Investigations

A stroke is a medical emergency. Anyone suspected of having a stroke should be taken to a medical
facility immediately for evaluation and treatment. However, there are many other possibilities that can
be responsible for these symptoms. Other conditions that can mimic a stroke include:

• brain tumors,
• brain abscess (a collection of pus in the brain caused by bacteria or a fungus),
• migraine headache,
• bleeding in the brain either spontaneously or from trauma,
• meningitis or encephalitis,
• an overdose of certain medications, or
• an electrolyte imbalance in the body.

Computerized tomography: In order to help determine the cause of a suspected stroke, a special X-ray
test called a CT scan of the brain is often performed. A CT scan is used to look for bleeding or masses
within the brain that may cause symptoms that mimic a stroke, but are not treated with thrombolytic
therapy with TPA.

MRI scan: Magnetic resonance imaging (MRI) uses magnetic waves rather than X-rays to image the
brain. The MRI images are much more detailed than those from CT, but due to the length of time to do
the test and lack of availability of the machines in many hospitals, is not a first line test in stroke. While a
CT scan may be completed within a few minutes, an MRI may take more than an hour to complete. An
MRI may be performed later in the course of patient care if finer details are required for further medical
decision making. People with certain medical devices (for example, pacemakers) or other metals within
their body, cannot be subjected to the powerful magnetic field of an MRI.

Other methods of MRI technology: An MRI scan can also be used to specifically view the blood vessels
non-invasively (without using tubes or injections), a procedure called an MRA (magnetic resonance
angiogram). Another MRI method called diffusion weighted imaging (DWI) is being offered in some
medical centers. This technique can detect the area of abnormality minutes after the blood flow to a
part of the brain has ceased, whereas a conventional MRI may not detect a stroke until up to six hours
after it has started, and a CT scan sometimes cannot detect it until it is 12 to 24 hours old. Again, this is
not a first line test in the evaluation of a stroke patient, when time is of the essence.

Computerized tomography with angiography: Using dye that is injected into a vein in the arm, images
of the blood vessels in the brain can give information regarding aneurysms or arteriovenous
malformations. Moreover, other abnormalities of brain blood flow may be evaluated. With faster
machines and better technology, CT angiography may be done at the same time as the initial CT scan to
look for a blood clot within an artery in the brain. CT and MRI images often require a radiologist to
interpret their results.

Conventional angiogram: An angiogram is another test that is sometimes used to view the blood
vessels. A long catheter tube is inserted into an artery in the groin or arm and threaded into the arteries
of the brain. Dye is injected while X-rays are taken and information can be obtained about blood flow in
the brain. The decision to perform CT angiography versus conventional angiography depends upon a
patient's specific situation and the technical capabilities of the hospital.
Carotid Doppler ultrasound: A carotid Doppler ultrasound is a non-invasive test that uses sound waves
to look for narrowing or stenosis and decreased blood flow in the carotid arteries (the major arteries in
the front of the neck that supply blood to the brain).

Heart tests: Certain tests to evaluate heart function are often performed in stroke patients to search for
the source of an embolism. Electrocardiograms (EKG or ECG) may be used to detect abnormal heart
rhythms like atrial fibrillation that are associated with embolic stroke. Ambulatory rhythm monitoring
may be considered if the patient complains ofpalpitations or passing out episodes (syncope) and the
doctor cannot find reason for it on the EKG. The patient can wear a Holter monitor for 1-2 days and
sometimes longer looking from a potential electrical conduction problem with the heart.
Echocardiograms or ultrasounds of the heart can help evaluate the structure and function of the heart
including the heart muscle, valves and the motion of the heart chamber when the heart beats. As well,
specifically for stroke patients, this test may be able to find blood clots within the heart and the
presence of a patent foramen ovale, both potential causes of stroke.

Lumbar puncture

A lumbar puncture is required to rule out meningitis or subarachnoid hemorrhage when the CT scan is
negative but the clinical suspicion remains high.

Laboratory studies

Laboratory tests performed in the diagnosis and evaluation of ischemic stroke include the following:

Complete blood count (CBC): A baseline study that may reveal a cause for the stroke (eg, polycythemia,
thrombocytosis, thrombocytopenia, leukemia) or provide evidence of concurrent illness (eg, anemia).

Basic chemistry panel: A baseline study that may reveal a stroke mimic (eg, hypoglycemia,
hyponatremia) or provide evidence of concurrent illness (eg, diabetes, renal insufficiency).

Coagulation studies: May reveal a coagulopathy and are useful when fibrinolytics or anticoagulants are
to be used.

Cardiac biomarkers: Important because of the association of cerebral vascular disease and coronary
artery disease.

Toxicology screening: May assist in identifying intoxicated patients with symptoms/behavior mimicking
stroke syndromes.

Pregnancy testing: A urine pregnancy test should be obtained for all women of childbearing age with
stroke symptoms; recombinant tissue-type plasminogen activator (rt-PA) is a pregnancy class C agent.

Arterial blood gas analysis: In selected patients with suspected hypoxemia, arterial blood gas defines
the severity of hypoxemia and may be used to detect acid-base disturbances.