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Background: Too few patients with acute stroke receive thrombolytic therapy owing to the limited time window for treatment and prehospital delay. The purpose of this study is to describe the prehospital path for patients with acute stroke and, in particular, what distinguishes patients who contact the Emergency Medical Communication Centre (EMCC) from those who contact their general practitioner (GP) or Out-of-hours (OOH) services., Material and Method: Patients with acute cerebral infarction and intracerebral haemorrhage admitted to the Stroke Unit, Department of Neurology, Akershus University Hospital, were included. Data on the prehospital path (prehospital delay, medical contacts) were collected over the period 15 April 2009 – 1 April 2010., Results: A total of 299 patients were included in the study. The median age was 75 years and 48.5 % were women. In all, 63.9 % of patients with acute stroke called the EMCC, and 93.7 % of these were taken directly to hospital by ambulance. Of those who called the GP’s office or OOH services, 60.7 % were asked to go to the GP’s office or OOH services in person. Patients who called and attended the GP’s office or OOH services had milder neurological deficits (p < 0.001) and longer patient delay (p = 0.018) than those who called the EMCC., Interpretation: Six out of ten patients who contacted the primary health care services were asked to go to the GP’s office/OOH services in person, which resulted in unnecessary delay. The findings from this study may indicate a need for specific training of this group of health care professionals in the prompt handling of patients with possible stroke.

Background: Numerous physiological changes occur in the nervous system with increasing age. On clinical neurological examination, such changes may be misinterpreted as pathology in the nervous system. The objective of this article is to provide a review of the clinical neurological findings that may be caused by normal ageing., Material and Methods: The present manuscript is based on a non-systematic search in PubMed as well as on the clinical experience of the authors., Results: Cognitive functions are usually fairly well preserved in old age, apart from executive functioning, psychomotor speed and episodic memory, which are reduced with increasing age. Physiological changes related to increasing age include, in particular, vertical eye movements (upwards), vibration sense, Achilles reflexes, primitive reflexes and motor speed. Muscle power is reduced by 20-40% in healthy individuals aged over 70 years., Interpretation: A correct diagnosis based on findings in the neurological examination cannot be made without knowledge of how ageing affects the physiology of the nervous system. However, the evidence regarding physiological changes in the nervous system is limited, and more research is needed in this field.

Background: In Norway, few studies have been done to map the extent of do-not-resuscitate (DNR) orders and the consequence for patients (treatment and outcome)., Material and Methods: All patients with DNR orders, referred to the stroke unit of Akershus University Hospital during the year 2005, were identified and data on treatment and outcome were recorded., Results: A DNR order was found for 79 of 855 (9 %) patients (mean age 80 years [SD 9]). Reasons for referral to hospital were: cerebral infarction (49 [62 %] patients), intracerebral haemorrhage (28 [35 %] patients), and other diseases (2 [3 %] patients). Mean NIH Stroke Scale was 19 (SD 6) (scale 0 - 42; 0 in score meaning no stroke related symptoms). Hospital mortality was 39/79 (49 %). Apart from once, all decisions regarding withholding and/or withdrawing life-sustaining treatment were taken in the aftermath of a DNR order. For 43 patients (54 %), treatment was limited in some way and hospital mortality for this group was 27/43 (63 %). Mortality was 12/36 (33 %) for those who had full treatment. 45 patients (57 %) with a DNR order had a bacterial infection and 32 of them were treated with antibiotics (71 %)., Interpretation: Patients with DNR orders were old and had had severe stroke. Treatment was rarely withheld despite high morbidity and mortality among the patients.

Background: A stroke will often have serious consequences for the patients and families involved. Rehabilitation in the acute phase is very important for the long-term prognosis., Material and Methods: The article is based upon selected literature, in particular relevant systematic reviews, as well as our own clinical experience., Results and Interpretation: All stroke victims should be quickly admitted to a stroke unit, and rehabilitation should start as soon as the patient is clinically stable. Stroke rehabilitation is a complex process where the aim is to maximize the functional independence and the subjective well being of the patients. Multidisciplinary, coordinated programs including early mobilization and functional training in activities of daily living are the cornerstones in stroke rehabilitation. The process should be conducted on a step-by-step approach with short-term and long-term goals, according to the patient's own request. A comprehensive evaluation of the patient should take place early, followed by goal-directed planning. The effectiveness of stroke unit care has been clearly demonstrated, but more research about the different components of rehabilitation is needed. A future challenge will be to maintain the focus on early rehabilitation and at the same time introduce new acute treatment modalities.

Background: There is a lack of knowledge of stroke symptoms in the population and among health professionals. Many non-cerebrovascular diseases present with a strokelike clinical picture. The present study focuses on non-cerebrovascular conditions that were referred to a neurological acute stroke unit as strokes., Methods: In an observational study, 354 consecutive patients who presented to the stroke unit with a diagnosis of stroke were evaluated. Patients were assessed by neurologists and classified as non-stroke patients or true stroke patients., Results: Eighty-eight were non-stroke patients (25%), who were younger than the true strokes (65.5 vs 71.5). Clinical features were falls (23%), sensory impairment (19%), vertigo (13%), loss of consciousness (11%) and confusion (9%). Half of the non-stroke diagnoses were either migraine, infection, postural vertigo or sequelae after a previous stroke. In 25% another neurological disease was present, such as epilepsy, cranial nerve disorder, neuropathy, transient global amnesia or demyelinating disease. There were 6 patients with previous stroke among the 11 non-stroke patients who had a final diagnosis of infection., Discussion: Misdiagnosis of stroke is common among non-neurologists. Non-stroke patients often have another neurological disease. All stroke patients should be seen by a neurologist in the early phase.