithrombotic-treatment-of-acute-ischemic-stroke-and-transient-ischemic-attack/print 42/49 7/5/23, 12:10 PM Early antithrombotic treatment of acute ischemic stroke and transient ischemic attack - UpToDate Graphic 77371 Version 3.0 https://www.uptodate.com/contents/early-antithrombotic-treatment-of-acute-ischemic-stroke-and-transient-ischemic-attack/print 43/49 7/5/23, 12:10 PM Early antithrombotic treatment of acute ischemic stroke and transient ischemic attack - UpToDate Modified Rankin Scale Score Description 0 No symptoms at all 1 No significant disability despite symptoms; able to carry out all usual duties and activities 2 Slight disability; unable to carry out all previous activities, but able to look after own affairs without assistance 3 Moderate disability; requiring some help, but able to walk without assistance 4 Moderately severe disability; unable to walk without assistance and unable to attend to own bodily needs without assistance 5 Severe disability; bedridden, incontinent, and requiring constant nursing care and attention 6 Dead Reproduced with permission from: Van Swieten JC, Koudstaa PJ, Visser MC, et al. Interobserver agreement for the assessment of handicap in stroke patients. Stroke 1988; 19:604. Copyright 1988 Lippincott Williams & Wilkins. Graphic 75411 Version 13.0 https://www.uptodate.com/contents/early-antithrombotic-treatment-of-acute-ischemic-stroke-and-transient-ischemic-attack/print 44/49 7/5/23, 12:10 PM Early antithrombotic treatment of acute ischemic stroke and transient ischemic attack - UpToDate Antithrombotic therapy according to cause of transient ischemic attack (TIA) This algorithm is intended to provide basic guidance regarding the use of antithrombotic therapy based on mechanism for patients with a TIA. For further details, including suggested dosing regimens of antithrombot agents, refer to the relevant UpToDate topic reviews. ICA: internal carotid artery; CEA: carotid endarterectomy; CAS: carotid artery stenting; DAPT: dual antiplatelet 2 therapy (eg, aspirin and clopidogrel, or aspirin and ticagrelor); ABCD : age, blood pressure, clinical features, duration of symptoms, and diabetes; BP: blood pressure; SBP: systolic blood pressure; DBP: diastolic blood pressure. Indications for long-term oral anticoagulation include atrial fibrillation, ventricular thrombus, mechanical h valve, and treatment of venous thromboembolism. Some experts prefer DAPT based upon observational evidence. Long-term single-agent antiplatelet therapy using aspirin, clopidogrel, or aspirin-extended-release dipyrida Graphic 131695 Version 3.0 https://www.uptodate.com/contents/early-antithrombotic-treatment-of-acute-ischemic-stroke-and-transient-ischemic-attack/print 45/49 7/5/23, 12:10 PM Early antithrombotic treatment of acute ischemic stroke and transient ischemic attack - UpToDate Antithrombotic therapy according to cause of acute ischemic stroke This algorithm is intended to provide basic guidance regarding the immediate use of antithrombotic therapy with an acute ischemic stroke. For further details, including scoring of the NIHSS and suggested dosing regim antithrombotic agents, refer to the relevant UpToDate topic reviews. https://www.uptodate.com/contents/early-antithrombotic-treatment-of-acute-ischemic-stroke-and-transient-ischemic-attack/print 46/49 7/5/23, 12:10 PM Early antithrombotic treatment of acute ischemic stroke and transient ischemic attack - UpToDate HTN: hypertension; SBP: systolic blood pressure; DBP: diastolic blood pressure; ICA: internal carotid artery; C endarterectomy; OA: oral anticoagulation; CAS: carotid artery stenting; DAPT: dual antiplatelet therapy (eg, a clopidogrel, or aspirin and ticagrelor); NIHSS: National Institutes of Health Stroke Scale; CT: computed tomog magnetic resonance imaging. Brain and neurovascular imaging, cardiac evaluation, and (for select patients) other laboratory tests. Indications for long-term oral anticoagulation include atrial fibrillation, ventricular thrombus, mechanical h treatment of venous thromboembolism. "Large" infarcts are defined as those that involve more than one-third of the middle cerebral artery territor one-half of the posterior cerebral artery territory based upon neuroimaging with CT or MRI. Though less relia infarct size can also be defined clinically (eg, NIHSS score >15). Long-term aspirin therapy is alternative (though less effective) if OA contraindicated or refused. Direct oral anticoagulant agents have a more rapid anticoagulant effect than warfarin, a factor that may inf choice of agent and timing of OA initiation. Some experts prefer DAPT, based upon observational evidence. Long-term single-agent antiplatelet therapy for secondary stroke prevention with aspirin, clopidogrel, or as release dipyridamole. Graphic 131701 Version 2.0 https://www.uptodate.com/contents/early-antithrombotic-treatment-of-acute-ischemic-stroke-and-transient-ischemic-attack/print 47/49 7/5/23, 12:10 PM Early antithrombotic treatment of acute ischemic stroke and transient ischemic attack - UpToDate Heparin-adjusted nomogram for stroke Initial dosing for continuous intravenous heparin infusion Weight (kg) Initial infusion (U/hour) <50 500 50 to 59 600 60 to 69 700 70 to 79 800 80 to 89 900 90 to 99 1000 100 to 109 1100 110 to 119 1200 >119 1400 Heparin adjustment based upon aPTT drawn six hours after initiation of therapy aPTT (seconds) Stop infusion Rate change Repeat aPTT <40 No Increase by 250 U/hour 6 hours 40 to 49 No Increase by 150 U/hour 6 hours 50 to 59 No Increase by 100 U/hour 6 hours 60 to 90 No No change Next morning 91 to 100 No Decrease by 100 U/hour 6 hours 101 to 120 No Decrease by 150 U/hour 6 hours >120 No Decrease by 250 U/hour 6 hours No bolus is administered in patients with acute stroke. Data from: Toth C, Voll C. Validation of a weight-based nomogram for the use of intravenous heparin in transient ischemic attack or stroke. Stroke 2002; 33:670. Graphic 53377 Version 2.0 https://www.uptodate.com/contents/early-antithrombotic-treatment-of-acute-ischemic-stroke-and-transient-ischemic-attack/print 48/49 7/5/23, 12:10 PM Early antithrombotic treatment of acute ischemic stroke and transient ischemic attack - UpToDate Contributor Disclosures Jamary Oliveira-Filho, MD, MS, PhD No relevant financial relationship(s) with ineligible companies to disclose. Michael T Mullen, MD Grant/Research/Clinical Trial Support: NINDS [Asymptomatic carotid disease]. All of the relevant financial relationships listed have been mitigated. Scott E Kasner, MD Grant/Research/Clinical Trial Support: Bayer [Stroke]; Bristol Meyers Squibb [Stroke]; Medtronic [Stroke]; WL Gore and Associates [Stroke]. Consultant/Advisory Boards: Abbvie [Stroke]; AstraZeneca [Stroke]; BMS [Stroke]; Diamedica [Stroke]; Medtronic [Stroke]. All of the relevant financial relationships listed have been mitigated. Alejandro A Rabinstein, MD Grant/Research/Clinical Trial Support: Chiesi [Small investigator-initiated project]. Consultant/Advisory Boards: AstraZeneca [Secondary stroke prevention]; Brainomix [AI for stroke diagnostics]; Novo Nordisk [Stroke risk]; Shionogi [Stroke neuroprotection]. Other Financial Interest: Boston Scientific [Adverse event adjudication committee member for stroke risk reduction device in patients with atrial fibrillation]. All of the relevant financial relationships listed have been mitigated. John F Dashe, MD, PhD No relevant financial relationship(s) with ineligible companies to disclose. Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are addressed by vetting through a multi-level review process, and through requirements for references to be provided to support the content. Appropriately referenced content is required of all authors and must conform to UpToDate standards of evidence. Conflict of interest policy https://www.uptodate.com/contents/early-antithrombotic-treatment-of-acute-ischemic-stroke-and-transient-ischemic-attack/print 49/49