DIAGNOSTIC EVALUATION FOR SECONDARY STROKE PREVENTION Recommendations for Diagnostic Evaluation Referenced studies that support recommendations are summarized in online Data Supplements 1 and 2. COR LOE Recommendations In patients suspected of having a stroke or TIA, an ECG is recommended to screen for atrial fibrillation (AF) and atrial flutter and to assess for other concomitant cardiac condi- In patients with ischemic stroke or TIA, a diag- nostic evaluation is recommended for gaining insights into the etiology of and planning opti- mal strategies for preventing recurrent stroke, with testing completed or underway within 48 hours of onset of stroke symptoms.42 45 In patients with symptomatic anterior circulation cerebral infarction or TIA who are candidates for revascularization, noninva- sive cervical carotid imaging with carotid ultrasonography, CT angiography (CTA), or magnetic resonance angiography (MRA) is recommended to screen for stenosis.46 50 In patients suspected of having a stroke or TIA, CT or MRI of the brain is recommended to confirm the diagnosis of symptomatic ischemic cerebral vascular disease.51 53 In patients with a confirmed diagnosis of symptomatic ischemic cerebrovascular disease, blood tests, including complete blood count, prothrombin time, partial throm- boplastin time, glucose, HbA1c, creatinine, and fasting or nonfasting lipid profile, are recommended to gain insight into risk factors for stroke and to inform therapeutic In patients with cryptogenic stroke, echocar- diography with or without contrast is reason- able to evaluate for possible cardiac sources of or transcardiac pathways for cerebral In patients with cryptogenic stroke who do not have a contraindication to anticoagula- tion, long-term rhythm monitoring with mobile cardiac outpatient telemetry, implantable loop recorder, or other approach is reasonable to detect intermittent AF.58 60 In patients suspected of having ischemic stroke, if CT or MRI does not demonstrate symptomatic cerebral infarct, follow-up CT or MRI of the brain is reasonable to confirm In patients suspected of having had a TIA, if the initial head imaging (CT or MRI) does not demonstrate a symptomatic cerebral infarct, follow-up MRI is reasonable to predict risk of early stroke and to support the In patients with cryptogenic stroke, tests for inherited or acquired hypercoagulable state, bloodstream or cerebral spinal fluid infections, infections that can cause central nervous system (CNS) vasculitis (eg, HIV and syphilis), drug use (eg, cocaine and amphetamines), and markers of systemic inflammation and genetic tests for inherited diseases associated with stroke are reason- able to perform as clinically indicated to identify contributors to or relevant risk factors In patients with ischemic stroke or TIA, noninvasive imaging of the intracranial large arteries and imaging of the extracranial vertebrobasilar arterial system with MRA or CTA can be effective to identify atheroscle- rotic disease, dissection, moyamoya, or other etiologically relevant vasculopathies.73 75 In patients with ischemic stroke and a treatment plan that includes anticoagulant therapy, CT or MRI of the brain before therapy is started may be considered to assess for hemorrhagic transformation and final size of infarction.76 In patients with ESUS, transesophageal echocardiography (TEE), cardiac CT, or cardiac MRI might be reasonable to identify possible cardioaortic sources of or transcardiac pathways for cerebral In patients with ischemic stroke or TIA in whom patent foramen ovale (PFO) closure would be contemplated, TCD (transcranial Doppler) with embolus detection might be reasonable to screen for right-to-left Synopsis Patients presenting with signs and symptoms of acute stroke will undergo an evaluation tailored to ensure that, when appropriate, they receive reperfusion therapy (Fig- ure 2). 