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

Initial Workup and Management of Suspected Stroke

The initial workup for suspected stroke requires rapid evaluation of airway, breathing, and circulation followed by immediate brain imaging, focused neurological examination using a standardized scale, and targeted laboratory investigations to determine stroke type and guide time-sensitive treatment decisions. 1

Initial Emergency Department Assessment

Primary Assessment (First 5-10 Minutes)

• ABCs (Airway, Breathing, Circulation) assessment 1
  • Ensure patent airway
  • Provide supplemental oxygen only if oxygen saturation <94% 1
  • Assess circulatory status and establish IV access

Neurological Assessment

• Conduct focused neurological examination to identify focal deficits 1
• Use standardized stroke scale:
  • National Institutes of Health Stroke Scale (NIHSS) (preferred) 1
  • Canadian Neurological Scale (CNS) as alternative 1

Vital Signs Monitoring

• Assess and document:
  • Heart rate and rhythm
  • Blood pressure (do not aggressively treat hypertension unless systolic >220 mmHg or diastolic >120 mmHg) 1
  • Temperature
  • Oxygen saturation
  • Hydration status
  • Presence of seizure activity 1

Immediate Diagnostic Testing

Neuroimaging (Highest Priority)

• Brain CT or MRI within 30 minutes of arrival 1
  • Must be completed before any treatment decisions 1
  • Distinguishes between ischemic and hemorrhagic stroke 1

Vascular Imaging

• CT angiography (CTA) from aortic arch to vertex
  • Ideally performed concurrently with initial brain CT 1
  • Evaluates both extracranial and intracranial circulation 1
• Alternatives when CTA unavailable:
  • Carotid ultrasound (for extracranial vessels)
  • MR angiography 1

Laboratory Investigations

• Critical labs (should not delay imaging or treatment decisions) 1:
  • Electrolytes
  • Random glucose (hypoglycemia can mimic stroke)
  • Complete blood count
  • Coagulation studies (INR, aPTT)
  • Creatinine and eGFR
  • Troponin

Cardiac Assessment

• 12-lead ECG to assess for atrial fibrillation or structural heart disease 1
  • Can be deferred until after acute treatment decisions if patient is hemodynamically stable 1
• Consider cardiac monitoring for at least 24 hours to detect paroxysmal atrial fibrillation 1

Management Considerations

Seizure Management

• New-onset seizures occurring at stroke onset or within 24 hours should be treated with short-acting medications (e.g., lorazepam IV) if not self-limiting 1
• Single self-limiting seizures do not require long-term anticonvulsant therapy 1
• Avoid prophylactic anticonvulsants as they may negatively affect neural recovery 1

Swallowing Assessment

• Keep patient NPO (nothing by mouth) until swallowing assessment completed 1
• Perform swallowing screen using validated tool within 24 hours of arrival 1
• Administer medications via alternative routes (IV, rectal) until swallowing safety confirmed 1

Time-Critical Treatment Decisions

• For ischemic stroke:
  • Determine eligibility for thrombolytic therapy (IV tPA) within 4.5 hours of symptom onset 2
  • Assess for endovascular therapy candidacy in large vessel occlusion 1
• For hemorrhagic stroke:
  • Consult neurosurgery
  • Manage blood pressure according to hemorrhagic stroke guidelines 1

Common Pitfalls to Avoid

1. Delaying neuroimaging - Brain imaging should be prioritized over other tests like ECG or chest X-ray unless patient is hemodynamically unstable 1

2. Missing stroke mimics - Consider conditions that can present with stroke-like symptoms 1:

   • Hypoglycemia
   • Seizures with postictal deficits
   • Complicated migraine
   • Hypertensive encephalopathy
   • Conversion disorder

3. Aggressive blood pressure reduction - Lowering blood pressure too rapidly may worsen cerebral ischemia; only treat if systolic >220 mmHg or diastolic >120 mmHg in ischemic stroke (unless thrombolysis is planned) 1

4. Administering dextrose-containing fluids - May exacerbate cerebral injury; use normal saline unless treating hypoglycemia 1

5. Delaying treatment decisions - "Time is brain" - treatment decisions should be made as rapidly as possible, with a goal of door-to-needle time under 60 minutes for thrombolysis 3

By following this structured approach to the initial workup and management of suspected stroke, clinicians can optimize the chances for favorable patient outcomes through rapid diagnosis and appropriate time-sensitive interventions.