Urgent Stroke Evaluation and Management

Immediate Triage and Assessment

The American Heart Association recommends treating stroke-like symptoms as a highest priority emergency, equivalent to acute myocardial infarction, regardless of symptom severity 2
Establishing the time of symptom onset is crucial, defined as when the patient was last at baseline or symptom-free, to guide timely interventions 2
Activating the stroke team/pathway immediately upon arrival is essential for prompt evaluation and treatment 2, 3
The American College of Emergency Physicians suggests performing a validated stroke screening using the FAST (Face, Arm, Speech, Time) assessment to quickly identify potential stroke patients 3, 4
Obtaining capillary blood glucose immediately is necessary to exclude hypoglycemia as a stroke mimic 2, 3
Assessing ABCs (airway, breathing, circulation) first is vital to ensure patient stability 2

The American Heart Association recommends non-contrast CT or MRI brain to exclude hemorrhage and confirm ischemia within 24 hours of symptom onset 1, 2, 5
CTA or MRA from aortic arch to vertex should be performed to assess extracranial and intracranial vasculature 1
Carotid imaging is necessary to identify symptomatic stenosis requiring revascularization 1

Complete blood count, electrolytes, renal function, coagulation studies (aPTT, INR), random glucose, and troponin should be conducted to identify potential stroke causes or comorbidities 1
A 12-lead ECG is recommended to assess for atrial fibrillation or other cardiac arrhythmias 1, 5
Lipid profile and HbA1c can be deferred to outpatient if needed, but are important for long-term stroke prevention 1

If symptoms began within 48 hours, the patient is at very high risk for recurrent stroke and requires immediate ED transfer with stroke capabilities 4, 6
If symptoms began 48 hours to 2 weeks ago, comprehensive evaluation by a stroke specialist within 24 hours is still necessary 1
If symptoms began >2 weeks ago, lower urgency but still needs neurologist evaluation within one month 1
Dizziness with speech impairment suggests posterior circulation involvement, a stroke pattern not typical of migraine, according to the International Journal of Stroke 1, 6