Template:Stroke workup

Stroke Work-Up

• Labs
  • POC glucose
  • CBC
  • Chemistry
  • Coags
  • Troponin
  • T&S
• ECG
  • In large ICH or stroke, may see deep TWI and prolong QT, occ ST changes
• Head CT (non-contrast)
  • In ischemia stroke CT has sensitivity 42%, specificity 91%
  • In acute ICH the sensitivity is 95-100%
  • The goal of CTH is to identify stroke mimics (ICH, mass lesions, etc .)
• Also consider:
  • CTA brain and neck
    • To check for large vessel occlusion for potential thrombectomy
    • Determine if there is carotid stenosis that warrants endarterectomy urgently
  • Pregnancy test
  • CXR (if infection suspected)
  • UA (if infection suspected)
  • Utox (if ingestion suspected)

MR Imaging (for Rule-Out CVA or TIA)

• MRI Brain with DWI, ADC (without contrast) AND
• Cervical vascular imaging (ACEP Level B in patients with high short-term risk for stroke):
  • MRA brain (without contrast) AND
  • MRA neck (without contrast)
    • May instead use Carotid CTA or US (Carotid US slightly less sensitive than MRA) (ACEP Level C)

Mullins ME, Schaefer PW, Sorensen AG, Halpern EF, Ay H, He J, Koroshetz WJ, Gonzalez RG. CT and conventional and diffusion-weighted MR imaging in acute stroke: study in 691 patients at presentation to the emergency department. Radiology. 2002 Aug;224(2):353-60.

Suarez JI, Tarr RW, Selman WR. Aneurysmal subarachnoid hemorrhage. N Engl J Med. 2006; 354(4):387–396.

Douglas VC, Johnston CM, Elkins J, et al. Head computed tomography findings predict short-term stroke risk after transient ischemic attack. Stroke. 2003;34:2894-2899.

ACEP Clinical Policy: Suspected Transient Ischemic Attackfull text

Nederkoorn PJ, Mali WP, Eikelboom BC, et al. Preoperative diagnosis of carotid artery stenosis. Accuracy of noninvasive testing. Stroke. 2002;33:2003-2008.