| Neuroimaging of brain and vessels |
| Magnetic resonance imaging (MRI) and MR angiography (MRA) to: |
| Exclude haemorrhage |
| Define extent and territory of infarct |
| Define vascular anatomy of circle of Willis and neck vessels |
| T1 weighted spin echo with fat saturation sequence to exclude dissection |
| Computed tomography (CT) scan to exclude haemorrhage if MR not available acutely |
| Conventional angiography if haemorrhage without coagulopathy or MRA normal |
| For those with haemorrhage |
| Basic coagulation studies and platelets |
| Conventional angiography if no bleeding diasthesis |
| For those with no infarct |
| Electroencephalogram (unihemispheric slowing in hemiplegic migraine) |
| For those with an infarct in a vascular distribution and/or cerebrovascular disease |
| Precordial echocardiography |
| Consider transoesophageal if normal (?same general anaesthetic as arteriogram) |
| Consider transcranial Doppler ultrasound with bubble contrast |
| Blood tests (4 ml EDTA, 6–8 ml citrated, 2 ml heparinised, 5 ml clotted) |
| Full blood count, differential white cell count, and erythrocyte sedimentation rate |
| Iron, folate, red cell folate, and haemoglobin electrophoresis if appropriate ethnic group |
| Protein S (total and free)2-150, and protein C2-150 |
| Antithrombin III2-150, heparin cofactor II2-150, plasminogen2-150, von Willibrand factor antigen, factor VIII2-150, factor XII2-150,and lupus anticoagulant |
| Anticardiolipin antibodies2-150 |
| Factor V Leiden and activated protein C resistance |
| Prothrombin 20210 gene |
| Total homocysteine2-150 (+ thermolabile methylene tetrahydrofolate reductase gene, serum folate, B6, and B12) |
| Fasting cholesterol and triglycerides and Lp(a) lipoprotein |
| Infection screen, includingMycoplasma, Chlamydia, Helicobacter, and Borrelia titres, and aspartate aminotransferase |
| Serum and cerebrospinal fluid to look for intrathecal production of antibodies to varicella zoster |
| Sleep study |
| For those with infarction in the territory supplied by the vertebrobasilar system (in addition) |
| x Ray cervical spine in flexion and extension |
| For those with infarction not in a typical vascular distribution |
| Cerebrospinal fluid lactate |
| Plasma ammonia and amino acids |
| Urine organic acids |
↵2-150 If performed acutely, must be repeated after 3 months.