What are the initial steps for a stroke workup and admission?

Initial Steps for Stroke Workup and Admission

Urgent neurological evaluation and brain imaging within 30 minutes of hospital admission are the essential first steps in stroke workup to distinguish between ischemic and hemorrhagic stroke and determine appropriate treatment pathways. 1

Immediate Assessment and Stabilization

• Ensure access to neurological expertise within 30 minutes of hospital admission on a 24/7 basis, provided by a neurologist or internist experienced in stroke medicine 1
• Monitor and stabilize vital functions (airway, breathing, circulation) as the first priority 2
• Perform clinical evaluation using a standardized neurological impairment scale, preferably the National Institutes of Health Stroke Scale (NIHSS), to determine stroke severity and monitor for changes 1, 3
• Determine exact time of symptom onset, which is crucial for deciding eligibility for reperfusion therapies 2

Essential Diagnostic Imaging

• Perform brain CT scan or MRI within 30 minutes of hospital admission to differentiate between ischemic stroke, hemorrhagic stroke, and stroke mimics 1
• Consider a one-stop diagnostic approach including CT perfusion scan and contrast-based CT angiography of cervical arteries when appropriate 1
• For patients with cerebellar symptoms, perform a HINTS (head-impulse, nystagmus, test of skew) examination, which is more sensitive for cerebellar stroke than early MRI 3
• If subarachnoid hemorrhage is suspected (particularly with sudden severe headache) but initial imaging is negative, consider lumbar puncture 3

Immediate Laboratory Tests

• For potential thrombolysis candidates, obtain 24/7 laboratory results within 20 minutes, including platelet count, prothrombin time, and international normalized ratio 1
• Check blood glucose immediately to rule out hypoglycemia, which can mimic stroke symptoms 3
• Consider specialized biomarker testing if available, though this is still emerging and not yet standard practice 4, 5

Cardiac Assessment

• Perform initial 12-lead ECG as soon as possible without delaying acute stroke treatment 1
• Initiate continuous cardiac monitoring for at least the first 24 hours to detect arrhythmias, especially atrial fibrillation 1, 2

Admission to Stroke Unit

• Admit patients to a dedicated stroke unit with monitored beds for at least the first 24 hours (except for stroke mimics) 1
• One monitored bed is recommended per 100 stroke patients per year, with an average monitoring phase of 72 hours 1
• Ensure the stroke unit has both acute monitored beds and post-acute step-down beds managed by the same multiprofessional team 1

Ongoing Monitoring and Care

• Monitor vital signs and neurological status frequently to detect changes in the patient's condition 1
• Monitor temperature every 4 hours for the first 48 hours; for temperature >37.5°C, increase monitoring frequency and investigate possible infections 1
• Implement venous thromboembolism prophylaxis with intermittent pneumatic compression devices within the first 24 hours after admission for immobile patients 1
• Begin frequent, brief, out-of-bed activity within 24 hours of stroke onset if there are no contraindications 1

Seizure Management

• Treat new-onset seizures that are not self-limiting with appropriate short-acting medications (e.g., lorazepam IV) 1
• A single, self-limiting seizure within 24 hours after ischemic stroke should not be treated with long-term anticonvulsants 1
• Monitor for recurrent seizure activity during routine monitoring of vital signs and neurological status 1

Common Pitfalls to Avoid

• Delaying brain imaging beyond 30 minutes can significantly worsen neurological prognosis, as a delay of just 15 minutes can impact outcomes 6, 7
• Failing to determine the exact time of symptom onset may exclude patients from potentially beneficial reperfusion therapies 2, 3
• Mixing stroke patients with patients experiencing other neurological disorders can compromise the dedicated multiprofessional approach that improves outcomes 1
• Neglecting early mobilization and adequate hydration increases the risk of venous thromboembolism 1