Initial Workup for Suspected Stroke in Hospitalized Patients

Immediate Clinical Assessment

The American Heart Association recommends performing rapid evaluation of airway, breathing, and circulation (ABCs) upon arrival, with particular attention to respiratory status and oxygen saturation, and administering supplemental oxygen if saturation falls below 94% to prevent hypoxemia-related secondary brain injury 1, 2
The American College of Emergency Physicians suggests assessing heart rate and rhythm, blood pressure, temperature, oxygen saturation, hydration status, and presence of seizure activity, as these are crucial for determining the patient's overall condition and guiding treatment decisions 3, 1
Measuring capillary blood glucose immediately is essential, as hypoglycemia is a common stroke mimic requiring urgent IV glucose correction, according to the American Diabetes Association 4, 2
Documenting the exact time the patient was last known to be at baseline (last known well) is crucial for all treatment window calculations, as emphasized by the American Heart Association 1, 2

The National Institute of Neurological Disorders and Stroke recommends conducting a neurological examination using a standardized stroke scale such as the National Institutes of Health Stroke Scale (NIHSS) to quantify stroke severity and guide treatment decisions 3, 1, 5
This assessment determines focal neurological deficits and helps predict prognosis, according to the American Academy of Neurology 3

The American College of Radiology suggests that non-contrast CT must be performed immediately to exclude intracranial hemorrhage and assess for ischemic changes, as it is the standard initial imaging modality because it is fast and widely available 1, 5, 2
CT angiography (CTA) from aortic arch to vertex should be performed at the time of initial brain CT when possible to assess both extracranial and intracranial circulation, particularly if endovascular therapy is being considered, according to the Society of Interventional Radiology 6, 1, 5

The American College of Emergency Physicians recommends that initial blood work should be conducted as part of the emergency evaluation and must include complete blood count (CBC), electrolytes and random glucose, coagulation studies (INR and aPTT), renal function (creatinine and eGFR), and troponin, as these tests are necessary for determining eligibility for thrombolytic therapy 3, 1, 5

The American Heart Association suggests that a 12-lead ECG should be completed immediately to identify atrial fibrillation, acute coronary syndrome, or other cardiac abnormalities that may represent the stroke etiology, and to provide information about structural heart disease such as previous myocardial infarction or left ventricular hypertrophy 6, 5
ECG monitoring for more than 24 hours is recommended for patients with suspected embolic stroke to detect paroxysmal atrial fibrillation, according to the American College of Cardiology 6, 5

The American Heart Association recommends that for patients NOT receiving thrombolytic therapy, blood pressure should only be lowered when systolic pressure exceeds 220 mmHg or diastolic pressure exceeds 120 mmHg, as aggressive reduction may worsen ischemia by decreasing cerebral perfusion pressure, and reflects the lack of clear evidence for optimal blood pressure targets in acute stroke 3, 1, 2
For patients who ARE candidates for thrombolytic therapy, blood pressure must be reduced to below 185/110 mmHg before administration to avoid hemorrhagic complications, according to the American College of Emergency Physicians 3, 1, 2

The American Speech-Language-Hearing Association recommends that swallowing screening using a validated tool should be completed within 24 hours by a trained practitioner to assess for dysphagia and prevent aspiration, and should be done as early as possible after arrival 1, 5
The American Academy of Neurology suggests that seizure assessment is essential, and new-onset seizures at the time of acute stroke should be treated with appropriate short-acting medications (e.g., lorazepam IV) if they are not self-limited, but a single self-limiting seizure occurring at onset should NOT be treated with long-term anticonvulsant medications, and prophylactic anticonvulsants are not recommended 3, 1, 2
Temperature monitoring every 4 hours for the first 48 hours is recommended, with temperature-reducing measures initiated if temperature exceeds 37.5°C, according to the American Heart Association 1, 2

The FAST mnemonic (Face, Arm, Speech, Time) achieves ≈ 87 % sensitivity for detecting stroke at first contact and is endorsed by the American Heart Association/American Stroke Association (AHA/ASA) guidelines for emergency screening. 7

A serial bedside neurological examination is the cornerstone of acute neurological assessment, superseding mnemonic‑based approaches. (Critical Care Society recommendation) 8
Vital‑sign monitoring—including heart rate/rhythm, blood pressure, temperature, oxygen saturation, hydration status, and seizure activity—should be performed immediately on presentation. (International Stroke Guidelines) 9
The National Institutes of Health Stroke Scale (NIHSS) is the gold‑standard tool for quantifying stroke severity and directing therapy; it should be completed on arrival, before any reperfusion treatment, and after thrombolysis. (AHA/ASA) [7][9]10 – Evidence strength: strong.
Serial examinations must incorporate mental status, brain‑stem reflexes (pupillary light response, oculo‑cephalic, corneal, cough/gag), and a comprehensive motor exam. (Critical Care Society) 8

Daily evaluation by a neurologist or neuro‑intensivist improves neurological outcomes in acute stroke patients. (Critical Care Society) 8 – Evidence strength: moderate.
Bedside nursing assessments performed every 1–4 hours are recommended for patients at risk of acute brain injury. (Critical Care Society) 8

Do not delay neuroimaging or acute treatment while awaiting laboratory results, except when specific tests (e.g., INR for patients on warfarin) are required. (International Stroke Guidelines) 9 – Evidence strength: moderate.
In patients receiving sedatives or paralytics (e.g., during ECMO), neurological evaluation may be confounded; multimodal monitoring is advised. (Critical Care Society) 8
Fixed, dilated pupils observed during CPR after epinephrine do not necessarily indicate irreversible brain injury; favorable neurological recovery remains possible. (Critical Care Society) 8

The AHA/ASA “Code Stroke” protocol includes:
Implementation of this protocol consistently achieves door‑to‑needle times < 60 minutes and door‑to‑imaging times < 25 minutes, benchmarks that are associated with reduced morbidity and mortality. (AHA/ASA) [7][10] – Evidence strength: strong.