What is the initial workup and management for a young adult who has experienced a stroke?

Initial Workup and Management for Young Adults with Stroke

The initial workup for a young adult with stroke should follow an organized protocol with the goal to complete evaluation and treatment decisions within 60 minutes of arrival at the emergency department, including immediate brain imaging, limited laboratory tests, and cardiac assessment. 1

Immediate Assessment and Stabilization

• Ensure ABCs (airway, breathing, circulation) are stabilized while simultaneously beginning the stroke evaluation protocol 1
• Determine the exact time of symptom onset, which is crucial for treatment decisions - defined as when the patient was last known to be at their baseline or symptom-free 1
• Use a validated stroke rating scale, preferably the National Institutes of Health Stroke Scale (NIHSS), to assess stroke severity and guide treatment decisions 1
• Designate an acute stroke team including physicians, nurses, and laboratory/radiology personnel to expedite evaluation 1

Essential Diagnostic Imaging

• Perform non-contrast CT scan of the brain within 25 minutes of arrival to exclude hemorrhage and identify early signs of ischemia 1
• For patients who are candidates for thrombolytic therapy, aim for CT interpretation within 45 minutes of arrival (door-to-interpretation time) 1
• Consider multimodal imaging approaches including CT perfusion and CT angiography in selected cases to evaluate cerebral blood flow and vessel status 1
• MRI with diffusion-weighted imaging may provide more sensitive detection of acute ischemia and help with prognostication 1

Laboratory Evaluation

• Obtain a limited set of essential laboratory tests during initial emergency evaluation 1:
  • Complete blood count
  • Blood glucose
  • Electrolytes
  • Renal function tests
  • Coagulation studies (PT/INR, aPTT)
• Additional tests to consider in young adults 2:
  • Lipid panel
  • Hemoglobin A1c
  • Thyroid function tests
  • Inflammatory markers (ESR, CRP)
  • Syphilis testing (RPR)
  • HIV testing
  • Toxicology screen
  • Pregnancy test (when appropriate)

Cardiac Assessment

• Perform a 12-lead ECG due to the high incidence of heart disease in stroke patients 1
• Initiate continuous cardiac monitoring for at least 24 hours to detect arrhythmias, especially atrial fibrillation 3
• Obtain a transthoracic echocardiogram with bubble study to evaluate for cardiac sources of embolism, which are common causes of stroke in young adults 2

Vascular Imaging

• Perform imaging of the neck and cerebral vasculature (CTA or MRA) to evaluate for arterial dissection, atherosclerosis, and other vascular abnormalities 2
• Consider conventional angiography in selected cases where other imaging is inconclusive 2

Etiologic Considerations in Young Adults

• Evaluate for unique causes of stroke in young adults 2, 4:
  • Arterial dissection (carotid or vertebral)
  • Cardioembolism (including patent foramen ovale)
  • Hypercoagulable states
  • Vasculopathies
  • Substance abuse
  • Genetic conditions
  • Inflammatory/autoimmune disorders

Acute Management

• For eligible patients with ischemic stroke, administer intravenous recombinant tissue plasminogen activator (rtPA) within 3-4.5 hours of symptom onset 5
• Consider endovascular thrombectomy for patients with large vessel occlusion 2
• Control blood pressure carefully, especially in patients receiving thrombolytic therapy 5
• Monitor neurological status frequently to detect early deterioration 3
• Treat fever aggressively as it can worsen neurological damage 5
• Begin venous thromboembolism prophylaxis with intermittent pneumatic compression devices within 24 hours for immobile patients 3

Hospital Admission and Ongoing Care

• Admit patients to a dedicated stroke unit with monitored beds for at least the first 24 hours 3
• Assess swallowing function before initiating oral intake to prevent aspiration 1
• Begin early mobilization within 24 hours if there are no contraindications 3
• Monitor for and manage complications including seizures, which may occur in the acute phase 3

Common Pitfalls in Young Adult Stroke Management

• Delayed diagnosis due to failure to recognize stroke symptoms in young patients - maintain high suspicion even in younger individuals 4
• Incomplete workup - young adults require a more extensive evaluation for uncommon etiologies 2
• Overlooking substance abuse as a potential cause - toxicology screening is important 2
• Failure to identify arterial dissection, which is a more common cause in young adults than in older populations 2, 6
• Missing cardiac sources of embolism by not performing adequate cardiac imaging 2

Following this systematic approach to the workup and management of stroke in young adults will help ensure timely diagnosis, appropriate treatment, and improved outcomes in this population.