What is the diagnostic workup for a patient presenting with symptoms of a cerebrovascular accident (CVA) or stroke?

From the Guidelines

The workup for stroke symptoms should begin immediately with a rapid neurological assessment using the FAST criteria (Face drooping, Arm weakness, Speech difficulties, Time to call emergency services) to identify potential stroke, followed by a non-contrast CT scan of the brain to differentiate between ischemic and hemorrhagic stroke, as recommended by the 2021 guideline for the prevention of stroke in patients with stroke and transient ischemic attack 1.

Initial Evaluation

The initial evaluation should include a rapid assessment of airway, breathing, and circulation, as well as 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) 1.

Diagnostic Tests

Diagnostic tests should include:

• Non-contrast CT scan of the brain to differentiate between ischemic and hemorrhagic stroke
• Blood tests, including complete blood count, coagulation studies, electrolytes, glucose, and cardiac enzymes
• ECG to screen for atrial fibrillation and other concomitant cardiac conditions 1
• Carotid ultrasound to screen for stenosis in patients with symptomatic anterior circulation cerebral infarction or TIA who are candidates for revascularization 1
• CT or MRI of the brain to confirm the diagnosis of symptomatic ischemic cerebral vascular disease 1

Treatment

For suspected ischemic stroke within the treatment window (typically 4.5 hours for IV thrombolytics), tissue plasminogen activator (tPA) at 0.9 mg/kg (maximum 90 mg) with 10% given as bolus and remainder over 60 minutes may be administered after ruling out contraindications. Mechanical thrombectomy may be considered for large vessel occlusions within 24 hours of symptom onset.

Secondary Prevention

Additional tests like lipid panel, HbA1c, and inflammatory markers help identify stroke risk factors, and a comprehensive approach allows for proper diagnosis, appropriate acute intervention, and development of secondary prevention strategies to reduce the risk of recurrent stroke 1.

From the Research

Workup for Stroke Symptoms

The workup for stroke symptoms typically involves a combination of clinical evaluation, imaging studies, and laboratory tests to determine the cause and severity of the stroke. Some key considerations in the workup for stroke symptoms include:

• Time of symptom onset: This is crucial in determining the eligibility for intravenous tissue plasminogen activator (IV tPA) therapy, which is most effective when administered within 4.5 hours of symptom onset 2, 3
• Imaging studies: Computed tomography (CT) or magnetic resonance imaging (MRI) scans are used to confirm the diagnosis of stroke and determine the location and extent of the infarct 3
• Laboratory tests: These may include complete blood counts, blood chemistry tests, and coagulation studies to identify any underlying conditions that may have contributed to the stroke 4
• Assessment of stroke severity: This is typically done using the National Institutes of Health Stroke Scale (NIHSS) score, which helps to determine the severity of the stroke and guide treatment decisions 5

Treatment Options

Treatment options for stroke depend on the cause and severity of the stroke, as well as the time of symptom onset. Some possible treatment options include:

• Intravenous tPA: This is a clot-busting medication that can be administered within 4.5 hours of symptom onset to improve outcomes in patients with acute ischemic stroke 2, 3
• Mechanical thrombectomy: This is a procedure that involves removing the clot from the affected blood vessel using a mechanical device, and is typically performed in patients with large vessel occlusion 5, 4
• Antiplatelet therapy: This may be started within 24 hours of stroke onset to prevent further clot formation and improve outcomes 5, 6
• Anticoagulant therapy: This may be used in patients with atrial fibrillation or other conditions that increase the risk of stroke, to prevent further clot formation 4, 6

Special Considerations

There are several special considerations in the workup and treatment of stroke, including:

• Wake-up stroke: This refers to a stroke that occurs during sleep, and can be challenging to diagnose and treat due to the uncertainty of the time of symptom onset 3
• Anticoagulated patients: Patients who are taking anticoagulant medications, such as warfarin or direct oral anticoagulants, may require special consideration in the workup and treatment of stroke 4
• Patients with mechanical valve replacements: These patients may require anticoagulant therapy with warfarin to prevent stroke, and may require special consideration in the workup and treatment of stroke 6