What are the initial orders for a stroke workup?

Initial Orders for Stroke Workup

The initial stroke workup must include immediate non-contrast CT head, CT angiography of head and neck, and basic laboratory tests including complete blood count, electrolytes, coagulation studies, and glucose within the first 30 minutes of hospital arrival. 1

Immediate Imaging Studies

1. Non-contrast CT head

   • Must be performed within 30 minutes of hospital arrival 1
   • Primary purpose: Distinguish between ischemic and hemorrhagic stroke 1
   • Look for early ischemic changes using specialized "Stroke Windows" settings to improve detection 2
   • Evaluate for hyperdense MCA/basilar artery sign, sulcal effacement, basal ganglia/subcortical hypodensity, and loss of gray-white differentiation 2

2. CT Angiography (CTA) of head and neck

   • Should be performed immediately after non-contrast CT 1, 3
   • Evaluate for large vessel occlusion (LVO) that may require endovascular thrombectomy 1
   • Assess cervical carotid arteries for stenosis or dissection 1

3. Consider CT Perfusion

   • Particularly useful for patients presenting 6-24 hours from symptom onset 1, 3
   • Helps determine eligibility for extended-window interventions 1

Laboratory Tests

1. Immediate blood work (results needed within 20 minutes) 1:

   • Complete blood count (CBC)
   • Electrolytes and glucose
   • Coagulation studies (INR, aPTT)
   • Renal function (creatinine)
   • Troponin

2. Important note: Laboratory tests should not delay imaging or treatment decisions 1

Neurological Assessment

1. Standardized stroke scale

   • National Institutes of Health Stroke Scale (NIHSS) 1, 3
   • Document baseline score and monitor for changes

2. Vital signs monitoring

   • Heart rate and rhythm
   • Blood pressure (target <185/110 mmHg if thrombolysis candidate) 1, 3
   • Temperature
   • Oxygen saturation (maintain ≥94%) 3
   • Blood glucose (treat if <60 mg/dL) 3

Additional Diagnostic Tests

1. Electrocardiogram (ECG)

   • Perform immediately on arrival 1
   • Evaluate for atrial fibrillation or acute myocardial infarction 1

2. Carotid/Transcranial Doppler ultrasound

   • Should be available within 24 hours 1
   • Complementary to CTA for evaluation of extracranial vessels 1

3. Echocardiography

   • Arrange for transthoracic or transesophageal echocardiography to evaluate for cardiac source of embolism 1

Treatment Preparation

1. Blood pressure management

   • For thrombolysis candidates: Lower BP to <185/110 mmHg 1, 3
   • For non-thrombolysis candidates: Only treat if >220/120 mmHg 1

2. Thrombolysis eligibility assessment

   • Determine "last known well" time 3
   • Review contraindications to IV thrombolysis
   • Target door-to-needle time <60 minutes (ideally <30 minutes) 1, 3

3. Endovascular thrombectomy consideration

   • Evaluate for LVO on CTA 1, 3
   • Assess clinical severity (typically NIHSS ≥6) 3
   • Determine time window (up to 24 hours with appropriate imaging) 3

Common Pitfalls to Avoid

1. Delayed imaging - CT should be performed within 30 minutes of arrival 1

2. Missing early ischemic changes - Use specialized stroke window settings on CT 2

3. Focusing only on ischemic stroke - Always rule out hemorrhage first 4, 5

4. Delaying thrombolysis for laboratory results - If clinically stable, proceed with thrombolysis while awaiting non-critical lab results 1

5. Inadequate vascular imaging - CTA should be routine in acute stroke evaluation to identify LVO 1, 6

By following this systematic approach to stroke workup, you can rapidly identify patients eligible for time-sensitive interventions like thrombolysis and endovascular thrombectomy, which significantly improve outcomes in terms of mortality and functional recovery 7, 5.