What is the basic stroke workup for outpatient ischemic stroke (cerebrovascular accident)?

From the Guidelines

The basic outpatient stroke workup should include brain imaging (MRI preferred over CT), vascular imaging (carotid ultrasound, CTA, or MRA), cardiac evaluation (ECG, and possibly extended cardiac monitoring), and laboratory tests (complete blood count, coagulation studies, lipid panel, HbA1c, and renal function) as recommended by the 2021 guideline for the prevention of stroke in patients with stroke and transient ischemic attack 1.

Key Components of the Workup

• Brain imaging: MRI is preferred over CT for its higher sensitivity in detecting ischemic changes and its ability to provide more detailed information about the brain tissue 1.
• Vascular imaging: carotid ultrasound, CTA, or MRA are recommended to screen for stenosis in patients with symptomatic anterior circulation cerebral infarction or TIA who are candidates for revascularization 1.
• Cardiac evaluation: a 12-lead ECG is recommended to screen for atrial fibrillation and atrial flutter, and to assess for other concomitant cardiac conditions 1.
• Laboratory tests: complete blood count, prothrombin time, partial thromboplastin time, glucose, HbA1c, creatinine, and fasting or nonfasting lipid profile are recommended to gain insight into risk factors for stroke and to inform therapeutic goals 1.

Additional Considerations

• Patients with cryptogenic stroke may benefit from echocardiography with or without contrast to evaluate for possible cardiac sources of or transcardiac pathways for cerebral embolism 1.
• Long-term rhythm monitoring with mobile cardiac outpatient telemetry, implantable loop recorder, or other approach may be reasonable to detect intermittent AF in patients with cryptogenic stroke who do not have a contraindication to anticoagulation 1.
• Lifestyle modifications, including smoking cessation, limited alcohol intake, regular exercise, and a Mediterranean or DASH diet, are essential for reducing the risk of stroke recurrence 1.

From the Research

Basic Stroke Workup for Outpatient Stroke

The basic stroke workup for outpatient stroke typically involves a combination of diagnostic tests and evaluations to determine the cause and severity of the stroke.

• Initial evaluation: A thorough history and physical examination, including a detailed family history and evaluation of the patient's general appearance, joint laxity, and abnormalities of the skin, eyes, and heart 2.
• Imaging tests:
  • Brain MRI to evaluate for ischemic or hemorrhagic stroke
  • Neck and cerebral vascular imaging (e.g., CTA for head and neck) to evaluate for carotid artery stenosis or other vascular abnormalities 2, 3
• Laboratory tests:
  • Basic risk factor blood work (e.g., lipid panel, hemoglobin A1c, TSH, ESR, CRP, RPR, HIV, and toxicology screen) to evaluate for underlying risk factors such as diabetes, hypertension, and hyperlipidemia 2
  • Blood cultures or lumbar puncture if indicated
• Other tests:
  • Transthoracic echocardiogram with a bubble study to evaluate for cardiac sources of embolism 2
  • Telemetry monitoring to evaluate for arrhythmias such as atrial fibrillation 2

Risk Factors for Stroke

Several risk factors have been identified as contributing to the development of stroke, including:

• Hypertension: A major risk factor for stroke, particularly in patients with diabetes 4
• Diabetes: A significant risk factor for stroke, particularly in patients with hypertension 4
• Atrial fibrillation: A cardiac arrhythmia that increases the risk of stroke 5, 2
• Carotid artery stenosis: A narrowing of the carotid artery that can increase the risk of stroke 5, 3
• Tobacco use: A significant risk factor for stroke, particularly in patients with other underlying risk factors 5

Screening for Asymptomatic Carotid Disease

Screening for asymptomatic carotid disease can be an effective way to prevent strokes, particularly in seniors.

• The quick carotid scan (QCS) is a rapid, color flow ultrasound scan of the cervical carotid arteries that can be used to screen for asymptomatic carotid disease 3.
• The QCS has a sensitivity of 97% and can be used to identify patients who require further evaluation and management to prevent stroke 3.