What is the appropriate workup for a patient with a suspected cerebrovascular accident (CVA) or stroke?

From the Guidelines

A comprehensive stroke workup should include a rapid neurological examination, immediate brain imaging with CT or MRI, and laboratory tests such as complete blood count, coagulation studies, and cardiac biomarkers, as recommended by the most recent guidelines 1. The initial assessment of a patient with suspected stroke should prioritize a rapid evaluation of airway, breathing, and circulation, followed by 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) 1. Key components of the stroke workup include:

• Brain imaging with CT or MRI to distinguish between ischemic and hemorrhagic stroke
• Laboratory tests, including complete blood count, coagulation studies, comprehensive metabolic panel, lipid profile, hemoglobin A1c, and cardiac biomarkers
• ECG to detect arrhythmias, particularly atrial fibrillation, and continuous cardiac monitoring for at least 24 hours
• Additional cardiac evaluation, including echocardiography to identify cardiac sources of emboli
• Vascular imaging, such as carotid Doppler ultrasound, CTA, or MRA, to identify patients with severe internal carotid artery stenosis who may benefit from urgent carotid endarterectomy or stenting 1. The most recent guidelines recommend that a diagnostic evaluation of stroke etiology should be started or ideally completed within 48 hours of stroke onset, and that blood work, including complete blood count, prothrombin time, partial thromboplastin time, glucose, HbA1c, creatinine, and fasting or non-fasting lipid profile, is recommended in patients with ischemic stroke or TIA 1. The goal of the stroke workup is to enable appropriate treatment decisions, including eligibility for thrombolysis or endovascular thrombectomy, and to identify underlying causes of the stroke to guide secondary prevention strategies 1.

From the Research

Stroke Workup Overview

• Stroke is a major contributor to death and disability worldwide, with over 5.5 million deaths annually 2
• Imaging is required before treating a stroke, and computed tomography (CT) is the most common diagnostic tool for suspected stroke due to its affordability, wide availability, and speed of acquiring images 2

Diagnostic Approach

• A multidisciplinary team, including a vascular neurology specialist, is beneficial for optimal diagnosis and management of stroke in young adults 3
• A "heart to head" diagnostic approach is recommended, including a thorough history, physical examination, and additional testing such as brain MRI, neck and cerebral vascular imaging, and transthoracic echocardiogram 3
• The diagnostic workup should also include basic risk factor blood work, telemetry monitoring, and consideration of alternative etiologies such as substance abuse, carotid/vertebral artery dissections, and rare genetic conditions 3

Imaging and Testing

• CT is the initial imaging modality of choice for suspected stroke, with mobile stroke units bringing CT directly to the patient 2
• Additional testing, such as brain MRI, CTA, and transthoracic echocardiogram, may be necessary to determine the cause and extent of the stroke 3
• Thromboelastography (TEG) and conventional coagulation tests (CCT) can be used to analyze coagulation function in patients with acute ischemic stroke, with TEG potentially being superior for evaluating symptomatic intracranial hemorrhage and CCT being advantageous for evaluating early neurological deterioration 4

Management and Treatment

• The primary therapeutic goal of reperfusion therapy, including intravenous recombinant tissue plasminogen activator (IV TPA) and/or endovascular thrombectomy, is the rapid restoration of cerebral blood flow to the salvageable ischemic brain tissue at risk for cerebral infarction 5
• Long-term secondary prevention strategies aimed to reduce recurrent stroke risk by targeting and modifying vascular risk factors should be instituted, including aspirin, anticoagulation, statin therapy, blood pressure reduction, smoking cessation, and optimal glucose control in diabetic patients 3