From the Guidelines
The outpatient workup for a stroke should begin with a comprehensive evaluation including brain imaging, vascular assessment, cardiac evaluation, and laboratory tests, as recommended by the 2021 guideline for the prevention of stroke in patients with stroke and transient ischemic attack 1.
Initial Evaluation
The initial evaluation should include a rapid assessment of airway, breathing, and circulation, as well as a neurological examination to determine focal neurological deficits and assess stroke severity, using a standardized stroke scale such as the National Institutes of Health Stroke Scale (NIHSS) or the Canadian Neurological Scale (CNS) 1.
Brain Imaging
Initial imaging typically involves a non-contrast CT scan to rule out hemorrhage, followed by MRI with diffusion-weighted imaging to identify ischemic changes, as recommended by the 2021 guideline 1.
Vascular Assessment
Vascular imaging should include carotid ultrasound, CT angiography, or MR angiography to assess for stenosis or occlusion, particularly in patients with symptomatic anterior circulation cerebral infarction or TIA who are candidates for revascularization 1.
Cardiac Evaluation
Cardiac evaluation should consist of a 12-lead ECG to screen for atrial fibrillation and atrial flutter, as well as other concomitant cardiac conditions, and may include echocardiogram (preferably transesophageal) and at least 24-hour cardiac monitoring, with consideration for extended monitoring up to 30 days in cases of suspected atrial fibrillation 1.
Laboratory Tests
Laboratory tests should include complete blood count, comprehensive metabolic panel, lipid profile, hemoglobin A1c, and coagulation studies, as well as blood tests to gain insight into risk factors for stroke and to inform therapeutic goals 1.
Additional Testing
For younger patients or those without obvious risk factors, additional testing may include hypercoagulability workup, inflammatory markers, and screening for autoimmune disorders, as well as tests for inherited or acquired hypercoagulable state, bloodstream or cerebral spinal fluid infections, and markers of systemic inflammation and genetic tests for inherited diseases associated with stroke 1.
Risk Factor Modification
Risk factor modification is essential, including blood pressure control (target <130/80 mmHg), statin therapy (typically high-intensity such as atorvastatin 40-80mg or rosuvastatin 20-40mg daily), antiplatelet therapy (aspirin 81mg daily, clopidogrel 75mg daily, or dual therapy in select cases), and lifestyle modifications including smoking cessation, diet improvement, exercise, and diabetes management. Some key points to consider in the outpatient workup for a stroke include:
- The importance of a comprehensive evaluation to identify the stroke etiology and guide secondary prevention strategies
- The use of brain imaging, vascular assessment, cardiac evaluation, and laboratory tests to inform diagnosis and treatment
- The need for risk factor modification to reduce the risk of recurrent stroke
- The consideration of additional testing for younger patients or those without obvious risk factors
- The importance of lifestyle modifications, including smoking cessation, diet improvement, exercise, and diabetes management, to reduce the risk of recurrent stroke.
From the Research
Outpatient Workup for Stroke
The outpatient workup for stroke typically involves a series of diagnostic tests to determine the cause and extent of the stroke. Some of the key tests include:
- Computed Tomography (CT) scans, which are often the first line of imaging due to their affordability, wide availability, and speed 2
- Magnetic Resonance Imaging (MRI), which can provide more detailed images of the brain and is often used in conjunction with CT scans 3, 4
- CT and MR angiography, which can help identify blockages in the blood vessels 4
- Diffusion-weighted MR imaging, which can help identify areas of the brain that are at risk of damage 3, 4
- Cerebral perfusion studies, which can help identify areas of the brain that are not receiving enough blood flow 4
Diagnostic Criteria
The diagnostic criteria for stroke typically involve a combination of clinical evaluation and imaging tests. The goal of these tests is to quickly and accurately diagnose the stroke and determine the best course of treatment. According to the American Heart Association/American Stroke Association guidelines, the evaluation of patients with acute ischemic stroke should include a comprehensive history and physical examination, as well as imaging tests such as CT or MRI 5.
Treatment Options
The treatment options for stroke depend on the cause and severity of the stroke, as well as the individual patient's medical history and other factors. Some of the treatment options include:
- Intravenous recombinant tissue plasminogen activator (IV TPA), which can help dissolve blood clots and restore blood flow to the brain 6
- Endovascular thrombectomy, which involves removing the blood clot from the blood vessel 6
- Secondary prevention measures, such as medications to prevent further strokes and lifestyle changes to reduce risk factors 5