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  1. Keith W Muir
  1. Dr Keith W Muir, Institute of Neurological Sciences, Southern General Hospital, Glasgow G51 4TF, UK k.muir{at}

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Management of stroke has been revolutionised over the past decade, and therapeutic nihilism is no longer justified. The advent of acute treatments, especially thrombolysis, where the window of opportunity for intervention is very short and the treatment carries risk, emphasises the paramount importance of correct clinical diagnosis. Neurologists will need to adopt a front line role that is unfamiliar in the UK if therapeutic advances are to be implemented safely. Closer involvement in stroke care also necessitates that neurologists keep abreast of developments in cardiovascular medicine: vascular neurologists require to be both electrician and plumber.

Clinical diagnosis

Misdiagnosis of stroke is common: 20% of emergency department diagnoses may be incorrect, and 10% of stroke unit patients are discharged with an alternative diagnosis. Many common misdiagnoses are characterised by global rather than focal cerebral dysfunction (sepsis, hypoglycaemia, drug overdose, and metabolic disturbance all being common). These problems attest to major and basic deficits in public and non-specialist medical knowledge of the characteristics of stroke. Many misdiagnoses are serious and treatable conditions. Some common neurological differential diagnoses require prompt treatment (for example, seizure, brain tumour, subdural haematoma) while more benign conditions (for example, Bell's palsy, peripheral nerve pressure palsies) are important largely in order to avoid unnecessary treatment. Uncommon neurological disorders often cause diagnostic difficulty to non-neurologists: for example, when faced with “progressing brainstem stroke” it is wise to consider Miller Fisher syndrome or myasthenia gravis.

Pertinent features of the clinical examination are usefully summarised by the test items included in the US National Institutes of Health stroke scale (see box below), and a syndromic classification derived from the Oxfordshire community stroke project (OCSP) is clinically useful with respect to aetiology and prognosis (table 1). However, the accuracy of OCSP classification is limited in the first 24 hours after onset, and diffusion weighted magnetic …

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