Do CT (Computed Tomography) and echo (echocardiogram) need to be done in all patients with stroke?

CT and Echocardiography in Stroke Patients

All patients with suspected acute stroke must undergo immediate non-contrast brain CT imaging, while echocardiography should be performed selectively in patients where a cardiac cause of stroke is suspected, rather than routinely in all stroke patients. 1, 2

Brain Imaging Requirements

CT Imaging - Essential for All Stroke Patients

• All patients with suspected acute stroke must undergo immediate non-contrast brain CT imaging to distinguish between ischemic and hemorrhagic stroke, which is crucial for treatment decisions 1, 2
• Non-contrast CT should be performed within 30 minutes of hospital admission to guide hyperacute care 1, 3
• CT angiography (CTA) including extracranial and intracranial arteries should be performed alongside non-contrast CT to identify large vessel occlusions and guide treatment decisions 1, 2
• Advanced CT imaging including CT perfusion (to assess cerebral blood flow) should be considered for patients eligible for acute stroke treatments, but must not delay thrombolytic therapy 1, 4

MRI - Alternative or Supplementary Option

• MRI with diffusion-weighted imaging is more sensitive than CT for early detection of ischemic changes but should not delay treatment if not immediately available 2, 5
• Additional MRI may be considered after initial CT imaging but must not delay decision-making and treatment with thrombolysis or endovascular therapy 1, 5

Cardiac Assessment in Stroke Patients

ECG - Required for All Stroke Patients

• All patients with suspected TIA or ischemic stroke should undergo an ECG to assess baseline cardiac rhythm and provide information regarding evidence of structural heart disease 1
• ECG should not delay assessment for thrombolysis and can be deferred until after acute treatment decisions are made 1

Echocardiography - Selective Use

• Echocardiography should be performed selectively, not routinely in all stroke patients 1
• Indications for echocardiography include:
  • When a cardiac cause of stroke is suspected 1
  • In young adults and children who present with stroke 1
  • When infectious endocarditis is suspected 1
  • In patients with cryptogenic stroke to evaluate for possible cardiac sources of or transcardiac pathways for cerebral embolism 1

Type of Echocardiography

• Transthoracic echocardiography (TTE) is the initial cardiac imaging modality of choice 1
• Transesophageal echocardiography (TEE), cardiac CT, or cardiac MRI might be reasonable in patients with embolic stroke of undetermined source (ESUS) to identify possible cardioaortic sources or transcardiac pathways for cerebral embolism 1

Clinical Implications and Pitfalls

Timing Considerations

• Brain imaging must be prioritized and performed rapidly to guide time-sensitive treatment decisions 2, 6
• Delaying treatment for advanced imaging must be balanced against the time-sensitive nature of reperfusion therapies 2
• Echocardiography should not delay acute stroke management and can typically be performed after initial stabilization and treatment 1

Common Pitfalls to Avoid

• Focusing solely on non-contrast CT without vascular imaging may miss large vessel occlusions requiring endovascular therapy 2, 6
• Performing echocardiography in all stroke patients without clinical indications of cardiac etiology is not supported by evidence and may delay other critical aspects of care 1
• Delaying thrombolytic therapy to obtain multimodal imaging studies beyond basic CT is not recommended 1

By following this evidence-based approach, clinicians can ensure appropriate diagnostic evaluation while maintaining focus on time-critical interventions that impact morbidity and mortality in acute stroke patients.