What is the appropriate workup for a patient with a suspected cerebrovascular accident (CVA) or stroke?

From the Guidelines

A comprehensive stroke workup should include immediate brain imaging with CT or MRI, followed by vascular imaging of the head and neck with CT angiography or MR angiography, as well as blood work and cardiac monitoring to identify the cause and guide treatment. The initial assessment should involve a rapid neurological examination using the NIH Stroke Scale 1. According to the 2021 guideline for the prevention of stroke, a diagnostic evaluation is recommended for gaining insights into the etiology of and planning optimal strategies for preventing recurrent stroke, with testing completed or underway within 48 hours of onset of stroke symptoms 1.

Key Components of a Stroke Workup

• Immediate brain imaging with CT or MRI to distinguish between ischemic and hemorrhagic stroke 1
• Vascular imaging of the head and neck with CT angiography or MR angiography to identify stenosis or occlusions 1
• Blood work, including complete blood count, coagulation studies, electrolytes, glucose, lipid panel, and HbA1c, to gain insight into risk factors for stroke and to inform therapeutic goals 1
• Electrocardiogram and cardiac monitoring for at least 24 hours to detect atrial fibrillation 1
• For cryptogenic strokes, extended cardiac monitoring (14-30 days), echocardiography, and hypercoagulability testing may be warranted 1

Secondary Prevention

• Antiplatelet therapy, such as aspirin 81-325 mg daily, clopidogrel 75 mg daily, or aspirin-dipyridamole 1
• Statins, blood pressure management, and lifestyle modifications to address the underlying pathophysiology and prevent recurrence 1

The 2021 guideline for the prevention of stroke recommends a comprehensive diagnostic evaluation, including imaging and blood work, to guide treatment and prevent recurrent stroke 1. The Canadian Stroke Best Practice Recommendations also emphasize the importance of immediate brain imaging and vascular imaging in acute stroke management 1. Overall, a systematic approach to stroke workup and treatment is crucial to ensure proper diagnosis and treatment, and to address the underlying pathophysiology to prevent recurrence.

From the Research

Stroke Workup

• Stroke is the chief differential diagnosis in patients presenting to the emergency room with abrupt onset focal neurological deficits 2
• Neuroimaging, including non-contrast computed tomography (CT), magnetic resonance imaging (MRI), vascular and perfusion imaging, is a cornerstone in the diagnosis and treatment decision-making of stroke 2

Diagnostic Imaging

• Non-contrast CT brain, or in some centers MRI, can help differentiate ischemic stroke and intracerebral hemorrhage (ICH) 2
• Advanced imaging such as MRI or perfusion imaging can also assist in making a diagnosis of ischemic stroke versus mimics such as migraine, Todd's paresis, or functional disorders 2
• CT or MR angiography can identify medium-large vessel occlusions and trigger consideration of endovascular thrombectomy (EVT) 2

Predicting Hemorrhagic Transformation

• Radiomics features from initial non-contrast CT scans of infarcted brain tissue can predict hemorrhagic transformation susceptibility in stroke patients undergoing revascularization 3
• Textural features on non-contrast CT are associated with the frailty of the infarcted tissue and can predict hemorrhagic transformation 3
• A deep learning model using non-contrast CT and clinical data can predict hemorrhagic transformation and its subtypes in acute ischemic stroke patients following intravenous thrombolysis (IVT) 4

Treatment Selection

• Non-contrast CT and CT-angiogram can select late-presenting patients for endovascular treatment (EVT) 5
• In centers without access to perfusion-based neuroimaging, this pragmatic approach could be safe, particularly for strokes of unknown onset 5

Outcome

• Asymptomatic hemorrhagic transformation after endovascular treatment is associated with poorer functional outcomes and higher mortality in patients with acute ischemic stroke 6
• Any hemorrhagic transformation, regardless of its clinical impact or radiologic category, should be considered as an additional EVT safety measure 6