What are the steps for diagnosing and treating a stroke?

Acute Stroke Diagnosis and Treatment

All patients with suspected stroke require immediate brain imaging with non-contrast CT to exclude hemorrhage, followed by rapid assessment for thrombolytic therapy eligibility if ischemic stroke is confirmed within 4.5 hours of symptom onset. 1, 2

Immediate Emergency Department Evaluation

Triage and Initial Stabilization

• Triage stroke patients with the same priority as acute myocardial infarction or major trauma, regardless of deficit severity 1, 3
• Assess airway, breathing, and circulation immediately upon arrival 1, 3
• Establish precise time of last known well (when patient was last at baseline or symptom-free); for wake-up strokes, this is when they were last known normal 2, 3

Neurological Assessment

• Perform neurological examination using the National Institutes of Health Stroke Scale (NIHSS) to assess severity and guide treatment decisions 1, 2
• Document focal neurological deficits systematically 1

Vital Signs Monitoring

• Assess heart rate and rhythm, blood pressure, temperature, oxygen saturation, hydration status, and seizure activity 1, 2
• Blood pressure management is critical and differs based on thrombolysis eligibility:
  • For thrombolysis candidates: BP must be reduced to <185/110 mmHg before treatment 1, 3
  • For non-candidates: only lower BP if systolic >220 mmHg or diastolic >120 mmHg 1
  • Aggressive BP lowering may worsen ischemia by decreasing perfusion pressure 1

Diagnostic Imaging

Emergent Brain Imaging

• Obtain non-contrast CT brain immediately to exclude hemorrhage and assess extent of ischemic changes 1, 2
• CT is typically faster and more widely available for initial assessment 2
• 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 2
• These imaging studies should not delay treatment decisions—they must be completed rapidly 1

Vascular Imaging

• Perform CT angiography from aortic arch to vertex at the time of initial brain CT to evaluate for large vessel occlusion if endovascular therapy is being considered 2, 3
• Concordant results from at least two noninvasive imaging techniques can determine treatment eligibility for revascularization procedures 2

Laboratory Investigations

Essential blood work must be obtained but should not delay imaging or treatment decisions: 1, 2

• Complete blood count (CBC) 1, 2
• Electrolytes and random glucose 1, 2
• Coagulation studies (INR and aPTT) 1, 2
• Renal function (creatinine and eGFR) 2
• Troponin (preferred over creatine phosphokinase due to increased sensitivity and specificity) 1, 2

Cardiac Evaluation

• Complete 12-lead ECG to identify atrial fibrillation, acute coronary syndrome, or other cardiac abnormalities 1, 2
• ECG monitoring for >24 hours is recommended for patients with suspected embolic stroke to detect paroxysmal atrial fibrillation 2
• Echocardiography should be performed for patients with suspected cardiac source of embolism, including evaluation for intracardiac thrombus, valvular disease, patent foramen ovale, and other structural abnormalities 2
• This cardiac assessment should not delay reperfusion strategies 1

Acute Treatment Decisions

Intravenous Thrombolysis

• Administer IV tissue plasminogen activator (tPA) 0.9 mg/kg (maximum 90 mg) to eligible patients within 3-4.5 hours of symptom onset 3
• Strict adherence to inclusion/exclusion criteria is mandatory 3
• Blood pressure must be <185/110 mmHg before and during treatment 1, 3
• Patients with involvement of more than one third of the MCA territory by early ischemic signs have increased hemorrhage risk and were excluded from major trials 1

Endovascular Therapy

• Consider endovascular therapy for patients with large vessel occlusion on CTA, in addition to or instead of IV thrombolysis, based on time window and patient selection criteria 3
• Additional cerebrovascular imaging should be considered in patients with large vessel occlusions presenting within 24 hours of last known well 2

Seizure Management

• 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
• Patients with immediate post-stroke seizures should be monitored for recurrent seizure activity 1

Early Complication Prevention

• Complete swallowing screening within 24 hours using a validated tool to prevent aspiration 2, 3
• Monitor temperature every 4 hours for 48 hours and 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

Extended Evaluation for Stroke Etiology

For patients beyond the acute treatment window (>4.5 hours), emphasis shifts to secondary prevention workup: 2

• Vascular imaging (CTA, MRA, or duplex ultrasound) to assess carotid arteries 2
• Extended cardiac monitoring (>24 hours) to detect paroxysmal atrial fibrillation 2
• Echocardiography to assess for cardiac sources 2
• Consider investigations for rarer causes including vasculitis, hypercoagulable states, and arterial dissection based on clinical suspicion 2

Critical Pitfalls to Avoid

• Do not delay imaging or treatment for chest radiography unless there are specific concerns about intrathoracic issues such as aortic dissection 1
• Do not aggressively lower blood pressure in non-thrombolysis candidates as this may worsen ischemia 1
• Do not assume absence of atrial fibrillation on admission ECG excludes it as the cause—ongoing monitoring is essential 1
• Living alone reduces likelihood of early arrival, so these patients may present later and require heightened awareness 4