What is the recommended work‑up for a patient presenting with suspected stroke?

Recommended Stroke Work-Up

All patients with suspected acute stroke require immediate non-contrast CT (NCCT) of the head upon hospital arrival, followed by rapid vascular imaging with CT angiography (CTA) of the head and neck to determine eligibility for acute interventions 1, 2.

Initial Assessment and Imaging (Within 60 Minutes of Arrival)

Stroke Severity Quantification

• Use the National Institutes of Health Stroke Scale (NIHSS) to quantify neurological deficit 1
• This score guides treatment decisions, predicts complications, and facilitates communication between providers

Brain Imaging Protocol

Primary imaging sequence:

1. Non-contrast CT head (Class I, Level B-NR recommendation) 1

   • Detects acute intracranial hemorrhage (critical for treatment decisions)
   • Identifies early ischemic changes
   • Most cost-effective initial test
   • Required before any antithrombotic or thrombolytic therapy

2. CTA head and neck (usually appropriate) 2

   • Identifies large vessel occlusion for endovascular thrombectomy candidacy
   • Evaluates extracranial carotid stenosis
   • Should be performed rapidly in the acute setting
   • Essential for determining mechanical thrombectomy eligibility

MRI considerations:

• MRI with diffusion-weighted imaging (DWI) is more sensitive than CT for detecting acute ischemic stroke 1
• However, routine MRI in all patients is not cost-effective 1
• Specific MRI indications include:
  • Wake-up strokes (unknown time of onset) 1, 3
  • Evaluation for patent foramen ovale closure 2
  • Puzzling clinical presentations where CT is negative 1
  • Uncertain stroke localization 1

Vascular Evaluation

Carotid Artery Assessment

For patients with TIA or minor stroke who are candidates for carotid endarterectomy or stenting:

• Noninvasive imaging of cervical carotid arteries within 24 hours of hospitalization or 48 hours of symptom onset 2
• This addresses the high early risk of recurrent stroke in symptomatic carotid stenosis

Imaging options (in order of preference for acute setting):

1. CTA neck (rapid, accurate for stenosis quantification) 2
2. MRA neck (alternative if contrast contraindicated) 2
3. Carotid duplex ultrasound (accurate, noninvasive, no contrast needed) 2

Intracranial Vascular Assessment

• CTA head or MRA head identifies intracranial steno-occlusive disease 2
• Time-of-flight MRA is sufficiently sensitive for screening 2

Cardiac Evaluation

Essential cardiac workup:

1. 12-lead ECG (100% compliance expected) 4

   • Identifies atrial fibrillation, acute coronary syndrome, conduction abnormalities

2. Enhanced and prolonged Holter monitoring (superior to routine ECG monitoring) 5

   • Number needed to change decision: 8 patients (vs. 17 for routine monitoring)
   • Detects paroxysmal atrial fibrillation missed on standard ECG
   • Should play a more prominent role than current guidelines suggest 5

3. Echocardiography 5

   • Transesophageal echocardiography (TEE): Number needed to change decision = 12
   • Transthoracic echocardiography (TTE): Number needed to change decision = 330
   • TEE significantly more likely to alter management than TTE
   • Consider TEE for cryptogenic stroke, suspected cardioembolic source, or when TTE is non-diagnostic

Additional Laboratory and Diagnostic Testing

Standard laboratory evaluation:

• Blood glucose (predictor of poor outcomes) 1
• Complete blood count
• Coagulation studies (PT/INR, aPTT)
• Metabolic panel
• Lipid panel (for secondary prevention planning) 4

Hypercoagulable workup:

• Not routine for all stroke patients 6
• Consider in cryptogenic stroke, particularly in younger patients
• Stepwise approach: Exclude acquired/secondary hypercoagulable states before testing for primary thrombophilia 6
• Acquired conditions exceed genetic causes in frequency

Critical Time Benchmarks

• Door-to-imaging time: ≤60 minutes (guideline standard) 7
• Optimal door-to-imaging: ≤20 minutes (achievable benchmark) 7
• Vascular imaging for intervention candidates: Within 48 hours of onset 2

Common Pitfalls to Avoid

1. Delaying CT for MRI: NCCT must be performed first to exclude hemorrhage before any treatment decisions 1
2. Inadequate vascular imaging: Missing large vessel occlusion delays thrombectomy candidacy determination 2
3. Insufficient cardiac monitoring: Standard ECG misses paroxysmal atrial fibrillation; enhanced monitoring changes management in 1 of 8 patients 5
4. Premature hypercoagulable testing: Test for acquired conditions before primary thrombophilia 6
5. Delayed carotid imaging: High-grade symptomatic stenosis requires evaluation within 24-48 hours due to high early recurrence risk 2

Special Populations

Wake-up stroke (unknown onset time):

• MRI with DWI-FLAIR mismatch protocol 1, 2, 3
• Over 80% of hospitals use standardized institutional protocols 3
• 75% order MRI in the acute setting for these cases 3

Suspected venous sinus thrombosis:

• CT venography (CTV) or MR venography (MRV) 2
• Assess for venous infarction and hemorrhage complications