What is the initial workup for a patient admitted with suspected stroke?

Initial Workup for Suspected Stroke in Hospitalized Patients

All patients admitted with suspected stroke require immediate brain imaging (CT or MRI), rapid clinical assessment with a validated stroke scale, and essential laboratory tests—these should be completed emergently to determine eligibility for time-sensitive treatments like thrombolysis and endovascular therapy. 1, 2

Immediate Clinical Assessment

Perform rapid evaluation of airway, breathing, and circulation (ABCs) upon arrival, with particular attention to respiratory status and oxygen saturation 1, 3. Administer supplemental oxygen if saturation falls below 94% to prevent hypoxemia-related secondary brain injury 3.

Vital Signs and Monitoring

• Assess heart rate and rhythm, blood pressure, temperature, oxygen saturation, hydration status, and presence of seizure activity 4, 1
• Measure capillary blood glucose immediately—hypoglycemia is a common stroke mimic requiring urgent IV glucose correction 4, 3
• Document the exact time the patient was last known to be at baseline (last known well), as this is crucial for all treatment window calculations 1, 3

Neurological Examination

Conduct a neurological examination using a standardized stroke scale such as the National Institutes of Health Stroke Scale (NIHSS) to quantify stroke severity and guide treatment decisions 4, 1, 2. This assessment determines focal neurological deficits and helps predict prognosis 4.

Emergent Brain Imaging

Non-contrast CT must be performed immediately to exclude intracranial hemorrhage and assess for ischemic changes—this is the standard initial imaging modality because it is fast and widely available 1, 2, 3. CT should not be delayed, as it determines eligibility for thrombolytic therapy 2.

CT angiography (CTA) from aortic arch to vertex should be performed at the time of initial brain CT when possible to assess both extracranial and intracranial circulation, particularly if endovascular therapy is being considered 4, 1, 2. This detailed vascular imaging identifies stroke etiology and guides management decisions 4.

MRI with diffusion-weighted imaging (DWI), FLAIR, and gradient-recalled echo (GRE) is more sensitive for ischemic changes but should only be used if it does not delay treatment decisions 2, 3.

Essential Laboratory Investigations

Initial blood work should be conducted as part of the emergency evaluation and must include 4, 1, 2:

• Complete blood count (CBC) to assess for anemia, thrombocytopenia, or infection
• Electrolytes and random glucose to identify metabolic derangements
• Coagulation studies (INR and aPTT) to determine bleeding risk and thrombolytic eligibility
• Renal function (creatinine and eGFR) to assess kidney function before contrast studies
• Troponin to evaluate for concurrent acute coronary syndrome

These tests should not delay imaging or treatment decisions but are necessary for determining eligibility for thrombolytic therapy 4, 2.

Cardiac Evaluation

A 12-lead ECG should be completed immediately to identify atrial fibrillation, acute coronary syndrome, or other cardiac abnormalities that may represent the stroke etiology 4, 2. The ECG also provides information about structural heart disease such as previous myocardial infarction or left ventricular hypertrophy 4.

ECG monitoring for more than 24 hours is recommended for patients with suspected embolic stroke to detect paroxysmal atrial fibrillation 4, 2. In cases where initial monitoring does not show atrial fibrillation but a cardioembolic mechanism is suspected, prolonged ECG monitoring up to 30 days duration is recommended 4.

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 4, 2.

Critical Blood Pressure Management

For patients NOT receiving thrombolytic therapy: lower blood pressure only when systolic pressure exceeds 220 mmHg or diastolic pressure exceeds 120 mmHg, as aggressive reduction may worsen ischemia by decreasing cerebral perfusion pressure 4, 1, 3. This conservative approach reflects the lack of clear evidence for optimal blood pressure targets in acute stroke 4.

For patients who ARE candidates for thrombolytic therapy: blood pressure must be reduced to below 185/110 mmHg before administration to avoid hemorrhagic complications 4, 1, 3. Elevated blood pressure above this threshold is a contraindication to thrombolysis 4.

Additional Early Assessments

Swallowing screening using a validated tool should be completed within 24 hours by a trained practitioner to assess for dysphagia and prevent aspiration 1, 2. This should be done as early as possible after arrival 1.

Seizure assessment is essential: New-onset seizures at the time of acute stroke should be treated with appropriate short-acting medications (e.g., lorazepam IV) if they are not self-limited 4, 1, 3. However, a single self-limiting seizure occurring at onset should NOT be treated with long-term anticonvulsant medications 4, 3. Prophylactic anticonvulsants are not recommended 1.

Temperature monitoring every 4 hours for the first 48 hours is recommended, with temperature-reducing measures initiated if temperature exceeds 37.5°C 1, 3. Hyperthermia has been shown to negatively affect stroke outcome 5.

Common Pitfalls to Avoid

• Do not delay imaging for laboratory results—brain imaging takes priority and determines immediate treatment eligibility 4, 2
• Do not aggressively lower blood pressure in non-thrombolytic candidates—this may decrease cerebral perfusion and worsen ischemia 4, 3
• Do not skip vascular imaging—CTA or MRA is essential for identifying large vessel occlusions that may benefit from endovascular therapy 4, 2
• Do not forget to establish time last known well—this single piece of information determines all treatment windows 1, 3