How do you work up an ischemic CVA?

A) Initial Evaluation

 • ABCs

 • IV access, monitor

 • Finger glucose

 • Medication administration review

 • Physical exam (complete neuro, NIHSS)

 • Non-contrast CT (NCCT) head (r/o hemorrhage and other mimics)

B) Evaluate ischemic CVA (core, penumbra)

 • Can be visualized on a NCCT or

 • MRI brain w/o contrast (most sn/sp) or

 • CTA +/- CTP (if available)

C) Evaluate underlying cause & classify (TOAST)

Intracranial/Extracranial:

 • Detected on NCCT vs MRI w/o contrast

 • Carotid US

Cardioembolic:

 • ECG + 24 hr telemetry monitoring

 • TTE +/- TEE (high Afib suspicion)

 • +/- bubble study (r/o PFO if <60 y)

 • +/- loop v Holter (r/o Afib)

Other: 

 • CBC, coags

 • +/- hypercoagulable w/u

 • +/- Cerebral angiography

 • +/- Vit B12, TSH, RPR

Cryptogenic - Defined if

1) CT/MRI-confirmed non-lacunar CVA

2) No major-risk embolic source

3) Relevant vasculature w/o > 50% stenosis

4) Ruled out other causes



- Dr. Uday Gulati, DO @udaygulati



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