Diagnostic Approach to Suspected Stroke

Initial Management Protocol

The American Heart Association recommends activating the stroke protocol immediately, regardless of suspicion for malingering, as clinical judgment alone is insufficient to exclude cerebrovascular events 1, 2
Perform rapid triage using validated stroke assessment tools (FAST: Face, Arm, Speech, Time) within 10 minutes of arrival, as these objective measures help distinguish true neurological deficits from inconsistent presentations 3, 4, 2
Obtain brain imaging (non-contrast CT or MRI) within 30 minutes of hospital arrival, as this is the only definitive way to differentiate ischemic stroke, hemorrhagic stroke, or stroke mimics 5, 1, 6

The American College of Cardiology recommends brain CT or MRI to exclude ischemic or hemorrhagic stroke, as clinical features alone have inadequate sensitivity and specificity 1, 6
CT angiography or MR angiography from aortic arch to vertex within 24 hours to evaluate for vascular occlusion 7
12-lead ECG to identify arrhythmias like atrial fibrillation that could cause embolic stroke 7, 8
Laboratory tests including complete blood count, electrolytes, glucose, renal function, coagulation studies (PT/INR, aPTT), and troponin 7, 1, 2
Check blood glucose immediately to exclude hypoglycemia, which is a common stroke mimic that can present with focal neurological symptoms 3, 4, 2

Seizures with post-ictal Todd's paralysis presenting as focal weakness 1
Hypoglycemia or other metabolic derangements (electrolyte abnormalities, hepatic encephalopathy) 1
Complicated migraine with aura causing transient focal neurological symptoms 1
Brain tumors or subdural hematoma causing progressive focal deficits 1
Toxic ingestions or medication effects 1

Do not administer thrombolytic therapy or antiplatelet agents until hemorrhagic stroke is definitively excluded by imaging, regardless of how convincing the clinical presentation appears 1, 6
Do not assume stroke type based on severity alone, as there is substantial overlap between hemorrhagic and ischemic presentations 6