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

Initial Workup and Management for Stroke

The initial workup for a patient with suspected stroke must include immediate non-contrast CT head, CT angiography of head and neck, and basic laboratory tests within the first 30 minutes of hospital arrival to distinguish between ischemic and hemorrhagic stroke and evaluate for large vessel occlusion. 1

Initial Assessment (First 30-60 Minutes)

Immediate Stabilization

• Assess and stabilize airway, breathing, and circulation (ABCs) 2
• Provide supplemental oxygen only if oxygen saturation <94% 1
• Monitor vital signs: blood pressure, heart rate, respiratory rate, temperature, oxygen saturation 1
• Blood pressure management:
  • For thrombolysis candidates: maintain <185/110 mmHg
  • For non-thrombolysis candidates: treat only if >220/120 mmHg 1

Critical History Elements

• Determine exact time of symptom onset or "last known well" time 2
• Document circumstances around symptom development 2
• Assess for stroke risk factors (hypertension, diabetes, atrial fibrillation, etc.) 2
• Obtain medication history, especially anticoagulants 2
• Identify witnesses who can provide additional history if patient cannot communicate 2

Neurological Examination

• Perform standardized stroke scale assessment (NIHSS preferred) 2
• Document level of consciousness, orientation, speech/language function 2
• Assess cranial nerves, motor function, sensory function, coordination 2
• Evaluate for signs of increased intracranial pressure 2

Urgent Diagnostic Studies

Imaging (Within 30 Minutes)

• Non-contrast CT head (primary goal: rule out hemorrhage) 1, 3
  • Look for early ischemic changes using specialized stroke windows 4
  • Assess for hyperdense vessel sign, sulcal effacement, loss of gray-white differentiation 4
• CT angiography of head and neck (immediately after non-contrast CT) 1
  • Evaluate for large vessel occlusion
  • Assess cervical carotid arteries for stenosis or dissection

Laboratory Tests (Results Needed Within 20 Minutes)

• Complete blood count with platelets 2, 1
• Coagulation studies (PT/INR, aPTT) 1
• Basic metabolic panel (electrolytes, renal function) 1
• Blood glucose 1
• Cardiac enzymes 2

Additional Urgent Tests

• 12-lead ECG (evaluate for atrial fibrillation or acute MI) 2, 1
• Chest X-ray (if clinically indicated, but should not delay treatment) 2

Treatment Decision-Making

IV Thrombolysis Assessment

• Determine eligibility based on:
  • Time window (within 4.5 hours of symptom onset) 1
  • Absence of contraindications
  • CT findings (no hemorrhage, limited early ischemic changes)
• Target door-to-needle time <60 minutes (ideally <30 minutes) 1
• Standard dose: alteplase 0.9 mg/kg (maximum 90 mg) 2, 1

Endovascular Thrombectomy Consideration

• Evaluate for:
  • Large vessel occlusion on CTA
  • Clinical severity (typically NIHSS ≥6)
  • Time window (up to 24 hours in select patients)
  • ASPECTS score ≥6 1

Secondary Prevention and Complications Management

Early Management

• Implement DVT prophylaxis with intermittent pneumatic compression devices 2
• Consider pharmacological DVT prophylaxis in high-risk patients 2
• Monitor temperature every 4 hours for first 48 hours; treat fever >37.5°C 2
• Begin early mobilization within 24 hours if no contraindications 2
• Prevent aspiration with proper positioning and swallow evaluation 1

Further Diagnostic Evaluation (Within 24-48 Hours)

• Carotid/transcranial Doppler ultrasound 1
• Echocardiography to evaluate for cardiac source of embolism 1
• Extended cardiac monitoring (>24 hours) for suspected embolic stroke 2
• Additional testing based on suspected etiology 2

Common Pitfalls to Avoid

1. Delayed Imaging: Every 15-minute delay worsens neurological prognosis 3
2. Overlooking Stroke Mimics: Conditions like seizures, migraines, or hypoglycemia can present with focal deficits 2
3. Missing Early Ischemic Changes: Using standard CT window settings detects only 18% of early changes versus 70% with specialized stroke windows 4
4. Inadequate Blood Pressure Control: Failing to lower BP appropriately in thrombolysis candidates increases hemorrhage risk 1
5. Incomplete Vascular Assessment: Missing large vessel occlusions or dissections that would change management 1
6. Delayed Treatment Decision: Laboratory tests should not delay imaging or treatment decisions 1

By following this structured approach to stroke workup and management, clinicians can optimize patient outcomes by ensuring rapid diagnosis and appropriate treatment selection based on stroke type, severity, and time of onset.