TABLE 1.
Algorithm for standard stroke and TIA evaluation
| Type of evaluation | Examinations | Purpose and clinical comments |
|---|---|---|
| Stroke topography | CT and MRI of the brain |
To confirm the diagnosis of ischemic stroke and exclude stroke mimics To exclude lacunar infarctions |
| MRI superior to CT in detecting acute infarctions, essential in detecting clinically evident and subclinical strokes, small lesions and lesions in the brain stem and cerebellum that may be important to characterize the stroke mechanism | ||
| Infarct location, volume, and multiplicity (single territory vs. multi‐territory lesions) | ||
| Neurovascular evaluation | CTA/MRA of pre‐ and cerebral vessels |
Extracranial end intracranial vascular survey to exclude proximal occlusive atherosclerosis, dissection (MRI with fat‐suppressed images), and cerebral venous sinus thrombosis |
| Carotid duplex ultrasound | ||
| Cardiac evaluation | ECG | To rule out concomitant cardiac ischemia and screen for cardiac arrhythmias |
| 24–72 h telemetry or Holter monitoring | If no arrhythmia detected with preliminary monitoring | |
| TTE, TEE | To detect major‐risk cardioembolism sources 1 | |
| TTE for ventricular imaging, used first in patients with coronary artery disease, congestive heart failure, or other ventricular disease evident from history or ECG | ||
| TTE superior in detecting aortic arch atheroma and cardiac shunt (bubble test), visualization of the left arterial appendage and left atrium; in case of unrevealed TTE results | ||
| Cardiac biomarkers (troponin I or T, BNP, NT‐proBNP) | May predict underlying cardiac condition | |
| Screening for vascular risk factors and hypercoagulable states | Patient's history | Previous TIA or stroke, history of MI, angina, claudication, carotid bruit, venous thrombosis, migraine with aura |
| Smoking and alcohol abuse, family history Complications during pregnancy 2 | ||
| BP measurements | Hypertension | |
| Fasting glucose, HbA1c | Diabetes mellitus | |
| BMI | Overweight | |
| Lipid profile | Dyslipidemia | |
| Blood tests for thrombophilia in patients <50 years old | Atrial and venous hypercoagulability 3 |
Abbreviations: BMI, Body mass index; BNP, Brain natriuretic peptide; BP, Blood pressure; CT, Computed tomography; CTA/MRA, Angiography; ECG, Electrocardiogram; HbA1c, Glycated hemoglobin; MI, Myocardial infarction; MRI, Magnetic resonance tomography; NT‐proBNP, N‐Terminal pro‐b‐type natriuretic peptide; TEE, Transesophageal echocardiography; TTE, Transthoracic echocardiography.
Major‐risk cardioembolism sources: mechanical prosthetic valve, mitral stenosis with atrial fibrillation, atrial fibrillation/atrial flutter, sick sinus syndrome, myocardial infarction <4 weeks, left ventricular thrombus, dilated cardiomyopathy, akinetic left ventricular segment, left ventricular ejection fraction<30%, left atrial/atrial appendage thrombus, atrial myxoma and other cardiac tumors, infective endocarditis.
Pregnancy complications: hypertension, diabetes mellitus, preeclampsia/eclampsia, spontaneous miscarriages, venous thrombosis.
Arterial and venous hypercoagulability screening: d‐dimer, erythrocyte sedimentation rate, lupus anticoagulant, anticardiolipin and ß‐2 glycoprotein antibodies, antithrombin III activity, protein C and S functional, prothrombin 20210a mutation, Factor V Leiden gene mutation. Thrombophilia tests may be falsely abnormal in acute phase and testing should be delayed for several weeks and when a patient is off anticoagulation. Initially, positive antiphospholipid antibody result needs to be confirmed three months later.