From the Guidelines
The workup for stroke in a young woman should begin with a rapid initial evaluation for airway, breathing, and circulation, followed by a neurological examination to determine focal neurological deficits and assess stroke severity using a standardized stroke scale such as the National Institutes of Health Stroke Scale (NIHSS) or the Canadian Neurological Scale (CNS) 1. The initial evaluation should also include assessment of heart rate and rhythm, blood pressure, temperature, oxygen saturation, hydration status, and presence of seizure activity 1. Acute blood work should be conducted as part of the initial evaluation, including electrolytes, glucose, hematology (CBC), coagulation (INR, aPTT), creatinine, eGFR, and troponin 1. An electrocardiogram should be completed, but unless the patient is hemodynamically unstable, it should not delay assessment for thrombolysis and endovascular therapy and can be deferred until after a decision regarding acute treatment is made 1. A patient swallowing screen should be completed as early as possible by a practitioner trained to use a validated swallowing screening tool, and patients should remain NPO until swallowing screen is completed for patient safety 1. Seizure assessment is also crucial, and new-onset seizures at the time of an acute stroke should be treated using appropriate short-acting medications if they are not self-limited 1. Key considerations in the workup of a young woman with stroke include:
- Brain imaging (CT or MRI) to confirm the stroke and determine its type
- Comprehensive cardiovascular assessment, including echocardiogram
- Vascular imaging of the head and neck with CT angiography or MR angiography
- Laboratory testing, including complete blood count, comprehensive metabolic panel, lipid profile, and inflammatory markers
- Specific testing for hypercoagulable states and autoimmune disorders
- Evaluation for potential hormone-related factors and drug screening for stimulant use. However, the initial steps as outlined by the Canadian stroke best practice recommendations should be prioritized to ensure timely and appropriate management of the acute stroke 1.
From the Research
Stroke in Young Women Workup
- The evaluation and diagnosis of ischemic stroke in young women presents a challenging situation in the emergency department due to a range of sex-specific risk factors and broad differentials 2.
- Several risk factors for ischemic stroke exist for young women, including oral contraceptive (OCP) use and migraine with aura 2.
- Pregnancy and the postpartum period is also an important transient state during which risks for both ischemic stroke and cerebral hemorrhage are elevated, accounting for 18% of strokes in women under 35 2.
Diagnostic Tools
- Computed tomography (CT) is the most common diagnostic tool for suspected stroke because of its affordability, wide availability, and speed of acquiring images 3.
- Magnetic resonance imaging (MRI) may diagnose acute ischemic stroke when stroke mimics are favored but not certain, and can identify tissue-type plasminogen activator (tPA)-eligible stroke patients among those initially favored to have stroke mimics 4.
- A streamlined hyperacute MRI protocol can permit tPA administration to a small but significant subset of acute ischemic stroke patients initially considered to have stroke mimics 4.
Treatment
- Current evidence regarding the management of acute ischemic stroke in young women is summarized, including the use of thrombolytic agents (e.g., tissue plasminogen activator) in both pregnant and nonpregnant individuals 2.
- Thrombolytic therapy was safe in patients with stroke with minor deficits who were initially evaluated by MRI, with a low rate of symptomatic intracranial hemorrhage (sICH) 5.
- MRI-based thrombolysis in acute ischemic stroke may be associated with reduced rates of SICH and early death compared to CT-based thrombolysis 6.