What is the recommended workup for a stroke?

Stroke Workup

All patients with suspected acute stroke require immediate brain imaging (CT or MRI), rapid clinical assessment with a standardized stroke scale (NIHSS), and essential blood work—all completed within 48 hours of symptom onset to establish diagnosis, rule out mimics, and determine treatment eligibility. 1, 2

Immediate Clinical Assessment

Perform rapid ABC evaluation first (airway, breathing, circulation), followed immediately by neurological examination using the National Institutes of Health Stroke Scale (NIHSS) to quantify stroke severity and monitor for clinical changes. 1, 2

Vital signs monitoring must include:

• Heart rate and cardiac rhythm 1
• Blood pressure measurement 1, 2
• Temperature 1, 2
• Oxygen saturation 1
• Hydration status 1
• Seizure activity assessment 1

Establish the exact time of symptom onset (defined as when patient was last at baseline) to determine eligibility for thrombolytic therapy and endovascular treatment. 2

Essential Imaging Studies

Brain imaging with non-contrast CT or MRI must be performed immediately to differentiate ischemic from hemorrhagic stroke and rule out stroke mimics. 1, 2 This is the single most critical diagnostic test and should not be delayed.

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, particularly in patients presenting within 4.5 hours who may be candidates for acute interventions. 1, 2

Noninvasive cervical carotid imaging (carotid ultrasound, CTA, or MRA) is required in patients with symptomatic anterior circulation stroke or TIA who are candidates for revascularization to screen for stenosis. 1

Required Laboratory Tests

Initial blood work must include: 1, 2

• Complete blood count (CBC)
• Electrolytes
• Random or fasting glucose
• HbA1c 1
• Coagulation studies (INR, aPTT)
• Creatinine and eGFR 1
• Troponin 1
• Fasting or non-fasting lipid profile 1

Critical timing consideration: These tests should not delay imaging or treatment decisions for intravenous thrombolysis and endovascular therapy. 1 For patients eligible for thrombolysis, laboratory results must be available within 20 minutes of blood sampling. 1

Cardiac Evaluation

12-lead electrocardiogram (ECG) is required to screen for atrial fibrillation, atrial flutter, and other cardiac conditions. 1 Unless the patient is hemodynamically unstable, ECG should not delay assessment for thrombolysis and can be deferred until after acute treatment decisions. 1

Cardiac monitoring recommendations: 1

• At least 24 hours of cardiac monitoring for all patients
• Extended monitoring (at least 14 days) for patients with embolic stroke without identified atrial fibrillation on initial ECG

Echocardiography (transthoracic or transesophageal) is reasonable in patients with cryptogenic stroke to evaluate for cardiac sources of embolism or transcardiac pathways. 1

Chest X-ray should be completed when evidence of acute heart disease or pulmonary disease exists, but can be deferred until after acute treatment decisions. 1

Swallowing Assessment

Swallowing screen using a validated tool must be completed as early as possible (ideally within 24 hours) by a trained practitioner, though it should not delay acute stroke treatment decisions. 1, 2 Patients remain NPO until screening is completed and found normal. 1

Additional Diagnostic Considerations

For cryptogenic stroke, consider: 1

• Long-term rhythm monitoring (mobile cardiac outpatient telemetry, implantable loop recorder) to detect intermittent atrial fibrillation
• Tests for hypercoagulable states, infections causing CNS vasculitis (HIV, syphilis), drug use (cocaine, amphetamines), and markers of systemic inflammation as clinically indicated

Intracranial vascular imaging (MRA or CTA) can identify atherosclerotic disease, dissection, moyamoya, or other vasculopathies. 1

Critical Timing Targets

The door-to-needle time for thrombolysis should be ≤60 minutes, with an ambitious target of ≤30 minutes. 1 The diagnostic evaluation should be completed or underway within 48 hours of symptom onset. 1

Common Pitfalls to Avoid

Do not discharge patients from the emergency department without completing diagnostic evaluations, assessing functional impairments, initiating secondary prevention therapies, and establishing a plan for ongoing management. 1

Do not administer oral medications until swallowing screen is completed and found normal; use alternative routes (intravenous, rectal) while patient is NPO. 1

Do not use prophylactic anticonvulsants in acute stroke patients, as there is no supporting evidence and potential harm to neural recovery. 1, 2