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Stroke - Diagnosis

Description

An in-depth report on the causes, diagnosis, treatment, and prevention of stroke.

Alternative Names

Transient ischemic attack; TIA

Diagnosis:

Many of the same procedures are used to diagnose a stroke and to evaluate the risk of future major stroke in patients who have had a transient ischemic attack (TIA). A diagnostic work-up includes physical and neurological examinations, patient� ' s medical history, blood tests (to measure blood glucose levels, blood coagulation time, cardiac enzymes, and other factors), and imaging tests.

For patients who have suffered a major stroke, the first step is to determine as quickly as possible whether the stroke is ischemic (caused by blood clot blockage) or hemorrhagic (caused by bleeding). Clot-busting drug therapies can be life-saving for ischemic stroke patients, but they are effective only in the first 3 hours. However, if the stroke is caused by a hemorrhage, thrombolytic drugs cause will likely increase the bleeding and can be lethal.

Imaging Tests Used for Stroke and Risk Factors for Stroke

Carotid Ultrasound. Carotid ultrasound procedures such as carotid duplex are valuable tools for measuring the width of the artery and how the blood flows through it. Carotid ultrasound can help determine the severity of plaque build-up and narrowing and blocking of the carotid arteries (carotid stenosis).

Carotid duplex is an ultrasound procedure performed to assess blood flow through the carotid artery to the brain. High-frequency sound waves are directed from a hand-held transducer probe to the area. These waves "echo" off the arterial structures and produce a two-dimensional image on a monitor, which will make obstructions or narrowing of the arteries visible.

Computed Tomography and Magnetic Resonance Imaging. An important decision when someone presents to the emergency room with a possible stroke is whether or not to use clot busting drugs. If stroke is due to bleeding (hemorrhagic stroke), these drugs can be dangerous. If stroke is due to a blood clot (ischemic stroke), clot busting drugs given within the first three hours after symptoms begin can make the stroke less severe.

Evidence of bleeding can usually be seen with computed tomography (CT) scan soon after symptoms begin. The CT scan can also help indicate whether a stroke is relatively new or recent. Magnetic resonance imaging (MRI) scans are less accurate at being able to differentiate between a hemorrhagic stroke and an ischemic stroke during the first few hours after symptoms begin. Also, MRI scans are not as easily available, take longer to perform, and make it more difficult to manage an ill patient while being done

For these reasons, the CT scan is almost always the first test performed to evaluate stroke. The goal is to complete the CT examination and obtain and interpret the results within 45 minutes of arrival at the hospital.

Cerebral Angiography. Cerebral angiography is an invasive procedure that may be used for patients with TIAs who need surgery. It can also detect aneurysms and monitor thrombolytic therapy. It requires the insertion of a catheter into the groin, which is then threaded up through the arteries to the base of the carotid artery. At this point a dye is injected, and x-rays, CTs, or MRI scans determine the location and extent of the narrowing, or stenosis, of the artery.

Magnetic Resonance Angiography (MRA) and Computerized Tomography Angiography. Magnetic resonance angiography and computerized tomography angiography are noninvasive ways of evaluating the carotid arteries and the arteries in the brain. In many situations, these tests can be used instead of cerebral angiography, an invasive procedure which carries a risk for bleeding in stroke.

Other Techniques. Other imaging tests, including positron-emission tomography (PET) and single photon-emission computed tomography (SPECT), may also help the doctor identify injuries caused by the stroke.

Heart Evaluation

Electrocardiogram (ECG). A heart evaluation using an electrocardiogram (ECG) is important in any patient with a stroke or suspected stroke. An ECG records the electrical current in the heart muscle.

Echocardiogram. An echocardiogram uses ultrasound to view the chambers and valves of the heart. It is generally useful for stroke patients to identify blood clots or risk factors for blood clots that can travel to the brain and cause stroke. There two are types:

Transthoracic echocardiograms (TTE) view the heart through the chest. It is noninvasive and is the standard approach.
Transesophageal echocardiogram (TEE) examines the heart using an ultrasound tube that the patient literally swallows and passes down the throat. It is uncomfortable and requires sedation. It is typically used to obtain more accurate images of the heart if a TTE has suggested abnormalities, such as atrial fibrillation or patent foramen ovale (PFO).

ABCD² Score

Patients who have a TIA are at increased risk for a major stroke in the days and weeks that follow. The ABCD² score is a tool that helps doctors predict short-term stroke risk following a TIA. The ABCD² score assigns points for various factors, including:

Age (over 60 years)
Blood pressure (greater or equal to 140/90 mm Hg)
Clinical features (weakness on one side of the body, speech impairment without weakness)
Duration of TIA symptoms (at least 60 minutes)
Diabetes

Based on the number of points, a doctor can identify whether a patient is at low, moderate, or high risk of having a stroke within 2 days after a TIA. The ABCD² score can help doctors better decide which patients need hospitalization and emergency care.

Resources

www.strokeassociation.org -- American Stroke Association
www.americanheart.org -- American Heart Association
www.stroke.org -- National Stroke Association
www.ninds.nih.gov -- National Institute of Neurological Disorders and Stroke
www.aphasia.org -- National Aphasia Association
www.aan.com -- American Academy of Neurology
www.strokecenter.org/trials -- Stroke Trials Directory

References

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Reviewed last on: 5/21/2009
Harvey Simon, MD, Editor-in-Chief, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.

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