Stroke & TIA

Stroke & TIA: Clinical Assessment

How to assess the patient?

Healthcare professionals will assess the patient and secure the airway, support breathing, and blood circulation initially.

Blood sugar should be checked to exclude hypoglycaemia (low-blood sugar).

Healthcare professionals will make the diagnosis of stroke or TIA on a simple clinical history and examination.

Any person, who has symptoms of stroke or TIA should be assessed immediately using a test such as FAST (Face Arm Speech Time)

  • Face – sudden weakness of the face
  • Arm – Sudden weakness of one or both arms
  • Speech – slurring of speech, difficulty in speech
  • Time – the sooner management can be started, the better.

The diagnosis of stroke or TIA will be made by the healthcare professionals using an accepted test known as ROSIER (Recognition of Stroke in the Emergency Room)


ROSIER (Recognition of Stroke in the Emergency Room)

ROSIER scale is a stroke assessment tool with a scoring system. It should be assessed by a healthcare professional.

  • Has the patient had a loss of consciousness or syncope?

Yes:  -1             No: 0

  • Has the patient had a seizure (fits)?

Yes:  -1             No: 0

Is there a new acute onset (or on awakening from sleep)?

  • Asymmetric facial weakness

Yes:  +1            No: 0

  • Asymmetric arm weakness

Yes:  +1            No: 0

  • Asymmetric leg weakness

Yes:  +1            No: 0

  • Speech disturbance

Yes:  +1            No: 0

  • Visual field defect

Yes:  +1            No: 0

The total score is between -2 to +5. If the total score is above 0, a stroke is likely. If the score is 0 or less, the possibility of stroke is low, but not completely excluded. All patients with a suspected stroke should be admitted to the emergency admission unit irrespective of the score. If the onset of stroke symptoms within three hours and ROSIER score is above 0, the patient should be offered an urgent CT scan and considered thrombolysis treatment immediately.


ABCD2 scale for TIA assessment

ROSIER scale is not recommended for patients with suspected TIA without neurological signs when seen. Therefore, ABCD2 scale should be used to assess the risk of stroke in patients with TIA.

  • If the patient’s age (A) is 60 years or above:  one point
  • Blood pressure (B) is more than 140/90mmHg:  one point
  • Clinical features (C): (note, maximum score of two points)

Asymmetrical weakness:  two points
Speech disturbance without weakness:  one point
Other:  0 points

  • Duration (D):

More than 60 minutes:  two points
Between 10 to 60 minutes:  one point
Less than 10 minutes:  0 points

  • Diabetes (D):  one point

ABCD2 score is between zero to seven. If the patient has ABCD2 score of six to seven, he or she has an 8.1 % risk of stroke within two days. TIA patients with a high risk (ABCD2 score is five or more) should be seen by a healthcare professional within 24 hours at the TIA clinic or admitted for review, urgent tests, and treatment for secondary prevention. Patients with more than one episode of TIA in the last week have a 30 % greater risk of having a stroke within one week. They should be admitted to the emergency admission unit for further investigation and management.

If the patient has (or suspected of having) a stroke, he/she should be admitted to an acute stroke unit.


Imaging in stroke

A brain scan (CT or MRI scan) should be done for all patients, who have had a stroke. People with following features should have a brain scan immediately.

  • Unconsciousness
  • Prone to bleeding
  • Stroke symptoms with severe headache
  • Stroke symptoms are varying or worsening.
  • Taking anticoagulants (drugs to cut blood clotting) before the stroke
  • Stiff neck
  • Fever
  • Raised pressure at the back of the eyes (papilloedema)
  • Stroke symptoms suggest that it is beneficial from dissolving the blood clot (thrombolysis) or prevent blood clotting (anticoagulation).


(Photo courtesy: Seattle Municipal Archives)


Related Links:

Stroke and Transient Ischaemic Attack (TIA)
How to Manage a Stroke?
Management of Transient Ischaemic Attack (TIA)
How to Prevent a Stroke?
How to Detect a Stroke Early?

About the author
Dr. Nalaka Priyantha is the founder and author of 'DRN Health'. He currently works at the Ministry of Health, Sri Lanka as a senior medical officer. He is blogging about healthy living since 2012.
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