What is the initial workup for a hospital-based Cerebrovascular Accident (CVA)?

Initial Hospital-Based Workup for Cerebrovascular Accident (CVA)

For patients presenting with suspected acute stroke, immediate non-contrast CT of the head followed by CT angiography from aortic arch to vertex should be performed within 25 minutes of arrival to guide time-critical treatment decisions. 1

Immediate Assessment and Imaging

• Non-contrast CT of the head is essential in the initial evaluation to exclude intracranial hemorrhage (ICH) and other potential etiologies before administering IV thrombolytic therapy or initiating endovascular treatment (EVT) 1

• CT angiography (CTA) of the head and neck from aortic arch to vertex should be performed at the time of initial brain CT to rapidly assess for large vessel occlusion (LVO) and guide decisions about mechanical thrombectomy 1

• For patients presenting within the 6-hour window of symptom onset, CTA should be obtained without delay as the presence of LVO requires urgent intervention 1

• MRI with diffusion-weighted imaging (DWI) is an alternative to CT for initial assessment if immediately available, offering higher sensitivity for detecting acute ischemic changes 1, 2

Clinical Assessment and Monitoring

• Stroke severity should be assessed using the National Institutes of Health Stroke Scale (NIHSS) on arrival and before and after treatment with recombinant tissue plasminogen activator (r-tPA) 1

• Vital signs should be monitored closely, with temperature checks every 4 hours for the first 48 hours (temperature >37.5°C requires investigation for possible infection) 1

• Patients should be assigned a high-severity triage category to be seen within 10 minutes of emergency department arrival using a standardized triage system 1

Laboratory Investigations

• Initial bloodwork should include complete blood count, electrolytes, coagulation studies (aPTT, INR), renal function (creatinine, eGFR), random glucose or hemoglobin A1c, and troponin 1

• For patients over 50 years with symptoms suggestive of giant cell arteritis (headaches, scalp tenderness, jaw claudication), immediate erythrocyte sedimentation rate, C-reactive protein, and complete blood count with platelets should be obtained 1

• Subsequent laboratory tests should include lipid profile (fasting or non-fasting) and screening for diabetes with either glycated hemoglobin (HbA1c) or oral glucose tolerance test 1

Cardiac Evaluation

• All patients should have a 12-lead ECG to assess cardiac rhythm and identify atrial fibrillation/flutter or evidence of structural heart disease 1

• ECG monitoring for more than 24 hours is recommended as part of the initial stroke workup to detect paroxysmal atrial fibrillation 1

Extended Time Window Considerations

• For patients presenting between 6-24 hours after symptom onset with confirmed LVO, CT perfusion (CTP) or MR perfusion imaging may be required to determine eligibility for extended window EVT 1

• In the absence of thrombolytic eligibility or LVO, the workup becomes less time-critical and more focused on treatment of complications, rehabilitation, and secondary prevention 1

Venous Thromboembolism Prevention

• Early assessment for venous thromboembolism risk should be conducted, with consideration of low-molecular-weight heparin (enoxaparin) for high-risk patients 1

• Early mobilization and adequate hydration should be encouraged for all acute stroke patients to help prevent venous thromboembolism 1

Seizure Management

• New-onset seizures should be treated using appropriate short-acting medications (e.g., lorazepam IV) if they are not self-limiting 1

• A single, self-limiting seizure occurring at onset or within 24 hours after ischemic stroke should not be treated with long-term anticonvulsant medications 1

Rehabilitation Assessment

• Initial assessment by rehabilitation professionals should be conducted as soon as possible after admission and within 48 hours 1

• Rehabilitation therapy should begin as early as possible once the patient is medically stable enough to participate 1

Risk Stratification for Further Evaluation

• Patients with transient ischemic attack (TIA) or non-disabling stroke with unilateral motor weakness or speech disturbance should be considered at high risk for recurrent stroke and receive comprehensive evaluation within 24 hours 1

• For patients presenting between 48 hours and 2 weeks with symptoms without motor weakness or speech disturbance, evaluation should be completed within 2 weeks 1

• Patients presenting more than 2 weeks after symptom onset should be seen by a neurologist or stroke specialist within one month 1