What is the initial workup and management for a patient presenting with stroke-like symptoms in the hospital?

Initial Workup and Management for Stroke-Like Symptoms in Hospital

The initial workup for patients presenting with stroke-like symptoms must include rapid assessment of airway, breathing, and circulation, followed by immediate neurological examination using a standardized stroke scale (NIHSS or CNS), and urgent brain imaging to differentiate between ischemic and hemorrhagic stroke within minutes of patient arrival. 1, 2

Immediate Assessment (First 5-10 Minutes)

• Rapid evaluation of airway, breathing, and circulation (ABCs) should be performed immediately upon patient presentation 1, 2
• Assess stroke severity using a validated stroke scale such as the National Institutes of Health Stroke Scale (NIHSS) or Canadian Neurological Scale (CNS) 1, 2
• Determine time of symptom onset (when patient was last known to be at baseline) - this is critical for treatment eligibility 2
• Assess vital signs including heart rate and rhythm, blood pressure, temperature, oxygen saturation, hydration status, and presence of seizure activity 1, 2

Urgent Diagnostic Workup (First 15-30 Minutes)

• Immediate brain imaging (CT or MRI) must be performed to differentiate between ischemic and hemorrhagic stroke 2, 3
• 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 2
• Initial blood work should include:
  • Electrolytes, glucose, complete blood count (CBC)
  • Coagulation studies (INR, aPTT)
  • Renal function (creatinine, eGFR)
  • Troponin 1, 2
• ECG should be completed but should not delay assessment for thrombolysis and endovascular therapy 1
• Chest X-ray should only be performed when the patient has evidence of acute heart or pulmonary disease and should not delay acute treatment decisions 1

Acute Treatment Decisions (Within 60 Minutes of Arrival)

• For ischemic stroke within 3-4.5 hours of symptom onset, intravenous tissue plasminogen activator (tPA) at 0.9 mg/kg (maximum 90 mg) should be administered to eligible patients 2, 3
• Blood pressure must be below 185/110 mmHg before thrombolytic therapy 2
• For patients not receiving thrombolysis, blood pressure should only be lowered if systolic BP exceeds 220 mmHg or diastolic exceeds 120 mmHg 2, 4
• Patients with large vessel occlusions presenting within 24 hours of symptom onset should be evaluated for endovascular intervention 3

Early Management (First 24-48 Hours)

• Swallowing screening should be completed as early as possible by a trained practitioner using a validated tool to prevent aspiration 1, 2, 4
• Temperature should be monitored every 4 hours for the first 48 hours, with temperature-reducing measures initiated if temperature exceeds 37.5°C 1, 2
• New-onset seizures should be treated with appropriate short-acting medications (e.g., lorazepam IV) if not self-limiting 1, 2
• Early mobilization with frequent, brief, out-of-bed activity involving active sitting, standing, and walking should begin within 24 hours if there are no contraindications 1

Prevention of Complications

• Venous thromboembolism prophylaxis:
  • Intermittent pneumatic compression (IPC) devices should be applied to both legs as soon as possible after admission 1
  • Low-molecular-weight heparin should be considered for patients at high risk of venous thromboembolism 1
  • Early mobilization and adequate hydration should be encouraged 1
• Anti-embolism stockings alone are not recommended for post-stroke venous thromboembolism prophylaxis 1, 2

Special Considerations for In-Hospital Stroke

• In-hospital strokes often have delayed evaluation and treatment compared to patients presenting to the emergency department, contributing to higher morbidity and mortality 1
• Hospital systems should establish:
  • Stroke training for all hospital staff, including how to activate in-hospital stroke alerts
  • Rapid response teams with dedicated stroke training and immediate access to neurological expertise
  • Standardized evaluation protocols for potential in-hospital stroke 1

Common Pitfalls to Avoid

• Delaying brain imaging - this should be prioritized immediately upon recognition of stroke symptoms 1, 2
• Waiting for blood test results before initiating treatment - thrombolysis decisions should not be delayed 1
• Missing stroke in patients with "nontraditional" symptoms (e.g., generalized weakness, altered mental status, altered gait, dizziness) - these patients are more likely to have delayed diagnosis 5
• Overlooking cerebellar strokes - patients with cerebellar symptoms should receive a HINTS examination (head-impulse, nystagmus, test of skew) as it is more sensitive than early MRI 3
• Failing to establish the time of symptom onset, which is crucial for determining treatment eligibility 2, 6