From the Guidelines
A post-stroke workup should include a comprehensive evaluation to determine stroke etiology, prevent recurrence, and guide rehabilitation, as recommended by the most recent guidelines 1.
Key Components of Post-Stroke Workup
The workup should begin with brain imaging (CT or MRI) to confirm stroke type and location.
- Conduct cardiac assessment with ECG, echocardiogram, and possibly Holter monitoring to identify arrhythmias like atrial fibrillation.
- Vascular imaging of carotid and cerebral vessels using ultrasound, CTA, or MRA is essential to detect stenosis or other abnormalities.
- Laboratory tests should include complete blood count, lipid panel, HbA1c, and coagulation studies.
Secondary Prevention Strategies
For secondary prevention, start antiplatelet therapy (aspirin 81-325mg daily, clopidogrel 75mg daily, or aspirin-dipyridamole) for ischemic strokes without atrial fibrillation, as supported by recent guidelines 1.
- If atrial fibrillation is present, anticoagulation with direct oral anticoagulants (apixaban 5mg twice daily, rivaroxaban 20mg daily, or dabigatran 150mg twice daily) or warfarin (target INR 2-3) is indicated.
- Manage modifiable risk factors by prescribing statins (atorvastatin 40-80mg or rosuvastatin 20-40mg daily), antihypertensives to maintain BP <130/80 mmHg, and diabetes medications as needed, in line with recommendations from 1 and 1.
Rehabilitation and Follow-Up
Early rehabilitation assessment should address physical, occupational, speech, and swallowing therapy needs.
- Aerobic exercise is important for all patients after stroke, regardless of specific rehabilitation needs, as emphasized in 1.
- Primary care clinicians can improve physical activity participation by their patients through structured practices of assessment, counseling, and referral, as suggested in 1.
From the Research
Post-Stroke Workup
The post-stroke workup is a crucial step in determining the underlying cause of the stroke and guiding further management. The following are some key components of the post-stroke workup:
- Cardiac imaging: Echocardiography, CT, or MRI can be used to evaluate the heart for potential sources of embolism 2
- Lipid profile: A comprehensive analysis of the lipid profile can help identify patients at risk for recurrent stroke and guide treatment decisions 3
- Vascular imaging: Imaging of the neck and cerebral vessels can help identify potential sources of embolism or stenosis 4
- Blood work: Basic risk factor blood work, including lipid panel, hemoglobin A1c, TSH, ESR, CRP, RPR, HIV, and toxicology screen, can help identify underlying risk factors for stroke 4
Role of Echocardiography
Echocardiography plays a crucial role in the evaluation of patients with stroke, particularly in those with suspected cardioembolic stroke. It can help identify potential cardiac sources of embolism, such as atrial fibrillation, ventricular thrombus, and valvular heart disease 5, 6. Transthoracic and transesophageal echocardiography can provide comprehensive information on thromboembolic risk in patients with stroke.
Diagnostic Approach
A "heart to head" diagnostic approach is recommended for evaluating patients with stroke, starting with a thorough history and physical examination, followed by imaging studies, such as brain MRI, neck and cerebral vascular imaging, and echocardiography 4. A dedicated cardiologist experienced in the management of cardioembolism should provide a tailored clinical and echocardiographic assessment if a cardioembolic stroke is suspected 6.
Secondary Prevention
Secondary prevention strategies, such as aspirin, anticoagulation, statin therapy, blood pressure reduction, smoking cessation, optimal glucose control, and substance abuse counseling, should be instituted to reduce the risk of recurrent stroke 4. The choice of secondary prevention strategy depends on the underlying cause of the stroke and the patient's individual risk factors.