Clinical Guidelines for Acute Stroke Management - Living on the EDge

this test. Doppler ultrasound is widely available and
useful in most centres. Non invasive measures <strong>for</strong>
symptomatic events were much less accurate <strong>for</strong>
patients with 50-70% stenosis, however, too few
data exist and no clear conclusions can be made. 102
Carotid surgery is most beneficial early after nonseverely
disabling stroke (see section 7.7) and hence
carotid imaging should be undertaken as part of the
initial diagnostic workup in selected patients.
C. Cardiac imaging
Echocardiography may be considered to determine a
potential cardioembolic source in selected patients
(e.g. history of cardiac abnormalities or an abnormal
electrocardiogram where there are no current
indications <strong>for</strong> anticoagulation or in patients with
stroke of unknown origin after standard diagnostic
workup). 116 Transthoracic echocardiography (TTE) is
less invasive but less sensitive than transesophageal
echocardiography (TEE) in detecting sources of
cardiac emboli in patients with TIA or stroke. 116 TEE
also appears more useful than TTE in assisting clinical
decision making (i.e. aid decision whether to
commence anticoagulation or not). 117
3.3 IMAGING GRADE LEVEL
a) All patients with suspected stroke should have an urgent brain CT or MRI A Level I
(‘urgent’ is considered as soon as possible, but certainly less than
diagnostic
24 hours). study 100
b) A repeat brain CT or MRI should be considered urgently when a patient’s ✓ –
condition deteriorates.
c) All patients with carotid territory symptoms who would potentially be B Level I 102
candidates <strong>for</strong> carotid re-vascularisation should have an urgent carotid
duplex ultrasound.
d) Further brain, cardiac or carotid imaging should be undertaken in selected B Level I
cases including:
100, 102
and
• Patients where initial assessment has not confirmed likely source of Level III-2 116
ischaemic event;
• Patients with a history of more than one TIA;
• Patients likely to undergo carotid surgery.
Section 3 Early Assessment and Diagnosis
3.4 Investigations
Once clinical diagnosis has been made, investigations
are used to confirm the diagnosis and to determine
the potential cause of the event, specifically if there is a
cardiac or arterial source. Routine investigations
should include full blood count, electrolytes, renal
function, cholesterol and glucose levels and
electrocardiogram although direct evidence is lacking
<strong>for</strong> each of these investigations. If clinical history,
imaging and routine investigations do not adequately
diagnose the underlying cause then further
investigations may be warranted. Many tests exist
and need to be considered based on individual patient
needs. For example, thrombophilia screening may
be needed when the clinical history identifies a family
history of thrombosis (particularly <strong>for</strong> those