Stroke is now a global epidemic. It is the major cause of disability worldwide and the second leading cause of death.[1] In-hospital stroke is a very sensitive issue and carries a high level of medico-legal importance. Unfortunately, these stroke(s) have greater delays in time to intervention compared to out-of-hospital stroke.[2] There is the possibility of misdiagnosis by non-neurologists and by those who do not deal with critical care. If not identified in time, we will miss the opportunity of acute stroke intervention, and patients may have a catastrophic result. So, it requires timely identification of cases and interdepartmental coordination so that the best possible management can be given. As because, stroke team can select cases and manage more confidently; activation of stroke team on slightest doubt is the call of the day. “Stroke code” needs to be announced immediately so that the patient gets all facilities of emergency service including transport, fast imaging, and subsequent intervention.
Incidence of recurrent stroke is highest within 30 days after the initial ischemic stroke or transient ischemic attack.[3] So careful monitoring is of utmost importance post admission in these type cases. We need to be more vigilant about special cases like those with cardio-embolic stroke, large artery atherosclerotic disease, especially those with significant intracranial or extracranial stenosis and those having free floating thrombus in intra- or extracranial vasculature. Study has also shown patients with “stroke of other determined etiology” have also increased risk of 30-day recurrence.[3] As the chance of recurrent stroke is high in these patients, they need to be identified and monitored as potential candidates.
Scales like risk for in-patient stroke (RIPS), clinical deficit score (CDS), and 2CAN all significantly predict stroke as mentioned in article.[4] The scale used should be simple so that all caregivers can use and the scale should have high sensitivity and specificity. Nurses and other medical attendants who remain with patients for a longer time can raise an alarm at the right moment.
Proper management of delirious patient cannot be overemphasized. And it should be remembered that a small percentage of these patients might have acute stroke. Neurological assessment is impaired because of sedation. So, choice of sedation is important, and sedative drug with shorter half-life is preferable. Neurological assessment needs to be done periodically.
Wake-up stroke in the house is another challenging condition. In case of suspicion, MRI of the brain is a better option, as we can take advantage of DWI/FLAIR mismatch and decide regarding acute intervention more easily. Perfusion studies may be helpful in selective cases. As we move from time window to tissue window and after the DAWN and DEFUSE 3 trial, availability of this imaging modality in time is need of the day.
We face a lot of stroke mimickers, but it is better to over-diagnose and pursue these cases to rule out stroke rather than miss them. An urgent MRI of the brain is a better modality in drawing a conclusion in these cases.
In a significant number of cases, strategic stroke may cause a diagnostic dilemma. Patients may develop acute behavioral alternation with acute stroke with aphasia or non-dominant hemisphere involvement.[5] Timely identification is challenging and important at the same time.
With the rise in the burden of acute strokes, management is becoming more demanding and challenging. So, we need to be technically advanced and more prepared so that we can give our best in management of in-house stroke(s).
REFERENCES
1. Katan M, Luft A. Global burden of stroke. Semin Neurol 2018;38:208–11.
2. Park HJ, Cho HJ, Kim YD, Lee DW, Choi HY, Kim SM, et al. Comparison of the characteristics for in-hospital and out-of-hospital ischaemic strokes. Eur J Neurol 2009;16:582–8.
3. Khanevski AN, Bjerkreim AT, Novotny V, Næss H, Thomassen L, Logallo N, et al. Thirty-day recurrence after ischemic stroke or TIA. Brain Behav 2018;8:e01108.
4. Chinta VR, Krishnan P, Murgod U, Mahadevappa M, Roy AK, Srinivasan M, et al. Utility of the RIPS scale and 2CAN score for in hospital stroke prediction. Ann Indian Acad Neurol 2023;26:151–5.
5. Schmidley JW, Messing RO. Agitated confusional states in patients with right hemisphere infarctions. Stroke 1984;15:883–5.
