From the Guidelines
For patients presenting with cerebrovascular accident (CVA) symptoms, immediate neuroimaging with non-contrast CT scan of the brain is the first-line study to rule out hemorrhage and identify early ischemic changes, followed by CT angiography to evaluate vascular occlusions and stenosis, as recommended by the most recent guidelines 1. The diagnostic approach to CVA symptoms should prioritize morbidity, mortality, and quality of life outcomes.
Key Diagnostic Studies
- Non-contrast CT scan of the brain to rule out hemorrhage and identify early ischemic changes
- CT angiography to evaluate vascular occlusions and stenosis
- MRI with diffusion-weighted imaging to detect acute ischemia, especially in posterior circulation strokes
- 12-lead ECG to identify arrhythmias, particularly atrial fibrillation
- Continuous cardiac monitoring for at least 24 hours
- Complete blood count, comprehensive metabolic panel, coagulation studies (PT/INR, PTT), lipid profile, and hemoglobin A1c to gain insight into risk factors for stroke and inform therapeutic goals
Additional Recommendations
- Carotid ultrasound or CT angiography of the neck to evaluate for carotid stenosis
- Transthoracic echocardiography for suspected cardioembolic sources, with transesophageal echocardiography considered for patients under 60 or when a cardiac source is strongly suspected
- Blood tests, including complete blood count, prothrombin time, partial thromboplastin time, glucose, HbA1c, creatinine, and fasting or nonfasting lipid profile, to inform therapeutic goals 1 These diagnostic studies help determine stroke etiology, guide acute treatment decisions regarding thrombolysis or thrombectomy, and inform secondary prevention strategies to reduce recurrence risk, as supported by the American Heart Association/American Stroke Association guidelines 1.
From the Research
Diagnostic Studies for CVA Symptoms
The following diagnostic studies are recommended for patients presenting with cerebrovascular accident (CVA) symptoms:
- Computed Tomography (CT) scan: Nonenhanced CT can help exclude hemorrhage and detect early signs of infarction 2
- Perfusion CT: Provides information about brain perfusion, which permits differentiation of irreversibly damaged brain tissue from reversibly impaired tissue at risk 2
- CT Angiography: Can help detect stenosis or occlusion of extra- and intracranial arteries 2
- Magnetic Resonance Imaging (MRI): Diffusion-weighted MRI is shown to be equally effective as a CT scan in diagnosing ischemic and hemorrhagic strokes 3
- Magnetic Resonance Angiography (MRA): Can help detect stenosis or occlusion of extra- and intracranial arteries, and is useful in the diagnosis of cerebral venous thrombosis 4
Specific Diagnostic Studies for Different Types of CVA
- For ischemic stroke: CT scan, Perfusion CT, CT Angiography, and MRI are recommended 2, 3, 5
- For hemorrhagic stroke: CT scan and MRI are recommended, with MRI being more accurate than CT for the detection of chronic intracerebral hemorrhage 6
- For cerebral venous thrombosis: CT scan, MRI, and MRA are recommended, with MRA being useful in the diagnosis of this condition 4
Cost-Effectiveness of Diagnostic Studies
- A cost minimization analysis found that early MRI instead of CT head may be cost-effective in the evaluation of cerebrovascular events, with a potential saving of $335,340 on diagnostic imaging 3