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Difficulty: EasyDiagnostic Workup and Test Sequencing

A 68-year-old man is brought to the emergency department by ambulance 30 minutes after his wife noticed him slurring his words and unable to move his right arm and leg. He has a medical history of hypertension and type 2 diabetes mellitus. His blood pressure is 180/100 mm Hg, pulse is 92/min, and respirations are 16/min. Neurologic examination reveals right-sided facial droop, right-sided hemiparesis, and expressive aphasia. Which of the following are the most appropriate immediate next steps in the diagnostic workup? (Select two)

  1. Non-contrast computed tomography of the headAnswer
  2. Point-of-care capillary blood glucoseAnswer
  3. C
    Magnetic resonance imaging of the brain
  4. D
    Transthoracic echocardiography
  5. E
    Lumbar puncture

Answer

The most appropriate immediate next steps are to obtain a non-contrast computed tomography of the head and a point-of-care capillary blood glucose measurement.
In a patient presenting with acute focal neurologic deficits highly suspicious for stroke, the immediate priority is to determine candidacy for reperfusion therapy (e.g., thrombolysis). This requires two immediate tests: a non-contrast head CT to rapidly rule out intracranial hemorrhage (an absolute contraindication to thrombolytics), and a point-of-care blood glucose test to rule out severe hypoglycemia, which can present as a stroke mimic.

Step-by-Step Solution

1
Recognize the clinical presentation of an acute stroke.
The patient presents within the therapeutic window for thrombolysis with focal neurologic deficits (hemiparesis, aphasia).
Identifying the presentation establishes the immediate need to rule out contraindications to tissue plasminogen activator (tPA) administration.
2
Determine the fastest neuroimaging modality to rule out hemorrhage.
Select a non-contrast head CT.
A non-contrast head CT is rapidly available, takes only minutes, and definitively identifies intracranial hemorrhage, which is an absolute contraindication to tPA.
3
Identify easily reversible mimics of acute stroke.
Select a point-of-care blood glucose test.
Hypoglycemia is a well-known stroke mimic and must be excluded immediately before proceeding with stroke protocols.

Key Concept

The hyperacute evaluation of a suspected ischemic stroke requires immediate exclusion of intracranial hemorrhage via non-contrast CT and exclusion of hypoglycemia via a point-of-care blood glucose check.
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Diagnostic Workup and Test Sequencing

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