What is the recommended workup for a patient presenting with a stroke?

Recommended Stroke Workup

All patients presenting with suspected acute stroke require immediate brain imaging (CT or MRI) to differentiate hemorrhagic from ischemic stroke, followed by vascular imaging of the head and neck, cardiac evaluation with ECG and monitoring, and laboratory investigations to determine stroke mechanism and guide treatment decisions. 1, 2

Immediate Diagnostic Imaging

Brain Imaging (First Priority)

• Noncontrast CT or MRI must be performed immediately to exclude intracranial hemorrhage and assess extent of ischemic changes 1, 2
• CT is typically faster and more widely available for initial assessment 1
• MRI with diffusion-weighted imaging (DWI), FLAIR, and gradient-recalled echo (GRE) or susceptibility-weighted imaging (SWI) is preferred when available 24/7 and can be completed rapidly 1

Vascular Imaging (Concurrent with Brain Imaging)

• CT angiography (CTA) from aortic arch to vertex should be performed at the time of initial brain CT to evaluate both extracranial and intracranial circulation 2
• This identifies large vessel occlusions for potential endovascular therapy and assesses carotid atherosclerotic disease 1
• Alternative modalities include MR angiography (MRA), duplex ultrasound, or digital subtraction angiography 1
• Concordant results from at least two noninvasive imaging techniques can determine treatment eligibility for revascularization procedures 1

Laboratory Investigations

Essential Blood Work

• Complete blood count (CBC) 1, 2
• Electrolytes and glucose 1, 2
• Coagulation studies: INR and aPTT 1, 2
• Renal function: creatinine and eGFR 1, 2
• Troponin 1, 2

These tests should not delay imaging or treatment decisions but are necessary for determining eligibility for thrombolytic therapy 1

Cardiac Evaluation

Electrocardiogram

• 12-lead ECG should be completed to identify atrial fibrillation, acute coronary syndrome, or other cardiac abnormalities 1, 2
• Unless the patient is hemodynamically unstable, ECG should not delay assessment for thrombolysis and endovascular therapy 1

Extended Cardiac Monitoring

• ECG monitoring for >24 hours is recommended for patients with suspected embolic stroke to detect paroxysmal atrial fibrillation 1
• Prolonged monitoring or implantable loop recorders may be considered in cryptogenic stroke 3

Echocardiography

• Echocardiography should be performed for patients with suspected cardiac source of embolism 1
• This includes evaluation for intracardiac thrombus, valvular disease, patent foramen ovale, and other structural abnormalities 1

Additional Assessments

Clinical Evaluation

• Stroke severity must be assessed using a validated scale such as the National Institutes of Health Stroke Scale (NIHSS) or Canadian Neurological Scale (CNS) 1, 2
• Vital signs including heart rate and rhythm, blood pressure, temperature, oxygen saturation, and hydration status 1, 2
• Time of symptom onset (last known well) is crucial for determining treatment eligibility 2

Swallowing Screen

• Swallowing screening using a validated tool should be completed within 24 hours by a trained practitioner 1, 2
• Patients remain NPO until screening is completed 1
• This should not delay acute stroke treatment decisions 1

Chest X-ray

• Indicated when evidence of acute heart disease or pulmonary disease exists 1
• Can be deferred until after acute treatment decisions unless patient is hemodynamically unstable 1

Timing-Based Approach

For Patients Within Treatment Window (0-4.5 hours for IV tPA)

• Prioritize noncontrast CT or MRI to exclude hemorrhage 1
• Concurrent CTA if endovascular therapy is being considered 1, 2
• Laboratory work should not delay treatment but must include coagulation studies 1

For Patients Beyond Acute Treatment Window (>4.5 hours)

• Emphasis shifts to secondary prevention workup 1
• Focus on vascular imaging (CTA, MRA, or duplex ultrasound) to assess carotid arteries 1
• Echocardiography to assess for cardiac sources 1
• Extended cardiac monitoring to detect paroxysmal atrial fibrillation 1

Etiologic Workup for Cryptogenic Stroke

When standard workup fails to identify a clear cause:

• Ensure completion of routine investigations: brain imaging, noninvasive vascular imaging, 12-lead ECG, extended cardiac monitoring (>24 hours), echocardiography, and routine blood tests 1
• Consider investigations for rarer causes including vasculitis, hypercoagulable states, and arterial dissection based on clinical suspicion 1
• Patent foramen ovale evaluation in appropriate candidates 3

Common Pitfalls to Avoid

• Do not delay brain imaging for laboratory results unless patient is hemodynamically unstable 1
• Do not discharge patients from the emergency department without diagnostic evaluation, consideration of functional impairments, initiation of secondary prevention, and a plan for ongoing management 1
• Do not rely on gag reflex alone to assess aspiration risk; formal swallowing screening is required 1
• Do not assume normal early MRI excludes cerebellar stroke; HINTS examination (head-impulse, nystagmus, test of skew) is more sensitive for cerebellar stroke than early MRI 4