Guideline Recommendations for Diagnostic Workup of Stroke in Young Adults

Initial Imaging (Within the First Hour)

CT of the head without contrast is the most practical first test to rule out intracranial hemorrhage and to look for early ischemic changes. 2
MRI of the brain without contrast provides superior detection of small cortical, deep, and posterior‑fossa infarcts and can differentiate acute from chronic ischemia. 2
Complete brain imaging (CT or MRI) should be finished within 30 minutes of arrival to the emergency department. 4

Non‑invasive cervical and intracranial vascular imaging with CTA or MRA is essential to identify arterial dissection, large‑vessel atherosclerosis, and moyamoya disease. 1
CTA of the head and neck is the preferred rapid‑assessment modality for most patients. 5
Carotid duplex ultrasonography can be used to screen for stenosis when anterior‑circulation symptoms are present. 1
Transcranial Doppler ultrasonography detects intracranial vessel abnormalities and can be employed for embolus detection. 3

12‑lead ECG performed immediately screens for atrial fibrillation, atrial flutter, and acute myocardial infarction. 1
Continuous cardiac rhythm monitoring for at least 24–72 hours is recommended to capture intermittent arrhythmias. 4
Transesophageal echocardiography is reasonable in cryptogenic stroke to identify paradoxical embolism pathways and aortic sources of emboli. 1
Long‑term rhythm monitoring using mobile cardiac outpatient telemetry or an implantable loop recorder is reasonable for cryptogenic stroke to detect intermittent atrial fibrillation. 1
Transcranial Doppler with embolus detection may be used to screen for a right‑to‑left shunt when patent foramen ovale (PFO) closure is being considered. 1

Baseline laboratory panel should include a complete blood count, prothrombin time, partial thromboplastin time, glucose, HbA1c, creatinine, a fasting or non‑fasting lipid profile, and serologies for HIV and syphilis. 1

Imaging of the extracranial vertebrobasilar arterial system with MRA or CTA helps identify dissection and other vasculopathies. 1

Do not delay emergency treatment to obtain multimodal imaging; imaging should not postpone reperfusion therapy when patients are within the 3‑hour therapeutic window. 3
Routine chest radiography is not indicated unless there is specific clinical suspicion of pulmonary, cardiac, or vascular disease. 8
Prophylactic anticonvulsant drugs should not be given routinely to patients who have not experienced seizures. 10