Diagnostic Approach for Suspected Cerebrovascular Events

Initial Assessment and Urgent Evaluation

The American Heart Association recommends that symptoms of right-sided numbness, especially upon waking, should be treated as a neurological emergency due to high suspicion for stroke, which requires immediate medical attention 2, 1
The Cincinnati Prehospital Stroke Scale should be used for rapid assessment, evaluating facial droop, arm drift, and speech abnormalities, with a probability of stroke being 72% if any of these three signs is abnormal 1
The American College of Cardiology suggests that fatigue, feverishness, and right-sided numbness upon waking should undergo immediate brain imaging with MRI to rule out acute ischemic stroke, as these symptoms strongly suggest a cerebrovascular event affecting the left hemisphere 1

Brain MRI with diffusion-weighted imaging is the preferred initial imaging modality to detect acute ischemic changes, according to the American Heart Association 1, 3
The American College of Radiology recommends that CT head without contrast can be performed if MRI is not immediately available to rule out hemorrhage 1
CT angiography or MR angiography should be included to evaluate for carotid and vertebral artery disease, as suggested by the American Heart Association 2
Laboratory tests should include complete blood count, basic metabolic panel, coagulation studies, blood glucose measurement, and inflammatory markers to assess for various conditions that may contribute to stroke risk, as recommended by the American College of Physicians 4, 3, 5

If initial imaging is negative but symptoms persist, consider electroencephalogram to rule out seizure activity, especially with transient symptoms, as suggested by the American Academy of Neurology 6
Lumbar puncture should be considered if infectious or inflammatory CNS disease is suspected, according to the World Federation of Neurosurgical Societies 7
Evaluation for cerebral venous thrombosis with MR venography should be considered if patient has risk factors or conventional imaging is negative, as recommended by the American Heart Association 5, 8

If symptoms occurred upon waking, evaluate for sleep-related breathing disorders, positional vertebrobasilar insufficiency, and nocturnal seizures, as suggested by the American Academy of Sleep Medicine and the American Epilepsy Society 3, 9, 6
If fever is a prominent symptom, consider infectious causes of stroke, systemic infections with neurological manifestations, and COVID-19 infection, as recommended by the Infectious Diseases Society of America and the World Health Organization 3, 7