Certainty Of Stroke Symptom Onset Study
Certainty Of Stroke Symptom Onset Study
Intravenous tissue plasminogen activator (IV t-PA) is the only proven treatment of hyperacute
 cerebral infarction. The outcome of this treatment highly depends on the time from symptom
 onset to the administration of thrombolytic agent. Last known normal time is widely used as
 the standard to determine the symptom onset. These stroke symptoms are usually caused by a
 sudden decrease in cerebral blood flow related with an embolic or thrombotic event. However,
 in some cases various symptoms may occur one after another.

 Myocardial infarction is also caused by a sudden caseation of blood flow. The symptom of
 myocardial infarction usually contains chest pain, and it is easy to identify the exact time
 of onset. In contrast, cerebral infarction may cause various symptoms according to the
 infarcted area of the brain, and sometimes multiple symptoms are presented in rapid
 succession. Therefore, it may be much unclear and uncertain to determine the onset time of
 cerebral infarction. Despite the importance of onset time in therapeutic decision making,
 there was no study focusing on the certainty of onset time in cerebral infarction patients.

 In this study, we will investigate the subjective certainty of patient about the onset time
 in clear-onset cerebral ischemia. The discrepancy in diagnosing the onset time will be
 analyzed among the clinicians involved in the practice. Then, the factors associated with
 this uncertainty will be verified.
On the day after admission, the patients will be re-interviewed by a stroke neurologist
 during the rounding in the morning. First the history of symptom onset will be re-taken once
 more, focusing on the presentation of each neurological symptom. Then the history taken from
 the emergency department including the onset time will be presented to the patient, and the
 patient will be asked to choose the certainty for the onset time between 1 and 5.

 The symptom onset judged by the neurologist first assessed at the emergency department will
 be compared to that of the stroke neurologist re-interviewed after admission. If any
 discrepancy exists, the history of the patient will be re-written by the stroke neurologist
 and then reviewed by five experienced stroke neurologist. The judgment on stroke onset and
 the certainty of each stroke neurologist will be compared.

 Clinical variables will be obtained from the patient. The informant will be the patient.
 Demographics including the age and sex will be obtained. Additionally the year of education
 will be investigated. The situation of stroke onset will be obtained in detail. What the
 patient was doing immediately before the onset, the place, and the person accompanied with
 will also be investigated. These will be described on the re-written history which will be
 reviewed by the five stroke neurologists. The conventional risk factors for stroke and the
 stroke etiology according to the TOAST classification will be acquired. The initial severity
 of stroke will also be obtained evaluated by National Institutes of Health Stroke Scale
 (NIHSS). On the second interview and the re-written history, the symptoms will be
 investigated in detail. First as an open question, and then targeting the stroke symptoms and
 the onset of them will be asked. The symptom includes 1) weakness, 2) facial palsy 3)
 dysarthria 4) ataxia 5) visual field defect 6) sensory change 7) dizziness 8) headache and 9)
 Other non-specific symptoms. The onset time and the sequence will be investigated by each
 symptom.

 The result will be analyzed in two view points. First the discrepancy rate between clinicians
 will be first examined, and the clinical variables making difference will be analyzed.
 finally a protocol for systemized history taking of stroke onset will be used, and the change
 will be analyzed before and after the release of protocol.

 In the second point of veiw, the certainty of patient will be analyzed. The clinical
 variables will be compared according to the certainty of patient on symptom onset.
Inclusion Criteria:

 -  ischemic stroke patients admitted to Acute Stroke Unit at Asan Medical Center

 -  ischemic stroke patients older than 20 years old

 -  symptom onset within 24 hours

 Exclusion Criteria:

 -  patients who cannot explain the symptom onset due to altered consciousness, aphasia,
 or cognitive decline