Ischemic Stroke Workup
- Author: Edward C Jauch, MD, MS, FAHA, FACEP; Chief Editor: Helmi L Lutsep, MD more...
Emergent brain imaging is essential for confirming the diagnosis of ischemic stroke. Noncontrast CT scanning is the most commonly used form of neuroimaging in the acute evaluation of patients with apparent acute stroke. A lumbar puncture is required to rule out meningitis or subarachnoid hemorrhage when the CT scan is negative but the clinical suspicion remains high.
MRI with magnetic resonance angiography (MRA) has been a major advance in the neuroimaging of stroke. MRI not only provides great structural detail but also can demonstrate early cerebral edema. In addition, MRI has proved to be sensitive for detection of acute intracranial hemorrhage. However, MRI is not as available as CT scanning is in emergencies, many patients have contraindications to MRI imaging (eg, pacemakers, implants), and interpretation of MRI scans may be more difficult.
Carotid duplex scanning is one of the most useful tests in evaluating patients with stroke. Increasingly, it is being performed earlier in the evaluation, not only to define the cause of the stroke but also to stratify patients for either medical management or carotid intervention if they have carotid stenoses.
Digital subtraction angiography is considered the definitive method for demonstrating vascular lesions, including occlusions, stenoses, dissections, and aneurysms.
For more information, see Cerebral Revascularization Imaging.
Extensive laboratory testing is not routinely required before decisions are made regarding fibrinolysis. Testing can often be limited to blood glucose, plus coagulation studies if the patient is on warfarin, heparin, or one of the newer antithrombotic agents (eg, dabigatran, rivaroxaban). A complete blood count (CBC) and basic chemistry panel can be useful baseline studies.
Additional laboratory tests are tailored to the individual patient and may include the following:
Fasting lipid profile
Erythrocyte sedimentation rate
Antinuclear antibody (ANA)
Rapid plasma reagent (RPR)
A urine pregnancy test should be obtained for all women of childbearing age with stroke symptoms. The safety of the fibrinolytic agent recombinant tissue-type plasminogen activator (rt-PA) in pregnancy has not been studied in humans (ie, the agent is in the FDA pregnancy category C).
Brain Imaging With CT Scanning and MRI
Imaging with CT scanning has multiple logistic advantages for patients with acute stroke. Image acquisition is faster with CT scanning than with MRI, allowing for assessment with an examination that includes noncontrast CT scanning, CT angiography (CTA), and CT perfusion scanning in a short amount of time. Expedient acquisition is of the utmost importance in acute stroke imaging because of the narrow window of time available for definitive ischemic stroke treatment with pharmacologic agents and mechanical devices.
CT scanning can also be performed in patients who are unable to tolerate an MR examination or who have contraindications to MRI, including implantable pacemakers, some aneurysm clips, or other ferromagnetic materials in their bodies. Additionally, CT scanning is more easily accessible for patients who require special equipment for monitoring and life support.[64, 65]
Conventional (spin echo) MRI may take hours to produce discernible findings in acute ischemic stroke. Diffusion-weighted imaging (DWI) is highly sensitive to early cellular edema, which correlates well with the presence of cerebral ischemia. For this reason, many centers include DWI in their standard brain MRI protocol. DWI MRI can detect ischemia much earlier than standard CT scanning or spin echo MRI can and provides useful data in patients with stroke or transient ischemic attack (TIA). (See the image below.)[1, 66, 67, 68]
The most commonly used technique for perfusion MRI is dynamic susceptibility, which involves generating maps of brain perfusion by monitoring the first pass of a rapid bolus injection of contrast through the cerebral vasculature. Susceptibility-related T2 effects create signal loss in capillary blood vessels and parenchyma perfused by contrast.
For more information on MRI and MRA in this setting, see Magnetic Resonance Imaging in Acute Stroke.
Based on the central volume principle, dynamic brain perfusion data can be obtained. Cerebral blood volume (CBV), cerebral blood flow (CBF), and mean transit time (MTT) can be calculated using either perfusion MRI or CT scanning. (See the image below.)
An evidence-based guideline from the American Academy of Neurology advises that DWI is more useful than noncontrast CT scanning for the diagnosis of acute ischemic stroke within 12 hours of symptom onset and should be performed for the most accurate diagnosis of acute ischemic stroke (level A). No recommendations were made regarding the use of perfusion-weighted imaging (PWI) in diagnosing acute ischemic stroke, as evidence to support or refute its value in this setting is insufficient.
Intra-arterial contrast enhancement may be seen secondary to slow flow during the first or second day after onset of infarction. This finding has been correlated with increased infarct volume size.
Other Imaging Studies in Ischemic Stroke
Transcranial Doppler ultrasonography is useful for evaluating more proximal vascular anatomy—including the middle cerebral artery (MCA), intracranial carotid artery, and vertebrobasilar artery—through the infratemporal fossa. Echocardiography is obtained in all patients with acute ischemic stroke in whom cardiogenic embolism is suspected.
Chest radiography has potential utility for patients with acute stroke. However, obtaining a chest radiograph should not delay the administration of rt-PA, as radiographs have not been shown to alter the clinical course or decision-making in most cases.
The use of single-photon emission CT (SPECT) scanning in stroke is still experimental and is available only at select institutions. Theoretically, it can define areas of altered regional blood flow.
Conventional angiography is the gold standard in evaluating for cerebrovascular disease as well as for disease involving the aortic arch and great vessels in the neck. Conventional angiography can be performed to clarify equivocal findings or to confirm and treat disease seen on MRA, CTA, transcranial Doppler, or ultrasonography of the neck. (See the images below.)
A CBC serves as a baseline study and may reveal a cause for the stroke (eg, polycythemia, thrombocytosis, thrombocytopenia, leukemia) or provide evidence of concurrent illness (eg, anemia). The basic chemistry panel serves as a baseline study and may reveal a stroke mimic (eg, hypoglycemia, hyponatremia) or provide evidence of concurrent illness (eg, diabetes, renal insufficiency).
Coagulation studies may reveal a coagulopathy and are useful when fibrinolytics or anticoagulants are to be used. In patients who are not taking anticoagulants or antithrombotics and in whom there is no suspicion for coagulation abnormality, administration of rt-PA should not be delayed while awaiting laboratory results.
Cardiac biomarkers are important because of the association of cerebral vascular disease and coronary artery disease. Additionally, several studies have indicated a link between elevations of cardiac enzyme levels and poor outcome in ischemic stroke.
Toxicology screening may be useful in selected patients in order to assist in identifying intoxicated patients with symptoms/behavior mimicking stroke syndromes. In patients with suspected hypoxemia, arterial blood gas studies define the severity of hypoxemia and may detect acid-base disturbances. However, arterial punctures should be avoided unless absolutely necessary in patients being considered for fibrinolytic therapy.
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|VASCULAR TERRITORY||Structures Supplied|
|Anterior Circulation (Carotid)|
|Anterior Cerebral Artery||Cortical branches: medial frontal and parietal lobe
Medial lenticulostriate branches: caudate head, globus pallidus, anterior limb of internal capsule
|Middle Cerebral Artery||Cortical branches: lateral frontal and parietal lobes lateral and anterior temporal lobe
Lateral lenticulostriate branches: globus pallidus and putamen, internal capsule
|Anterior Choroidal Artery||Optic tracts, medial temporal lobe, ventrolateral thalamus, corona radiata, posterior limb of the internal capsule|
|Posterior Circulation (Vertebrobasilar)|
|Posterior Cerebral Artery||Cortical branches: occipital lobes, medial and posterior temporal and parietal lobes
Perforating branches: brainstem, posterior thalamus and midbrain
|Posterior Inferior Cerebellar Artery||Inferior vermis; posterior and inferior cerebellar hemispheres|
|Anterior Inferior Cerebellar Artery||Anterolateral cerebellum|
|Superior Cerebellar Artery||Superior vermis; superior cerebellum|
|1a||level of consciousness (LOC)||Alert
|1b||LOC questions (month, age)||Answers both correctly
Answers 1 correctly
Incorrect on both
|1c||LOC commands (open and close eyes,
grip and release nonparetic hand)
|Obeys both correctly
Obeys 1 correctly
Incorrect on both
|2||Best gaze (follow finger)||Normal
Partial gaze palsy
|3||Best visual (visual fields)||No visual loss
|4||Facial palsy (show teeth, raise brows,
squeeze eyes shut)
|5||Motor arm left* (raise 90°, hold 10 seconds)||No drift
Cannot resist gravity
No effort against gravity
|6||Motor arm right* (raise 90°, hold 10 seconds)||No drift
Cannot resist gravity
No effort against gravity
|7||Motor leg left* (raise 30°, hold 5 seconds)||No drift
Cannot resist gravity
No effort against gravity
|8||Motor leg right* (raise 30°, hold 5 seconds)||No drift
Cannot resist gravity
No effort against gravity
|9||Limb ataxia (finger-nose, heel-shin)||Absent
Present in 1 limb
Present in 2 limbs
|10||Sensory (pinprick to face, arm, leg)||Normal
|11||Extinction/neglect (double simultaneous testing)||No neglect
|12||Dysarthria (speech clarity to "mama,
baseball, huckleberry, tip-top, fifty-fifty")
Mild to moderate dysarthria
Near to unintelligible or worse
|13||Best language** (name items,
Mild to moderate aphasia
|* For limbs with amputation, joint fusion, etc, score 9 and explain.
** For intubation or other physical barriers to speech, score 9 and explain. Do not add 9 to the total score. NIH Stroke Scale (PDF)