From the Guidelines
The full workup for concerns of a possible stroke involves a comprehensive evaluation to rapidly diagnose and treat this time-sensitive emergency, prioritizing immediate brain imaging, laboratory tests, and cardiac monitoring to guide treatment decisions, as recommended by the most recent guidelines 1.
Initial Assessment
The initial assessment includes a focused neurological examination using standardized tools like the NIH Stroke Scale to evaluate deficits, as well as assessing airway, breathing, and circulation, and determining focal neurological deficits and stroke severity 1.
- A rapid initial evaluation for airway, breathing, and circulation should be conducted, with a neurological examination to determine focal neurological deficits and assess stroke severity.
- Assessment in the acute phase should include heart rate and rhythm, blood pressure, temperature, oxygen saturation, hydration status, and presence of seizure activity.
Imaging and Laboratory Tests
Immediate brain imaging is essential, typically starting with a non-contrast CT scan to rule out hemorrhage, followed by CT angiography to assess vessel occlusion, as recommended by recent guidelines 1.
- MRI with diffusion-weighted imaging provides more detailed information about brain tissue status.
- Laboratory tests include complete blood count, coagulation studies (PT/INR, PTT), comprehensive metabolic panel, cardiac enzymes, and blood glucose.
- An electrocardiogram is performed to identify arrhythmias like atrial fibrillation, and continuous cardiac monitoring is initiated.
Cardiac Workup and Vascular Imaging
Additional cardiac workup may include echocardiography to detect cardiac sources of emboli, and carotid ultrasound or other vascular imaging helps identify stenosis or other vascular abnormalities 1.
- For cryptogenic strokes, extended cardiac monitoring (48 hours to 30 days) may be necessary to detect paroxysmal arrhythmias.
- This comprehensive approach enables rapid treatment decisions, including consideration of thrombolysis with IV tPA (alteplase) within 3-4.5 hours of symptom onset or endovascular thrombectomy within 24 hours for large vessel occlusions, while also identifying the underlying cause to guide secondary prevention strategies 1.
From the Research
Initial Assessment
- The initial assessment for concerns of possible stroke involves a thorough history and physical examination to establish the diagnosis and identify the underlying cause 2.
- Brain imaging with CT or MRI scan is necessary to distinguish cerebral infarction from primary intracerebral haemorrhage 2.
Imaging Techniques
- Computed Tomography (CT) is the most common diagnostic tool for suspected stroke due to its affordability, wide availability, and speed of acquiring images 3.
- CT angiography has become the operational standard for rapid accurate identification of intracranial large-vessel occlusion (LVO) 4.
- Multiphase CT angiography of collateral vessels and source-image assessment or perfusion CT can be used to help estimate core infarct volume when diffusion-weighted MRI is unavailable 4.
Treatment Options
- Treatment options for acute ischemic stroke include thrombolysis and endovascular therapy 5.
- CT is the primary imaging modality used for selecting appropriate treatment in patients with acute stroke, including immediate treatment with intravenous tissue plasminogen activator and transfer of patients with LVO to comprehensive stroke centers for endovascular thrombectomy (EVT) 4.
Stroke Units and Multidisciplinary Care
- Stroke units are the cornerstones of stroke care and should be available to all stroke patients throughout their inpatient stay 2.
- Multidisciplinary stroke care should address the physical, psychological, and social consequences of stroke and consider the needs of both patients and carers 2.
- Ongoing assessment and treatment may be needed for various issues, including dysphagia, nutrition and hydration, continence and skin care, mobility and upper limb function, comprehension and communication, concentration and memory, spatial awareness and inattention, mood, pain, and spasticity 2.