Changes In Level Of Consciousness Research Articles

Reasons and Outcomes for Long‐Term Care Transfers to the Hospital: A Retrospective Review

Reasons and Outcomes for Long‐Term Care Transfers to the Hospital: A Retrospective Review

Manifestaciones neurológicas de la invaginación intestinal

IntroductionIntussusception is a potentially severe obstructive disease that occurs when a more proximal portion of bowel invaginates into a more distal part of the bowel. Patients with intussusception often present with a wide range of non-specific systemic symptoms, with less than one quarter presenting with the classic triad of vomiting, abdominal pain, and bloody stools. An acute change in level of consciousness could be the only clinical symptom of this disorder. ObjectivesTo ascertain the frequency and nature of the neurological symptoms in children with intussusception, and to describe the characteristics of the patients presenting in this atypical way. Patients and methodsWe retrospectively reviewed the records of 351 children presenting with intussusception from 2000 to 2012. General epidemiological data, abdominal and neurological signs and symptoms, duration of symptoms and effectiveness of treatment, were analysed in all patients. ResultsOf the 351 patients studied, 15 (4.27%) had one or more neurological symptoms recorded at presentation, with lethargy being the most frequent (66.66%), followed by hypotonia, generalized weakness, paroxysmal events, and fluctuating consciousness. Sixty per cent of these fifteen patients showed isolated neurological symptomatology, and eleven of them (73.3%) needed a laparotomy to reduce the intussusception. ConclusionsIntussusception should be considered in the differential diagnosis in infants and young children presenting as a pediatric emergency with lethargy, hypotonia, generalized weakness, paroxysmal events and/or sudden changes in consciousness, even in the absence of the classical symptoms of intussusception. An early recognition of intussusception may improve the global prognosis and avoid ischaemic intestinal sequelae.

Time to Consider Empiric Acyclovir

Purpose: A 63-year-old female presented to the emergency department with a two-day history of fever of 101.9°F and worsening fatigue. She denied a history of liver disease and was otherwise in good health, aside from a history of arthritis. She denied any recent changes in medications, use of antibiotics or travel history. Urine toxicology screen, acetaminophen level and hepatitis A-C serology were negative. Her laboratory assessment was notable for AST 4755 IU/L, ALT 3569 IU/L and an INR of 1.4. She was admitted into her local hospital and started on intravenous N-acetylcysteine. Overnight, she developed subtle changes in behavior without any change in level of consciousness. She was subsequently transferred to a liver transplant center. Upon arrival, the patient was oriented, but very somnolent, and remained febrile at 103.1°F. Physical exam was negative for stigmata of chronic liver disease, rash or asterixis. Laboratory assessment revealed total bilirubin 0.6 mg/dl, AST 7392 IU/L, ALT 5942 IU/L, INR of 2.2, WBC 2900 cells/ mm3, hemoglobin 16 g/dL and platelets of 29,000/mm3. Abdominal ultrasound showed a normalappearing liver with normal hepatic and portal flow. Further history from family revealed the patient was taking oral prednisone the past few weeks for chronic joint pain. Given this history, combined with fever, leukopenia and anicteric hepatitis, she was started on empiric IV acyclovir for possible herpes simplex virus (HSV)-induced liver failure. She underwent expedited liver transplant evaluation. A trans-jugular liver biopsy revealed minimal inflammation with scattered hepatocyptes with glassy nuclear inclusions, azonal areas of necrosis and positive HSV stain. Her serum HSV DNA testing by PCR was 1.2 x 10ˆ6 copies/ml, although her initial HSV IgM was within reference range. Her laboratory values normalized completely within 15 days, and she was discharged to a local rehab center. HSV-induced liver failure accounts for only 1% of all ALF, but confers a mortality rate of 75%. Although immunocompetent patients can be affected, 75% of affected patients are immunosuppressed or pregnant in the third trimester. Patients who present with fever, vesicular skin lesions, leukopenia and anicteric hepatitis need to be considered for empiric acyclovir therapy and transferred to a liver transplant center. Serological testing with antibodies against HSV in the serum is nonspecific and has low utility in early treatment decisions. Confirmation of diagnosis is best performed with liver biopsy and serum HSV PCR. Empiric therapy with acyclovir for patients at risk may obviate the need for liver transplantation.

Electroencephalogram signatures of loss and recovery of consciousness from propofol

Unconsciousness is a fundamental component of general anesthesia (GA), but anesthesiologists have no reliable ways to be certain that a patient is unconscious. To develop EEG signatures that track loss and recovery of consciousness under GA, we recorded high-density EEGs in humans during gradual induction of and emergence from unconsciousness with propofol. The subjects executed an auditory task at 4-s intervals consisting of interleaved verbal and click stimuli to identify loss and recovery of consciousness. During induction, subjects lost responsiveness to the less salient clicks before losing responsiveness to the more salient verbal stimuli; during emergence they recovered responsiveness to the verbal stimuli before recovering responsiveness to the clicks. The median frequency and bandwidth of the frontal EEG power tracked the probability of response to the verbal stimuli during the transitions in consciousness. Loss of consciousness was marked simultaneously by an increase in low-frequency EEG power (<1 Hz), the loss of spatially coherent occipital alpha oscillations (8-12 Hz), and the appearance of spatially coherent frontal alpha oscillations. These dynamics reversed with recovery of consciousness. The low-frequency phase modulated alpha amplitude in two distinct patterns. During profound unconsciousness, alpha amplitudes were maximal at low-frequency peaks, whereas during the transition into and out of unconsciousness, alpha amplitudes were maximal at low-frequency nadirs. This latter phase-amplitude relationship predicted recovery of consciousness. Our results provide insights into the mechanisms of propofol-induced unconsciousness, establish EEG signatures of this brain state that track transitions in consciousness precisely, and suggest strategies for monitoring the brain activity of patients receiving GA.

Introduction of Music Therapy for Stuporous Patient Attached to a Mechanical Ventilator at Bethany Hospital in Tacloban City, Philippines

Altered levels of consciousness (ALC) are among the most common problems in general medicine which intensive care unit is included. One of its deepest levels is stupor. Meanwhile, it has shown that the use of music therapy improved levels of consciousness in a patient that has altered levels of consciousness and is ventilated. This study was designed to evaluate the effect of music therapy after a series of listening classic CD songs attached to a built-in CD drive of the mechanical ventilator for stuporous patient using earphones in both ears. Quasi –experimental design was adopted utilizing the both primary data and secondary data. There were 24 stuporous patients invited to participate as respondents with an age range of 23-92 years old. Four parameters were evaluated: vital signs of patients when attached to a mechanical ventilator with music therapy; duration of the health status; health status as evidenced by a change in level of consciousness based on doctor’s order and nurses notes. Data were analyzed by SPSS version 19.The researchers found out the use of music therapy (attached to the mechanical ventilator) was effective in improving the level of consciousness; this has been useful in implementation in the Intensive Care Unit.

Safety of midazolam for sedation of HIV‐positive patients undergoing colonoscopy

Because of concerns regarding interactions between midazolam and antiretroviral therapy (ART), alternative sedatives are sometimes used during procedural sedation. Our objective was to compare outcomes in patients on ART who received intravenous (iv) midazolam vs. iv diazepam, a second-line agent, during colonoscopy. We conducted a retrospective analysis of adult HIV-positive patients who underwent colonoscopy over a 3.5-year period. Primary outcomes were sedation duration, nadir systolic blood pressure (SBP), nadir oxygen saturation, abnormal cardiac rhythm, and change in level of consciousness using a standardized scale. We calculated rates of adverse events according to benzodiazepine use and identified risk factors for complications using univariate and multivariate analyses. We identified 136 patients for this analysis: 70 received midazolam-based sedation and 66 received a diazepam-based regimen. There were no significant differences between the two groups with respect to sedation duration (mean 48.0 vs. 45.7 minutes for the midazolam and diazepam groups, respectively; P = 0.68), nadir SBP (mean 97.0 vs. 101.6 mmHg; P = 0.06), nadir oxygen saturation (mean 94.6 vs. 94.8%; P = 0.72) or rate of abnormal cardiac rhythm (11.4 vs. 19.7%; P = 0.18). More patients in the midazolam group experienced a depressed level of consciousness (91% vs. 74% in the diazepam group; P = 0.0075), but no patient required reversal of sedation or became unresponsive. We did not find evidence that patients who received midazolam for procedural sedation had clinical outcomes statistically different from those who received diazepam. These findings should be confirmed in prospective studies or in a randomized controlled trial.

Neuroleptic malignant syndrome associated with quetiapine and venlafaxine use: a case report and discussion

We report a case of neuroleptic malignant syndrome (NMS) in a 36-year-old man prescribed quetiapine, venlafaxine and methadone. NMS is a rare but potentially fatal side-effect of all antipsychotic medications characterized by fever and muscle rigidity, and two or more of diaphoresis, dysphagia, tremor, incontinence, changes in level of consciousness, mutism, autonomic dysfunction, leukocytosis and elevated creatine kinase. Complications include rhabdomyolysis, renal failure and death. Mortality appears to be reduced with second-generation antipsychotics. Although predominantly associated with antipsychotic use, NMS has been observed with antidepressants and lithium.

Nursing Home Resident Symptomatology Triggering Transfer: Avoiding Unnecessary Hospitalizations

The purpose of this study was to describe nursing home resident symptomatology and medical diagnoses associated with nursing home to hospital transfers. A retrospective chart review of documented transfers was conducted at a 120-bed, nonprofit urban Continuing Care Retirement Center nursing home facility located in the southwestern United States. The transferred residents (n = 101) had seventy different medical diagnoses prior to hospital transfer with hypertension, coronary artery disease, and congestive heart failure most frequently reported. Most frequently reported symptomatology included fatigue, lethargy or weakness, shortness of breath, and change in level of consciousness. Multiple symptomatology was indicative of a wide variety of medical diagnoses. The diagnoses and symptomatology recorded in this paper identify the importance of strategic planning concerning assessment and communication of common nursing home resident symptomatology and the importance of basic nursing and diagnostic procedures for prevention of potentially avoidable hospitalizations.

Possible Paliperidone-Induced Neuroleptic Malignant Syndrome: A Case Report

Possible Paliperidone-Induced Neuroleptic Malignant Syndrome: A Case Report

Case 1: Acute chorea

A previously healthy Caucasian boy, nine-and-a-half years of age, presented with a four-day history of involuntary movements of his eyes, lips and tongue, as well as of both arms and legs. The movements were uncontrollable and constant, but regressed when asleep. He experienced symptoms of dizziness and headache at the onset of the movements, but these had resolved. He had progressive difficulty ambulating, speaking and eating. There was no incontinence, change in vision, hallucinations, change in level of consciousness, aphasia or cognitive changes noted. He had no history of preceding illness or trauma. Initial physical examination revealed an afebrile boy who was awake and alert. His heart rate was 84 beats/min and blood pressure was 100/62mmHg. He was oriented to person, place and time. There was no papilledema. He exhibited no rash, mucosal ulcers, tonsillar abnormality or lymphadenopathy. The patient had a III/VI systolic murmur at the left lower sternal border. No S3 or rub were noted. Respiratory, abdominal and musculoskeletal examinations were normal. Neurological examination revealed ongoing choreiform movements of all limbs, tongue (darting) and lips. His hands alternately squeezed and released when gripping an object (milkmaid sign). The remainder of his neurological examination, including tone, power, reflexes, coordination and sensation, was normal. The patient’s white blood cell count was 3.8×109/L, lymphocyte count was 1.3×109/L, hemoglobin was 113 g/L and platelet count was 211×109/L. Direct antibody (Coombs) test was positive. Toxicology screen and metabolic work-up were negative. Cerebrospinal fluid analysis revealed a white blood cell count of 9×106/L and no red blood cells. Testing for mycoplasma and herpes viruses was negative. Brain magnetic resonance imaging demonstrated a tiny focus of diffusion restriction in the white matter of the right frontal lobe. Magnetic resonance angiography and venography were normal.

Falciform Ligament Sign After Shock Episode in an Elderly Man

An 86-year-old man presented with abdominal distension and septic shock after he had received 8 days of aspirin and dexamethasone treatment that was prescribed for acute paraplegia and suspected spinal cord compression. Coffee ground material was drained from a nasogastric tube, and a change in level of consciousness was also noted. On examination, a distended and tense abdomen became soft and flat about 6 h after presentation. A laboratory test revealed leukocytosis (white blood cell count 30,500/uL) without anemia (hemoglobin 14.6 g/dL).

Nonepileptic psychogenic status: Markedly prolonged psychogenic nonepileptic seizures

Little is known about markedly prolonged psychogenic nonepileptic seizures (PNES) though they are reported in up to 78% of PNES. Entry to the tertiary referral epilepsy monitoring unit (EMU) is often urgent and the stay usually brief, resulting thus far in almost no data regarding outcomes. The American Epilepsy Society (AES) Nonepileptic Seizure Task Force was asked to gather evidence for consensus of practice and treatment for PNES and its spectrum. As part of the subcommittee focusing on “pseudostatus epilepticus,” we sent questionnaires to AES membership inquiring about markedly prolonged events, which we call nonepileptic psychogenic status (NEPS). Ninety U.S. and international neurologists from at least 19 states in the United States responded, with approximately 45% reporting that they do not distinguish NEPS from PNES. Eighty percent of responders considered a period of 20 minutes or longer as “prolonged.” Lack of consensus between responders on how to manage these patients was uncovered. The NES Task Force subcommittee on “pseudostatus” recommends that the duration of PNES is tracked and those events lasting 20 minutes or longer, with or without change in level of consciousness, are considered NEPS. Future research needs are discussed.

SNAP II versus BIS VISTA monitor comparison during general anesthesia

Effectively monitoring the level of consciousness during general anesthesia is clinically beneficial to both the patient and the physician. An electroencephalogram (EEG)-based level-of-consciousness monitor can help minimize intraoperative awareness as well as the effects of over-sedation. In this study, we compared the SNAP II (Stryker Instruments, Kalamazoo, MI USA) and BIS VISTA (Aspect Medical Systems, Newton, MA USA) monitors' primary metrics (SI and BIS, respectively) in terms of correlation, agreement and responsiveness to return to preoperative baseline in surgical cases involving general anesthesia. With institutional approval and written informed consent, 33 patients received general anesthesia with isoflurane while undergoing abdominal surgery. We attached both the SNAP II and BIS VISTA electrodes to each patient. We collected data from each monitor simultaneously and continuously, beginning just prior to induction and ending after extubation. Each monitor's level-of-consciousness index is a unit less metric that ranges from 0 to 100, with 100 indicating full consciousness. We performed a Bland-Altman and parameter difference analyses on the data. We calculated the time it took for each monitor to return to preoperative baseline level following cessation of anesthesia. We established an equivalence between the two indices over their entire range for our particular clinical scenario. The indices were correlated (r = 0.736, P < 0.0001, N = 3,706 data point pairs). There was an overall difference between the two indices (median = 16.0, 25th/75th%ile = 10.0/21.1) with BIS lower than SI. A 40-60 BIS range (the typical target range during general anesthesia) was approximately equivalent to a 54-74 SI range. In all 33 subjects, SI reached baseline before BIS at the end of the case (median = 3.3 min, 25th/75th%ile = 1.6 min/8.2 min versus median = 8.9 min, 25th/75th = 3.7 min/14.5 min, P = 0.0200), even though both metrics were equal at the beginning of the case. Although the SI and BIS both can assess a patient's level of consciousness and are correlated, they are not in agreement with each other numerically and therefore are not interchangeable. It is difficult to assess each monitor's true responsiveness to acute changes in consciousness level from our study design. The differences between the metrics we observed in this study are most likely due to differences in signal processing methodologies, EEG frequencies employed and signal filtering utilized in the monitors.

Struck From Behind: Maintaining Quality of Life With Chronic Low Back Pain

A 38-year-old woman was the driver of a stopped car that was struck from behind by another vehicle. She developed sudden flexion and extension of her back, but without head trauma or change in level of consciousness. On the evening of the accident, she presented to the emergency room with severe mid and low back pain, and right knee pain, but was discharged with pain medications. One week following the accident, the pain became increasingly severe. For the past 6 months, she hasbeenunable toworkand is ondisability. Chiropractic treatment, trigger-point injections, epidural injections and physical therapy, nonsteroidal anti–inflammatory drugs, muscle relaxers, and hydrocodone provided no or minimal relief. An MRI of the thoracic spine revealed a subacute appearing left paracentral disc herniation at T11-T12, with effacement of the subarachnoid space, but without spinal-cord or nerve-root compression; an MRI of the lumbar spine revealed a disc bulge at L4-L5 without significant mass effect; and EMG and nerve-conduction studies of the lower extremities were normal. At the time of her initial presentation, she reported severe, constant right-sided mid and low back pain, as well as pain in the right anterior shin. The thoracic disc herniation was not considered a primary anatomic basis of her pain. She was treated in a multidisciplinary manner, including medication management, psychological counseling, physical therapy with a focus on myofascial release, and cognitive behavioral psychotherapy. She did not improve with numerous anticonvulsant and antidepressant medications. She has obtained pain relief with methadone in escalating doses up to 140 mg per day as well as bupropion 300 mg daily and lamotrigine 400 mg daily. She has been able to function reasonably well as a home-

Hyperammonemia Due to Valproic Acid in the Psychiatric Setting

Hyperammonemia Due to Valproic Acid in the Psychiatric Setting

Hyperammonemia Due to Valproic Acid in the Psychiatric Setting

In 1980 Coulter and Allen (1) reported the first case of hyperammonemia, to our knowledge, with otherwise normal hepatic function tests in a child with epilepsy treated with valproic acid. Since that time, there have been several additional case reports and studies within the neurology literature that have established hyperammonemia with otherwise normal hepatic function as a potential side effect of valproic acid, especially in children and adolescents (2). Settle (3) published the first case of hyperammonemia, to our knowledge, in a psychiatric setting in 1995. Several additional cases have followed it. Unfortunately, to date, to our knowledge, there has only been one prospective study published within the psychiatric literature (4). We present here a patient’s history that illustrates how the symptoms of a psychiatric disorder might make the diagnosis of hyperammonemic encephalopathy difficult.

Neuroleptic Malignant Syndrome with Delayed Onset of Fever Following Risperidone Administration

To report and discuss a case of neuroleptic malignant syndrome (NMS) with delayed onset of fever in a patient taking risperidone. A 59-year-old white female presented with progressive weakness, confusion, and disorientation 10 days after restarting risperidone 2 mg/day therapy for bipolar disorder. She had taken risperidone for several years prior to this episode and had stopped it for approximately 3 weeks; risperidone was discontinued on admission. The patient's creatine kinase (CK) level was elevated (901 IU/L; reference range 39-162) on admission and increased to 1991 IU/L the following day. She was initially afebrile and had no muscular rigidity. Elevated temperature (38.1 degrees C) did not occur until hospital day 2. The patient was successfully treated with diazepam, bromocriptine, and dantrolene and suffered no long-term sequelae. Other clinicians have reported atypical presentations of NMS in patients taking newer neuroleptic agents. Although this patient met diagnostic criteria for NMS, the hallmark symptoms of fever and muscle rigidity were delayed in onset. Also, the patient never remained febrile for more than 24 hours and her maximum temperature was only 38.6 degrees C. An objective causality assessment suggests that this case of NMS was probably related to restarting risperidone. Because of the life-threatening nature of this syndrome, clinicians should consider NMS in afebrile patients presenting with diaphoresis, changes in level of consciousness, mutism, tremors, tachycardia, leukocytosis, and elevated CK levels.

Syndrome of inappropriate antidiuretic hormone secretion (SIADH) in patients with limited stage small cell lung cancer

A few series in the literature were published before 1987 on syndrome of inappropriate antidiuretic hormone secretion (SIADH) in small cell lung cancer (SCLC). This study examines the outcome in more recent era. From 1981-1998, there were 1417 new cases of SCLC diagnosed in the provincial registry, of which 244 were of limited stage (LS). A chart review and statistical analyses were performed using Mann-Whitney test, chi-square test and Kaplan-Meier method. Fourteen LS patients (group A) had SIADH at presentation. Group B consisted of 230 LS patients without SIADH. There were more patients with poorer performance status (ECOG 2-4) in group A than B (28.6% versus 7.8%, P=0.03). Otherwise, sex, age at diagnosis, nodal spread, pleural effusion, bronchial obstruction, superior vena cava obstruction, performance status, weight loss, and lactic dehydrogenase at presentation, were comparable between the two groups. Treatments given, e.g., extent of surgical resection (if performed, whether complete/incomplete), total number of chemotherapy cycles, radiotherapy doses, were comparable (P>0.05). The response to chemo-radiation was not significantly different (P=0.7). Five-year overall survival (8% versus 19%, P=0.08), and cause-specific survival (16% versus 20%, P=0.13) showed that group A patients had a worse outcome, though of borderline significance. Symptoms related to SIADH included: weakness, 4 patients; tiredness, 3; change in level of consciousness, 1; seizure, 1. The range of lowest sodium level was 110-129. Two patients also had paraneoplastic myopathy. SIADH resolved in 12 patients at 1.6-44.7 weeks (median: 4.3). Among the 14 patients who initially presented with SIADH and recurred later, 10 had recurrence of SIADH at the time of tumor recurrence. Serum sodium was useful for post-treatment surveillance in SCLC patients who presented with SIADH, with 71% (10/14) developing SIADH again at the time of recurrence. SIADH is a poor prognostic factor for LS SCLC.

Changes in Level of Consciousness and Association with Hyperglycemia as Tool for Predicting and Preventing Re-bleeding after Spontaneous Subarachnoid Hemorrhage

It is crucial to predict and prevent re-bleeding from ruptured intracranial aneurysms in patients with subarachnoid hemorrhage (SAH). During the prehospital period and on arrival to the hospital, blood glucose and serum potassium levels, as well as changes in levels of consciousness were assessed in patients in the acute stage of spontaneous subarachnoid hemorrhage. These assessments were analyzed as possible risk factors for re-bleeding and as potential contributors to the prevention of re-bleeding, both in prehospital care and after hospital admission. Upon the arrival of 202 patients with spontaneous subarachnoid hemorrhage, the following indications were examined retrospectively: (1) presence/absence of re-bleeding; (2) time interval between the onset of SAH and re-bleeding; (3) level of consciousness using the Glasgow Coma Scale (GCS) score before and on arrival; (4) amount and distribution of subarachnoid blood using Fisher's Computerized Tomography Classification; (5) blood pressure; (6) blood glucose concentration; and (7) serum potassium concentration. The patients were hospitalized in the Yokohama City University Critical Care and Emergency Center (Yokohama, Japan) between January 1991 and December 2000. The re-bleeding rate was analyzed using the chi-square (chi2 test, and the averages and standard deviations of hematological data were compared using the Mann-Whitney U-test. The level of statistical significance was set at p < 0.05. The overall re-bleeding rate was 20.8%. Among 119 patients with a GCS score of 3-7 before arrival, 42 (35.3%) had re-bleeding, but none of the 83 patients with a GCS score of 8-15 before arrival had re-bleeding. Of 105 patients with a GCS score of 13-15 on arrival, 14 (51.8%) of 27 patients whose consciousness level was a GCS score of 3-7 before arrival experienced re-bleeding. The re-bleeding rate of this group was high. Moreover, this rebleeding group had a significantly higher blood glucose concentration than did the patients whose GCS score was 13-15 both before and on arrival. Between the patients with or without re-bleeding, there was no significant difference in the blood pressure on arrival or in distribution according to Fisher's Computerized Tomography Classification Since the re-bleeding rate is high in patients who have hyperglycemia and a history of a level of consciousness as low as a GCS score of 3-7, a detailed assessment of level of consciousness and blood glucose tests performed on arrival provide important information that will contribute to predicting and preventing re-bleeding. This may be extended to the prehospital phase, because blood glucose tests are simple and safe when performed by paramedics.

Sex and acute stroke presentation

Study objectives: We determine whether a sex difference exists for acute stroke emergency department presentation. Methods: The TLL Temple Foundation Stroke Project is a prospective observational study of acute stroke management that identified 1,189 validated strokes in nonurban community EDs from February 1998 to March 2000. Structured interview of the patient and the person with the patient at symptom onset identified the symptom or symptoms that prompted the patient to seek medical attention. Interview data were available for 1,124 (94%) patients. A physician blinded to sex classified the reported symptoms into 14 categories. Results: Nontraditional stroke symptoms were reported by 28% of women and 19% of men (odds ratio 1.62; 95% confidence interval 1.2 to 2.2). Nontraditional stroke symptoms, pain (men 8%, women 12%) and change in level of consciousness (men 12%, women 17%), were more often reported by women. Traditional stroke symptoms, imbalance (men 20%, women 15%) and hemiparesis (men 24%, women 19%), were reported more frequently by men. Trends were also found for women to present with nonneurologic symptoms (men 17%, women 21%) and men to present with gait abnormalities (men 11%, women 8%). There was no sex difference in the mean number of symptoms reported by an individual patient. Conclusion: This study suggests that a sex difference exists in reporting of acute stroke symptoms. Women with validated strokes present more frequently with nontraditional stroke symptoms than men. Recognition of this difference might yield faster evaluation and management of female patients with acute stroke eligible for acute therapies. [Ann Emerg Med. 2002;40:453-460.]