What is the initial workup for a patient admitted to hospital for cerebrovascular accident (CVA) or stroke evaluation?

From the Guidelines

The initial workup for a patient admitted to hospital for stroke workup should include a rapid neurological examination, immediate brain imaging with non-contrast CT or MRI, laboratory tests, and an ECG, as recommended by the 2018 guidelines for the early management of patients with acute ischemic stroke 1. The initial assessment should prioritize the identification of stroke type, cause, and appropriate treatment.

• A rapid neurological examination should be performed using the National Institutes of Health Stroke Scale (NIHSS) to assess stroke severity, as recommended by the Canadian Stroke Best Practice Recommendations for Acute Stroke Management 1.
• Immediate brain imaging with non-contrast CT or MRI is essential to differentiate between ischemic and hemorrhagic stroke, with a goal of completing the imaging study within 20 minutes of arrival in the emergency department 1.
• Laboratory tests should include complete blood count, coagulation studies (PT/INR, PTT), comprehensive metabolic panel, lipid profile, HbA1c, and cardiac biomarkers, as recommended by the Canadian Stroke Best Practice Recommendations for Secondary Prevention of Stroke 1.
• An ECG should be performed to identify arrhythmias, particularly atrial fibrillation, as recommended by the 2018 guidelines for the early management of patients with acute ischemic stroke 1. Additional tests may include vascular imaging with CT angiography, MR angiography, or carotid ultrasound to identify stenosis or occlusions, as well as echocardiogram to identify cardiac sources of emboli, extended cardiac monitoring if paroxysmal atrial fibrillation is suspected, and specialized tests based on patient age and risk factors. This comprehensive approach allows for rapid diagnosis and treatment initiation, which is critical as "time is brain" – each minute of untreated stroke results in the loss of approximately 1.9 million neurons. The use of a standardized stroke scale, such as the NIHSS, is recommended to assess stroke severity and guide treatment decisions 1. The initial workup should also include assessment of airway, breathing, and circulation, as well as evaluation for seizure activity, as recommended by the Canadian Stroke Best Practice Recommendations for Acute Stroke Management 1. Overall, the initial workup for a patient admitted to hospital for stroke workup should prioritize rapid and accurate diagnosis, as well as timely initiation of appropriate treatment, to minimize morbidity, mortality, and improve quality of life.

From the Research

Initial Workup for Stroke Patients

The initial workup for a patient admitted to the hospital for stroke workup involves several diagnostic tests to determine the cause and extent of the stroke.

• Computed tomography angiography (CTA), digital subtraction angiography (DSA), and magnetic resonance angiography (MRA) are the current gold standards for vascular imaging in stroke diagnosis 2.
• However, non-contrast MRI sequences such as T1-weighted imaging (T1WI), T2-weighted imaging (T2WI), fluid-attenuated inversion recovery (FLAIR), diffusion-weighted imaging (DWI), and apparent diffusion coefficient (ADC) are essential for determining infarct location, volume, and age 2.
• Susceptibility-weighted imaging (SWI) sequence can aid in identifying signs of hemorrhagic transformation within the infarcted region, while arterial spin labeling (ASL) can serve as a non-contrast alternative for mapping cerebral blood flow (CBF) 2.
• Non-contrast CT scans can also be used to predict hemorrhagic transformation risk in stroke patients undergoing revascularization, with radiomic features such as textural features and Hounsfield unit values being significant predictors 3, 4.

Diagnostic Tests

The following diagnostic tests are commonly used in the initial workup for stroke patients:

• Non-contrast CT scans to evaluate infarcted tissue and predict hemorrhagic transformation risk 3, 4.
• MRI sequences such as T1WI, T2WI, FLAIR, DWI, and ADC to determine infarct location, volume, and age 2.
• MRA and MRV to assess venous thrombosis, stenosis, or arterial occlusions 2.
• MR spectroscopy to provide insights into critical brain metabolites and determine patient prognosis 2.

Clinical Assessment

Clinical assessment is also an essential part of the initial workup for stroke patients, including:

• National Institute of Health Stroke Scale (NIHSS) to assess clinical outcome 5.
• Evaluation of hematoma volume, location of stroke, midline shift, intraventricular extension of bleed, and ventricle compression to predict clinical outcome in patients with acute intracerebral hemorrhage (ICH) 5.