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

Initial Workup and Management for Suspected Stroke

The initial evaluation of a patient presenting with symptoms of stroke must include immediate clinical assessment, urgent brain imaging, and determination of eligibility for thrombolytic therapy and endovascular treatment, followed by development of a plan for further management. 1

Initial Assessment and Stabilization

• Rapid evaluation of airway, breathing, and circulation (ABCs) should be performed immediately upon patient arrival 1
• A standardized neurological examination using a validated stroke scale such as the National Institutes of Health Stroke Scale (NIHSS) should be conducted to determine focal neurological deficits and assess stroke severity 1
• Vital signs assessment including heart rate and rhythm, blood pressure, temperature, oxygen saturation, hydration status, and presence of seizure activity 1
• Time of symptom onset must be established as the single most important piece of historical information, defined as when the patient was last at their previous baseline or symptom-free state 1

Immediate Diagnostic Workup

Neuroimaging

• Brain imaging (CT or MRI) should be completed immediately and is the highest priority diagnostic test 1
• CT angiography (CTA) from aortic arch to vertex should be performed at the time of initial brain CT when possible to assess both extracranial and intracranial circulation 1
• For patients eligible for thrombolysis or endovascular therapy, imaging should not be delayed 1

Laboratory Tests

• Initial blood work should include: 1
  • Complete blood count
  • Electrolytes
  • Coagulation studies (INR, aPTT)
  • Blood glucose
  • Renal function (creatinine, eGFR)
  • Troponin
• These tests should not delay imaging or treatment decisions for intravenous thrombolysis and endovascular therapy 1

Cardiac Assessment

• 12-lead ECG should be performed to assess cardiac rhythm and identify atrial fibrillation or flutter or evidence of structural heart disease 1
• ECG should not delay assessment for thrombolysis and endovascular therapy if the patient is hemodynamically stable 1

Acute Treatment Decisions

Thrombolytic Therapy

• Intravenous tissue plasminogen activator (tPA) at 0.9 mg/kg (maximum 90 mg) should be administered to eligible patients within 3-4.5 hours of symptom onset 1
• Patient selection criteria for tPA must be strictly followed to ensure safe administration 1
• The most common reason patients miss the opportunity for thrombolysis is delayed presentation beyond the treatment window 2

Blood Pressure Management

• For patients eligible for thrombolytic therapy, blood pressure must be below 185/110 mmHg before treatment 1
• For patients not receiving thrombolytic therapy, consensus-based recommendations suggest lowering blood pressure only when systolic pressure exceeds 220 mmHg or diastolic pressure exceeds 120 mmHg 1
• Both excessively high and low blood pressure levels have been associated with poor prognosis in acute stroke 3

Early Management Considerations

Swallowing Assessment

• Swallowing screening should be completed as early as possible by a trained practitioner using a validated tool, ideally within 24 hours of hospital arrival 1
• Patients should remain NPO (nothing by mouth) until swallowing screening is completed 1
• Oral medications should not be administered until swallowing has been assessed as normal 1

Temperature Management

• Temperature should be monitored every 4 hours for the first 48 hours 1
• For temperature >37.5°C, increase monitoring frequency, initiate temperature-reducing measures, and investigate possible infection 1

Seizure Management

• New-onset seizures should be treated with appropriate short-acting medications (e.g., lorazepam IV) if not self-limiting 1
• A single, self-limiting seizure occurring at onset or within 24 hours of stroke should not be treated with long-term anticonvulsant medications 1
• Prophylactic use of anticonvulsants is not recommended 1

Early Mobilization

• Initial assessment by rehabilitation professionals should be conducted as soon as possible after admission 1
• Frequent, brief, out-of-bed activity involving active sitting, standing, and walking, beginning within 24 hours of stroke onset is recommended if there are no contraindications 1

Prevention of Complications

• Early mobilization and adequate hydration should be encouraged to help prevent venous thromboembolism 1
• For patients at high risk of venous thromboembolism, low-molecular-weight heparin (e.g., enoxaparin) should be considered 1
• Anti-embolism stockings alone for post-stroke venous thromboembolism prophylaxis are not recommended 1

Common Pitfalls to Avoid

• Delaying brain imaging while waiting for laboratory results 1
• Waiting for symptoms to improve before seeking medical attention (a common reason for delayed presentation) 4
• Assuming mild symptoms don't require urgent evaluation (approximately one-third of patients with mild symptoms who are not treated may be left dependent or dead) 2
• Contacting primary care instead of emergency medical services (many people believe calling their GP is the most appropriate action) 4
• Failing to recognize the urgency of stroke symptoms by both patients and healthcare providers 4

Remember that "time is brain" - every minute delay in treatment results in loss of approximately 1.9 million neurons, emphasizing the critical importance of rapid assessment and treatment 3.