Acute Stroke Evaluation and Management

Critical Clinical Context

The American College of Radiology recommends immediate MRI brain with and without contrast, including diffusion-weighted imaging (DWI), to evaluate for acute stroke in patients with acute onset of aphasia and altered sensorium, even with a normal initial CT scan 1, 2
Acute aphasia is a focal neurologic deficit indicating stroke until proven otherwise, and normal head CT does not exclude acute ischemic stroke, as CT has poor sensitivity for early infarction, particularly in the first 6-24 hours 1, 2
The history of uterine mass raises concern for cardioembolic stroke from potential tumor embolization or hypercoagulability associated with malignancy 3

The American College of Radiology recommends obtaining emergent MRI brain with DWI sequences to detect acute ischemia with high sensitivity, even when CT is normal 1, 2
MRI detects 70% of ischemic strokes missed on initial presentation with altered mental status, and DWI sequences identify acute infarction within minutes of onset, while CT may remain normal for hours 1, 2
MRI better characterizes small infarcts, posterior circulation strokes, and brainstem lesions that commonly present with dizziness and altered sensorium 1, 4

The American College of Radiology recommends checking complete blood count, comprehensive metabolic panel, and coagulation studies to identify metabolic causes and assess bleeding risk 1
Measuring CA-125 is recommended if not already done, as elevated levels with uterine mass suggest potential metastatic disease 3
Documenting specific aphasia type and assessing for additional focal deficits, such as facial droop, arm drift, and visual field cuts, is crucial for localizing the lesion 1, 2

The American College of Radiology advises against relying on normal CT to exclude stroke in this presentation, as CT sensitivity for acute ischemia is only 12-26% in the first 6 hours 1, 2
The National Comprehensive Cancer Network recommends considering cancer-related complications, such as hypercoagulability, tumor emboli, and metastatic disease, in patients with known uterine mass 3

The American College of Radiology recommends deferring pelvic imaging until the neurologic emergency is addressed, and then obtaining pelvic MRI with contrast to characterize the uterine mass and assess for metastatic disease 3, 5
High-risk uterine tumors have a propensity for extrauterine spread and neurologic complications, and CT chest/abdomen/pelvis with contrast is recommended to stage disease if malignancy is confirmed 3