What is the initial workup and management for a patient with a suspected stroke?

Initial Workup and Management for Suspected Stroke

The initial workup for a patient with suspected stroke must include immediate brain imaging (preferably CT scan within 30 minutes of hospital arrival), basic laboratory tests, and neurological assessment using a standardized scale like NIHSS to guide time-sensitive treatment decisions. 1

Immediate Assessment (First 30 Minutes)

Clinical Evaluation

• Rapid assessment of ABCs (Airway, Breathing, Circulation) 1
• Focused neurological examination using National Institutes of Health Stroke Scale (NIHSS) 1
• Vital signs monitoring: blood pressure, pulse, temperature, oxygen saturation 1
• Determine time of symptom onset (critical for treatment decisions) 1

Essential Diagnostic Tests

1. Brain Imaging (STAT priority):

   • Non-contrast CT scan within 30 minutes of arrival 1
   • Purpose: Differentiate between ischemic stroke and hemorrhagic stroke 1
   • CT should be formally evaluated for early signs of infarction 1

2. Laboratory Studies (draw immediately but don't delay imaging): 1

   • Complete blood count with platelets
   • Electrolytes
   • Blood glucose
   • Coagulation studies (PT/INR, aPTT) - especially important if thrombolytic therapy is considered
   • Renal function (creatinine, eGFR)
   • Cardiac biomarkers (troponin)

3. 12-lead ECG to identify cardiac arrhythmias (especially atrial fibrillation) or acute myocardial infarction 1

Secondary Assessment (Within First Hour)

Vascular Imaging

• CT angiography (CTA) from aortic arch to vertex to identify large vessel occlusions 1, 2
• Should be performed immediately after non-contrast CT in patients who are potential candidates for endovascular therapy 1
• Alternatives include MR angiography or carotid ultrasound if CTA unavailable 1

Additional Tests Based on Clinical Presentation

• Oxygen saturation monitoring and supplemental oxygen if hypoxic 1
• Cardiac monitoring for arrhythmia detection 1
• Seizure assessment and treatment if seizures present 1
• Toxicology screen, blood alcohol level if history suggests 1

Management Decisions Based on Initial Workup

For Ischemic Stroke

1. Determine eligibility for thrombolytic therapy (IV rtPA):

   • Time since symptom onset (within 3-4.5 hours)
   • Absence of hemorrhage on CT
   • No contraindications based on lab values or clinical factors 1

2. Blood pressure management:

   • For rtPA candidates: maintain BP <185/110 mmHg 1
   • For non-rtPA candidates: only treat if BP >220/120 mmHg 1

3. Positioning and monitoring:

   • Position head of bed at 25-30° initially 1
   • Neurological checks and vital signs every 15 minutes during rtPA infusion, then every 30 minutes for 6 hours, then hourly 1

For Hemorrhagic Stroke

• Refer to hemorrhagic stroke protocols for specific management 1

Common Pitfalls to Avoid

1. Delaying brain imaging - CT scan should be completed within 30 minutes of arrival for all suspected stroke patients 1

2. Waiting for laboratory results before initiating imaging - Labs should not delay imaging or treatment decisions 1

3. Missing stroke mimics - Consider conditions that may mimic stroke (hypoglycemia, seizures, migraines) 1

4. Overlooking posterior circulation strokes - These may present with atypical symptoms and require careful assessment 1

5. Unnecessary testing delaying treatment - Chest X-rays and other non-essential tests should not be routinely performed in the acute setting unless clinically indicated 1

By following this structured approach to the initial workup and management of suspected stroke, clinicians can ensure timely diagnosis and appropriate treatment decisions that significantly impact patient outcomes in terms of mortality, morbidity, and quality of life.