What is the appropriate workup for a patient with a suspected cerebrovascular accident (CVA) or stroke?

From the Guidelines

A stroke workup should begin with a rapid assessment using the FAST criteria (Face, Arms, Speech, Time) to identify potential stroke symptoms, followed by immediate neuroimaging with a non-contrast CT scan or MRI to differentiate between ischemic and hemorrhagic stroke, as recommended by the most recent guidelines 1.

Initial Evaluation

The initial evaluation should include:

• A rapid assessment for airway, breathing, and circulation, as well as a neurological examination to determine focal neurological deficits and assess stroke severity 1
• Assessment of heart rate and rhythm, blood pressure, temperature, oxygen saturation, hydration status, and presence of seizure activity 1
• Acute blood work, including electrolytes, glucose, complete blood count, coagulation status, and creatinine 1
• An electrocardiogram (ECG) and cardiac monitoring for at least 24 hours to detect atrial fibrillation 1

Imaging and Intervention

• Non-contrast CT scan or MRI to differentiate between ischemic and hemorrhagic stroke, and to evaluate for large vessel occlusions (LVO) 1
• For eligible patients with LVO presenting within 24 hours, endovascular thrombectomy should be pursued 1
• For ischemic strokes identified within 4.5 hours of symptom onset, intravenous alteplase (tPA) at 0.9 mg/kg (maximum 90 mg) with 10% given as bolus and remainder over 60 minutes should be considered if no contraindications exist

Additional Workup and Secondary Prevention

• Additional workup includes MRI/MRA of the brain, carotid ultrasound or CTA to assess for stenosis, echocardiogram to identify cardiac sources of emboli, and comprehensive blood tests including complete blood count, coagulation studies, lipid panel, and HbA1c
• Secondary prevention typically includes antiplatelet therapy (aspirin 81-325 mg daily, clopidogrel 75 mg daily, or combination therapy depending on stroke etiology), statin therapy (atorvastatin 40-80 mg or rosuvastatin 20-40 mg daily), and blood pressure management targeting <130/80 mmHg 1

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Stroke Workup Overview

• The purpose of a stroke workup is to rapidly evaluate and select patients for treatment with I.V. fibrinolysis, as ischemic stroke is a medical emergency resulting from an embolic or thrombotic occlusion of an intracranial artery 2.
• Stroke prognosis estimation is a topic of interest, and laboratory findings such as complete blood count parameters can be used as prognostic factors 3.

Diagnostic Testing for Coagulopathies

• Coagulopathies are a rare cause of ischemic stroke, and current physician test-ordering practices for evaluating these conditions are not optimal 4.
• Specialized coagulation tests are reported to infrequently influence stroke patient management, and factors such as young patient age, history of thrombosis, and few traditional stroke risk factors can increase test-ordering 4.
• The diagnostic yield of coagulation tests may be increased by using tests with the highest specificities and targeting patients with clinical or historical features that increase pretest probability 5.

Importance of Full Blood Count in Cerebral Ischemia

• A full blood count can identify underlying hematological disorders, and almost half of ischemic strokes in young individuals are cryptogenic 6.
• Abnormalities in hematocrit level or platelet count were found in 25.1% of patients with stroke or transient ischemic attack, and primary hematological disorders such as myeloproliferative diseases and thrombotic thrombocytopenic purpura can be associated with stroke 6.
• The full blood count is important to exclude known causes of arterial cerebrovascular events in young patients, and at least 14% of patients merited further investigation 6.