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Difficulty: EasyDiagnostic Workup and Test Sequencing

Emergency medical services bring a 72-year-old woman to the acute care bay because she suddenly developed right-sided weakness, right facial droop, and severe expressive aphasia exactly 45 minutes prior to arrival. Her current blood pressure is 175/95 mmHg, and her heart rate is 92/min with an irregularly irregular rhythm. Medical records indicate a history of hypertension and atrial fibrillation, for which she recently stopped taking her anticoagulant medication. The clinical presentation is highly suspicious for an acute ischemic stroke. Which of the following are the most critical initial diagnostic tests that should be ordered immediately to determine her eligibility for acute pharmacological reperfusion therapy? (Select all that apply)

  1. Non-contrast computed tomography (CT) scan of the headAnswer
  2. Point-of-care blood glucose measurementAnswer
  3. C
    Magnetic resonance imaging (MRI) of the brain with intravenous contrast
  4. D
    Transesophageal echocardiogram (TEE)
  5. E
    Lumbar puncture for cerebrospinal fluid analysis

Answer

The most critical initial diagnostic tests are a non-contrast CT scan of the head and a point-of-care blood glucose measurement.
In a patient presenting with hyperacute focal neurologic deficits within the thrombolytic time window, the immediate priority is to determine eligibility for pharmacological reperfusion. The absolute minimum diagnostic tests required before administration are a non-contrast head CT (to definitively rule out intracranial hemorrhage) and a point-of-care blood glucose measurement (to rule out profound hypoglycemia, which is a common, easily reversible stroke mimic). Other tests should not delay these critical, time-sensitive steps.

Step-by-Step Solution

1
Identify the hyperacute presentation of focal neurologic deficits
The patient is within the standard 4.5-hour time window for intravenous thrombolytic therapy.
Establishing the timeline determines the urgency and specific pathway of diagnostic testing.
2
Select imaging to rule out absolute contraindications to thrombolytics
Non-contrast head CT is chosen.
It rapidly and definitively rules out intracranial hemorrhage, which strictly contraindicates the use of tissue plasminogen activator (tPA).
3
Select laboratory testing to rule out common stroke mimics
Point-of-care blood glucose is chosen.
Severe hypoglycemia must be excluded immediately, as it can present with identical focal symptoms and requires completely different management.

Key Concept

The immediate evaluation of a suspected acute stroke requires a non-contrast head CT to rule out hemorrhage and a blood glucose check to rule out hypoglycemia before administering any reperfusion therapy.
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Diagnostic Workup and Test Sequencing

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