What is the recommended workup and management for a new cerebrovascular accident (CVA) in an otherwise healthy patient?

Workup for New CVA in Otherwise Healthy Patients

For an otherwise healthy patient presenting with new stroke symptoms, immediately obtain non-contrast CT head to exclude hemorrhage, followed by CT angiography (CTA) of the head and neck to detect large vessel occlusion—this imaging sequence should be completed within minutes of arrival, as time-to-treatment directly determines neurological outcome and mortality. 1, 2

Hyperacute Phase (<24 Hours): Time-Critical Imaging and Assessment

Immediate Imaging Protocol

• Obtain non-contrast CT head first to exclude intracranial hemorrhage and identify early ischemic changes—this is the single most essential initial test and must not be delayed for any reason 1, 2

• Perform CTA head and neck immediately after non-contrast CT to detect large vessel occlusion (LVO), as mechanical thrombectomy can be performed up to 24 hours from symptom onset in selected patients 1, 2

• Document the exact time of symptom onset or last known normal—this is the single most critical piece of clinical information as it determines eligibility for IV thrombolysis (3-4.5 hour window) and mechanical thrombectomy (up to 24 hours) 2, 3

• Assess stroke severity using NIH Stroke Scale (NIHSS) to guide treatment decisions, though note that NIHSS correlates poorly with presence of LVO 1, 2

Advanced Imaging for Extended Time Windows

• CT perfusion (CTP) is NOT needed within the first 6 hours if the patient is a clear candidate for intervention—obtaining CTP in this setting may cause harmful delays 1

• CTP or MR perfusion becomes critical for patients presenting 6-24 hours after onset to determine eligibility for mechanical thrombectomy based on salvageable tissue 1

• MRI with diffusion-weighted imaging (DWI) can substitute for CTP in the extended window, though CT perfusion is typically faster in most clinical settings 1

Special Consideration: Direct to Angiography

• Proceed directly to catheter angiography after non-contrast CT (bypassing CTA) in highly selected cases: patients with hyperdense MCA sign on CT, clear LVO etiology (e.g., new atrial fibrillation), and no need for perfusion imaging—this allows immediate conversion to mechanical thrombectomy 1

Comprehensive Stroke Workup: Identifying the Etiology

Vascular Imaging

• CTA head and neck (already obtained in hyperacute phase) evaluates for carotid stenosis, vertebral artery disease, and intracranial atherosclerosis 1

• Carotid duplex ultrasound within 48 hours if CTA shows stenosis or was not performed—this is noninvasive and accurately quantifies degree of carotid stenosis to determine need for endarterectomy or stenting 1, 3

• Transcranial Doppler is NOT a first-line test in the acute setting due to poor anatomical delineation and potential for treatment delays 1

Cardiac Evaluation

• Continuous cardiac monitoring for at least 24 hours to detect paroxysmal atrial fibrillation—this is essential as AF is a major stroke etiology and changes secondary prevention strategy 2, 3

• Transthoracic echocardiography (TTE) to evaluate for cardiac thrombus, valvular disease, and structural abnormalities 1, 3

• Consider transesophageal echocardiography (TEE) if TTE is non-diagnostic and cardioembolic source is suspected, particularly in younger patients or those with cryptogenic stroke 1

• 12-lead ECG to identify atrial fibrillation, prior MI, or other cardiac abnormalities 2, 3

Laboratory Studies

• Complete blood count (CBC) to assess for polycythemia, thrombocytosis, or anemia 3

• Comprehensive metabolic panel including glucose (to exclude hypoglycemia as stroke mimic) and renal function 2, 3

• Lipid panel as statin therapy will be initiated regardless of baseline cholesterol 2, 3

• Hemoglobin A1c to screen for diabetes mellitus 3, 4

• Coagulation studies (PT/INR, aPTT) particularly if anticoagulation is being considered or patient is on anticoagulants 3

• Blood tests for prothrombotic factors in young patients (<50 years) or those without traditional risk factors: antiphospholipid antibodies, protein C/S, antithrombin III, factor V Leiden, prothrombin gene mutation 1, 3

Special Situations Requiring Additional Workup

For suspected cerebral venous thrombosis (CVT):

• MRI with MR venography (MRV) or CT venography (CTV) to directly visualize thrombus in cerebral venous sinuses 5, 6
• Note: Hemorrhage on imaging does NOT exclude CVT—in fact, hemorrhagic venous infarction is common with CVT 2, 5, 6

For young patients or cryptogenic stroke:

• Extended cardiac monitoring (30-day event monitor) to detect paroxysmal AF 3
• Hypercoagulability workup as detailed above 1, 3
• Consider vasculitis workup if clinical suspicion exists: ESR, CRP, ANA, ANCA 1

Critical Pitfalls to Avoid

• Never delay CT imaging to obtain detailed history—imaging must occur within minutes of arrival, as "time is brain" with up to 2 million neurons lost per minute during LVO stroke 1, 2

• Never assume absence of LVO based on NIHSS score alone—the correlation is poor due to variable collateral circulation and stroke mimics 1

• Never obtain CTP in the first 6 hours if the patient is a clear thrombectomy candidate—this causes harmful delays without adding useful information 1

• Never exclude CVT based on presence of hemorrhage—hemorrhagic venous infarction is common and anticoagulation should still be initiated 2, 5, 6

• Never withhold workup based on age alone—older patients should receive the same comprehensive evaluation as younger patients 2

Documentation Requirements

• Precise time of symptom onset or last known normal 2, 3
• Specific neurological deficits reported by patient or witnesses 3
• Vascular risk factors: hypertension, diabetes, hyperlipidemia, smoking, atrial fibrillation 3
• Previous stroke or TIA history 3
• Stroke type and vascular territory affected once imaging is complete 3