What is the appropriate diagnosis and management plan for a patient with a cerebral vascular accident (CVA) or stroke?

Stroke (CVA) Case Presentation Guide

Initial Emergency Assessment & Imaging

For any patient presenting with acute stroke symptoms, immediately obtain non-contrast CT head followed by CT angiography from aortic arch to vertex within 25 minutes of arrival 1, 2. This rapid imaging protocol is critical for three purposes: excluding hemorrhage before thrombolysis, identifying large vessel occlusion for thrombectomy, and determining stroke distribution 1.

Immediate Clinical Evaluation

• Assess stroke severity using the NIH Stroke Scale on arrival and document exact time of symptom onset or last known normal 2
• Assign high-severity triage to be evaluated within 10 minutes of ED arrival 2
• Obtain vital signs immediately, with particular attention to blood pressure (target <185/110 mmHg if thrombolysis candidate) and temperature monitoring every 4 hours for 48 hours 2

Critical History Points

• Time of symptom onset or last known normal (determines treatment eligibility) 1
• Specific neurological deficits: unilateral weakness (face/arm/leg), speech/language disturbance, visual changes, sensory symptoms, ataxia 1
• Stroke risk factors: hypertension, diabetes, hypercholesterolemia, atrial fibrillation, prior stroke/TIA 1
• Current medications, especially anticoagulants, antiplatelets, or cancer therapies (bevacizumab, sorafenib, carfilzomib increase CVA risk) 3

Diagnostic Imaging Protocol

Acute Presentation (<6 hours)

Non-contrast CT head is the first-line imaging to exclude hemorrhage and assess for early ischemic changes 1, 2. The ACR rates this as "usually appropriate" (rating 8/9) 1.

CT angiography head and neck (aortic arch to vertex) should be performed immediately after non-contrast CT to identify large vessel occlusion requiring mechanical thrombectomy 1. This is rated "usually appropriate" (8/9) by the ACR 1.

• CTA identifies candidates for endovascular intervention and provides complete vascular assessment in a single study 1
• MRI with diffusion-weighted imaging is an alternative if immediately available, offering higher sensitivity for acute ischemia 1, 2

Extended Window (6-24 hours)

For patients presenting 6-24 hours after onset with suspected large vessel occlusion, add CT perfusion or MR perfusion to determine salvageable tissue and eligibility for extended-window thrombectomy 1, 2.

Subacute/Chronic Presentation

MRI head without contrast is preferred for patients presenting >6 hours or with resolved symptoms (TIA), as it is more sensitive than CT for detecting acute infarcts 1.

MRA head and neck (with or without contrast) should accompany MRI to assess vascular anatomy and identify stenosis 1.

Laboratory Investigations

Immediate Bloodwork (All Patients)

• Complete blood count (assess for thrombocytopenia, polycythemia) 1, 2
• Coagulation studies (aPTT, INR) - critical before thrombolysis 1, 2
• Electrolytes and renal function (creatinine, eGFR) - needed for contrast studies 1, 2
• Random glucose or HbA1c - hyperglycemia worsens stroke outcomes 1, 2
• Troponin - cardiac ischemia can coexist with stroke 1, 2

Subsequent Testing

• Lipid profile (fasting or non-fasting) for secondary prevention 1
• ESR, CRP, and CBC with platelets if patient >50 years with symptoms suggesting giant cell arteritis 2

Cardiac Evaluation

12-lead ECG is mandatory to identify atrial fibrillation/flutter and structural heart disease 1, 2.

Continuous cardiac monitoring for >24 hours is recommended to detect paroxysmal atrial fibrillation 1, 2.

Risk Stratification for TIA/Minor Stroke

High Risk (Requires evaluation within 24 hours)

Patients with unilateral motor weakness (face/arm/leg) OR speech/language disturbance presenting within 48 hours are at highest risk for recurrent stroke (8.8% at 7 days) 1, 2.

Moderate Risk (Evaluation within 2 weeks)

Patients presenting 48 hours to 2 weeks with sensory symptoms, monocular vision loss, diplopia, dysarthria, dysphagia, or ataxia without motor/speech deficits 1.

Lower Risk (Evaluation within 1 month)

Patients presenting >2 weeks after symptom onset should see a neurologist within one month 1.

Acute Management Considerations

Ischemic Stroke

For progressive ischemic CVA, DOACs (rivaroxaban or dabigatran) are preferred over standard anticoagulants (LMWH, UFH, warfarin) due to better thrombus resolution and reduced recurrence 3.

Withhold immune checkpoint inhibitors in cancer patients with stroke, as these can exacerbate neurological symptoms 3.

Hemorrhagic Stroke

Non-contrast CT immediately identifies intracerebral hemorrhage (10% of strokes) and guides reversal of coagulopathy 1.

Common Pitfalls to Avoid

• Do not delay imaging for detailed history - the 25-minute door-to-imaging target is critical 1, 2
• Do not assume symptom resolution means no stroke - TIA patients have 11.6% stroke risk at 90 days and require urgent workup 1
• Do not overlook atrial fibrillation - extended cardiac monitoring beyond initial ECG is essential 1, 2
• Do not miss large vessel occlusion - CTA should be performed routinely, not selectively, as mechanical thrombectomy eligibility now extends to 24 hours 1, 4
• Do not forget vascular imaging - both parenchymal AND vascular imaging are needed for complete assessment 1

Early Rehabilitation Assessment

Rehabilitation professionals should assess patients within 48 hours of admission and begin therapy as soon as medically stable 2.

Cognitive assessment should screen for aphasia, apraxia, memory deficits, executive dysfunction, and visual-spatial deficits 3.