What is the initial evaluation and management for a young patient with a suspected stroke?

Initial Evaluation and Management of Young Stroke Patients

Young patients with suspected stroke require the same immediate, time-critical evaluation as all stroke patients, with rapid assessment of ABCs, neurological examination using NIHSS, and emergent brain imaging to determine eligibility for thrombolytic therapy within 60 minutes of arrival—but the subsequent etiologic workup must be more extensive to identify the broader spectrum of stroke causes unique to younger populations. 1, 2

Immediate Emergency Department Evaluation

Primary Assessment (First 10-25 Minutes)

Triage young stroke patients with the same priority as acute myocardial infarction or major trauma, regardless of deficit severity. 1

• Stabilize airway, breathing, and circulation immediately upon arrival 1, 3
• Establish precise time of symptom onset—defined as when the patient was last at baseline or symptom-free state; for wake-up strokes, this is when they were last known to be normal 1
• Perform neurological examination using a standardized stroke scale (NIHSS preferred) to assess severity and guide treatment decisions 1, 3

Vital Signs and Clinical Monitoring

• Assess heart rate and rhythm, blood pressure, temperature, oxygen saturation, hydration status, and seizure activity 1, 3
• Monitor blood pressure carefully: For thrombolysis candidates, BP must be <185/110 mmHg; for non-candidates, only lower BP if systolic >220 mmHg or diastolic >120 mmHg 1, 3

Immediate Laboratory Studies

Order these tests immediately but do not delay imaging or treatment decisions while awaiting results (unless clinically indicated, such as INR for warfarin patients): 1

• Complete blood count (CBC)
• Electrolytes and random glucose
• Coagulation studies (INR, aPTT)
• Creatinine and estimated glomerular filtration rate (eGFR)
• Troponin 1, 3

The critical caveat: Awaiting renal function results should not delay CT angiography in most patients with disabling symptoms—"neurons over nephrons" principle applies 1

Emergent Neuroimaging (Goal: Within 25 Minutes)

Obtain non-contrast CT brain immediately to exclude hemorrhage and assess for early ischemic changes. 1, 3

Perform CT angiography from aortic arch to vertex at the time of initial brain CT to evaluate both extracranial and intracranial circulation, particularly important for identifying large vessel occlusions amenable to endovascular therapy 3

Additional Initial Studies

• Electrocardiogram should be completed but should not delay thrombolysis assessment unless the patient is hemodynamically unstable 1
• Chest X-ray is only indicated if there is evidence of acute cardiac or pulmonary disease and should not delay acute treatment decisions 1

Stroke Mimics to Exclude

Young patients presenting with stroke-like symptoms require careful consideration of mimics: 1

• Seizures: Look for witnessed seizure activity, postictal period, or seizure history
• Hypoglycemia: Check glucose immediately in diabetic patients
• Complicated migraine: History of similar events with preceding aura
• Psychogenic: Inconsistent examination, non-vascular distribution of findings
• Drug toxicity: Consider lithium, phenytoin, carbamazepine 1

Acute Treatment Decisions

Administer IV tissue plasminogen activator (tPA) 0.9 mg/kg (maximum 90 mg) to eligible patients within 3-4.5 hours of symptom onset, with strict adherence to inclusion/exclusion criteria 3

For patients with large vessel occlusion on CTA, consider endovascular therapy in addition to or instead of IV thrombolysis based on time window and patient selection criteria 3

Seizure Management in Young Stroke Patients

• Treat new-onset seizures at stroke onset or within 24 hours with short-acting medications (e.g., lorazepam IV) if not self-limiting 1, 3
• Do not use prophylactic anticonvulsants for single, self-limited immediate post-stroke seizures 1, 3
• Monitor for recurrent seizure activity during routine vital sign checks; treat recurrent seizures as per standard seizure protocols 1

Special Considerations for Young Stroke Patients

The etiologic evaluation in young patients must be more comprehensive than in older adults because the differential diagnosis is substantially broader: 4, 2

• Arterial dissection (particularly extracranial carotid/vertebral)
• Cardiac sources: Patent foramen ovale, atrial septal defect, endocarditis
• Hypercoagulable states: Antiphospholipid syndrome, protein C/S deficiency, Factor V Leiden
• Vasculitis and inflammatory conditions
• Drug abuse (particularly cocaine, amphetamines)
• Pregnancy-related complications
• Genetic conditions: CADASIL, Fabry disease, mitochondrial disorders 4, 2, 5

This expanded workup typically occurs after acute stabilization and treatment decisions, but historical clues (drug use, recent trauma, family history, pregnancy) should be actively sought during initial evaluation 1, 2

Early Complication Prevention

• Complete swallowing screening within 24 hours using a validated tool to prevent aspiration 3
• Monitor temperature every 4 hours for 48 hours; initiate cooling measures if temperature exceeds 37.5°C 3
• Encourage early mobilization and adequate hydration to prevent venous thromboembolism 3
• Consider pharmacological VTE prophylaxis (low-molecular-weight heparin) for high-risk patients rather than anti-embolism stockings alone 3