Comprehensive Stroke Workup Protocol
A comprehensive stroke workup should include brain imaging, vascular imaging, cardiac evaluation, laboratory testing, and specialized investigations based on patient characteristics to determine stroke etiology and guide appropriate secondary prevention strategies.
Initial Emergency Assessment
- Immediate neuroimaging with non-contrast CT and CT angiography for all suspected stroke patients 1
- Rapid assessment of airway, breathing, and circulation followed by standardized neurological examination (e.g., NIHSS) 1
- Vital signs monitoring (heart rate, blood pressure, temperature, oxygen saturation) 1
- 12-lead ECG to assess cardiac rhythm and identify atrial fibrillation 1
Brain Imaging
- Non-contrast CT scan without delay to distinguish between ischemic and hemorrhagic stroke 2, 1
- CT angiography (CTA) from arch-to-vertex for patients potentially eligible for endovascular therapy 1
- Consider advanced imaging (CT perfusion or MRI with diffusion-weighted imaging) for patients presenting beyond the standard thrombolysis window 1
Vascular Imaging
- Extracranial vascular imaging to identify carotid stenosis requiring potential revascularization 2
- Intracranial vascular imaging to identify large vessel occlusions or stenosis 2
- Consider CTA or MRA from aortic arch to vertex to evaluate both extracranial and intracranial circulation 2
Cardiac Evaluation
- 12-lead ECG for all stroke patients 2
- At least 24 hours of cardiac monitoring to screen for atrial fibrillation 2
- Extended cardiac monitoring (at least 14 days) for patients with embolic stroke of undetermined source 2
- Echocardiography (transthoracic or transesophageal) for patients with suspected cardiac source 2
Laboratory Testing
- Complete blood count with platelets 1
- Coagulation studies (PT/INR, aPTT) 1
- Basic metabolic panel including electrolytes, glucose, and renal function 1
- Lipid profile 2
- HbA1c for diabetic patients 2
- Consider inflammatory markers (ESR, CRP) for patients >50 years with symptoms suggestive of giant cell arteritis 2
Risk-Based Additional Investigations
For patients ≤50 years or with cryptogenic stroke:
- Extended hypercoagulable testing (antiphospholipid antibodies, protein C/S, antithrombin III) 2
- Consider screening for substance use 2
- Evaluation for rare causes such as arterial dissection, vasculitis, or genetic disorders 2
For patients with retinal artery occlusion:
- Immediate referral to stroke center for prompt systemic evaluation 2
- Evaluation for giant cell arteritis in patients >50 years 2
Timing of Workup Based on Risk
Highest Risk (within 48 hours):
- Patients presenting within 48 hours of TIA or non-disabling stroke with unilateral weakness or speech disturbance require immediate evaluation 2
- Immediate brain and vascular imaging 2
- ECG without delay 2
Increased Risk:
- Patients presenting between 48 hours and 2 weeks from symptom onset should receive comprehensive evaluation within 24 hours 2
Lower Risk:
- Patients presenting more than 2 weeks after symptoms should be evaluated within one month 2
Common Pitfalls to Avoid
Delayed evaluation: Failure to recognize stroke as a medical emergency can lead to missed opportunities for acute intervention and secondary prevention 1
Incomplete vascular imaging: Focusing only on extracranial vessels may miss intracranial pathology 2
Insufficient cardiac monitoring: Standard 24-hour monitoring may miss paroxysmal atrial fibrillation; extended monitoring is often necessary 2
Premature classification as cryptogenic: Ensure thorough evaluation before labeling a stroke as cryptogenic 2
Overlooking rare causes: In younger patients or those without traditional risk factors, consider arterial dissection, vasculopathies, and hypercoagulable states 2
By following this systematic approach to stroke workup, clinicians can effectively identify stroke etiology, implement appropriate secondary prevention strategies, and reduce the risk of recurrent stroke and associated mortality and morbidity.