What is the initial workup for a patient presenting with symptoms of a stroke?

Initial Workup for Acute Stroke

All patients with suspected stroke require immediate brain imaging with non-contrast CT to exclude hemorrhage, followed by rapid clinical assessment using a standardized stroke scale, essential laboratory tests, ECG, and determination of last known well time—all performed urgently and in parallel to avoid treatment delays. 1, 2, 3

Immediate Priorities (First 10-15 Minutes)

Time-Critical Assessment

• Document the exact time the patient was last known to be at baseline ("last known well") - this is the single most important piece of information as it determines all treatment eligibility 1, 3
• For patients who awaken with symptoms or cannot provide history, the last known well time is when they were last awake and symptom-free 1
• Question witnesses, family, and EMS personnel about onset time; use creative anchors like cell phone timestamps or TV programming times to establish timing 1

Stabilization (ABCs)

• Rapidly assess airway, breathing, and circulation 1, 3
• Measure oxygen saturation and provide supplemental oxygen only if <94% 1, 3
• Check capillary blood glucose immediately—hypoglycemia is a common stroke mimic requiring urgent IV glucose 3
• Assess vital signs: heart rate/rhythm, blood pressure, temperature, hydration status, and seizure activity 1, 3

Emergent Brain Imaging (Within 25 Minutes of Arrival)

Primary Imaging

• Non-contrast CT of the head must be performed immediately to exclude intracranial hemorrhage and assess for early ischemic changes 1, 2, 3
• CT is the standard initial modality because it is fast and widely available 2, 3
• Imaging should be completed within 25 minutes of arrival with interpretation within 45 minutes 4

Vascular Imaging

• CT angiography (CTA) from aortic arch to vertex should be performed at the time of initial brain CT when possible, particularly if endovascular therapy is being considered 2, 3
• This evaluates both extracranial and intracranial circulation for large vessel occlusion 3
• MRI with diffusion-weighted imaging (DWI), FLAIR, and gradient-recalled echo is preferred when available 24/7 and can be completed rapidly 2

Neurological Assessment

Standardized Stroke Scale

• Perform neurological examination using the National Institutes of Health Stroke Scale (NIHSS) to quantify stroke severity, guide treatment decisions, and predict prognosis 1, 2, 3
• The examination should be brief but thorough, completed in 5-10 minutes 1
• Document focal neurological deficits including level of consciousness, orientation, motor function, sensory deficits, visual fields, gaze, facial weakness, limb ataxia, language, and articulation 1

Essential Laboratory Investigations

These tests should NOT delay imaging or treatment decisions but must be obtained urgently: 1, 2

• Complete blood count (CBC) 1, 2, 3
• Electrolytes and random glucose 1, 2, 3
• Coagulation studies (INR and aPTT) - critical for determining thrombolytic eligibility 1, 2, 3
• Renal function (creatinine and eGFR) 1, 2, 3
• Troponin - to assess for concurrent acute coronary syndrome 2, 3

Cardiac Evaluation

Immediate ECG

• 12-lead ECG should be completed immediately to identify atrial fibrillation, acute coronary syndrome, left ventricular hypertrophy, or previous myocardial infarction 1, 2, 3

Extended Monitoring

• ECG monitoring for >24 hours is recommended for patients with suspected embolic stroke to detect paroxysmal atrial fibrillation 2, 3
• Echocardiography should be performed to evaluate for cardiac source of embolism, including intracardiac thrombus, valvular disease, patent foramen ovale, and structural abnormalities 2

Critical Blood Pressure Management

For Patients NOT Receiving Thrombolysis

• Only lower blood pressure when systolic >220 mmHg or diastolic >120 mmHg 1, 3
• Aggressive blood pressure reduction may worsen ischemia by decreasing cerebral perfusion pressure 1, 3
• Optimal blood pressure targets remain unknown, so this conservative approach is consensus-based 1

For Thrombolysis Candidates

• Blood pressure must be reduced to <185/110 mmHg before thrombolytic administration to avoid hemorrhagic complications 1, 3
• This is an absolute requirement for treatment eligibility 3

Additional Early Assessments

Swallowing Evaluation

• Swallowing screening using a validated tool should be completed within 24 hours by a trained practitioner to prevent aspiration 2, 3

Seizure Management

• New-onset seizures at stroke onset should be treated with short-acting medications (e.g., lorazepam IV) if not self-limited 1, 3
• A single self-limiting seizure should NOT be treated with long-term anticonvulsants 1, 3
• Prophylactic anticonvulsants are not recommended and may harm neural recovery 1

Temperature Monitoring

• Monitor temperature at least every 4 hours for the first 48-72 hours 3, 4
• Initiate temperature-reducing measures if >37.5°C 3, 4

History Taking Priorities

Key Historical Elements Beyond Timing

• Risk factors: hypertension, diabetes, hyperlipidemia, atrial fibrillation, smoking, prior stroke/TIA 1
• Alternative etiologies: drug abuse, migraine history, recent trauma, pregnancy, infection, seizure history 1
• Preceding transient symptoms: if neurological symptoms completely resolved before current presentation, the therapeutic clock resets 1
• Circumstances of symptom development to help distinguish stroke from mimics 1

Physical Examination Beyond Neurological Assessment

• Examine head/face for signs of trauma or seizure activity 1
• Auscultate neck for carotid bruits 1
• Cardiac examination for murmurs, arrhythmias, signs of heart failure 1
• Skin examination for stigmata of coagulopathies, embolic lesions (Janeway lesions, Osler nodes), or signs of endocarditis 1

Common Pitfalls to Avoid

• Do not wait for laboratory results before obtaining neuroimaging - the therapeutic window for thrombolysis is critical (0-4.5 hours) 1, 4
• Do not aggressively lower blood pressure in non-thrombolysis candidates - this may worsen cerebral perfusion 1, 3
• Do not assume "wake-up strokes" are untreatable - advanced imaging may identify candidates for therapy 1
• Do not miss stroke mimics: hypoglycemia, seizure with postictal state, complicated migraine, conversion disorder, hypertensive encephalopathy 1, 5, 6

Timing-Based Approach

Within 4.5 Hours of Last Known Well

• Prioritize non-contrast CT or MRI to exclude hemorrhage 2, 3
• Consider concurrent CTA if endovascular therapy is being considered 2, 3
• Focus on rapid determination of thrombolytic eligibility 2

Beyond 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 and echocardiography to detect paroxysmal atrial fibrillation and cardiac sources 2