Original article
Imaging Recommendations for Acute Stroke and Transient Ischemic Attack Patients: A Joint Statement by the American Society of Neuroradiology, the American College of Radiology and the Society of NeuroInterventional Surgery

https://doi.org/10.1016/j.jacr.2013.06.019Get rights and content

In the article entitled “Imaging Recommendations for Acute Stroke and Transient Ischemic Attack Patients: A Joint Statement by the American Society of Neuroradiology, the American College of Radiology and the Society of NeuroInterventional Surgery”, we are proposing a simple, pragmatic approach that will allow the reader to develop an optimal imaging algorithm for stroke patients at their institution.

Section snippets

Imaging Patients Presenting With Acute Stroke Symptoms

The initial step in the evaluation of patients with symptoms of acute stroke is to differentiate between hemorrhagic and ischemic stroke (Fig. 1). For patients with acute ischemic stroke who are candidates for intravenous (IV) tissue plasminogen activator (tPA), noncontrast CT (NCCT) of the head should be performed to determine eligibility for treatment. IV tPA can then be initiated without waiting for further imaging. In patients under consideration for endovascular therapy, 3 imaging options

Imaging Patients With Intracranial Hemorrhage

If intraparenchymal hemorrhage is present, as occurs in 15% of all strokes, the imaging evaluation in the acute phase may include CTA of the intracranial arteries for evaluation of an underlying vascular malformation or aneurysm [1, 2, 3]. MRI without and with contrast is sometimes obtained to assess for an underlying neoplastic or vascular mass or associated microhemorrhages that may suggest amyloid angiopathy, multiple cavernous malformations, or septic emboli, among other etiologies. In the

Imaging Patients With Acute Ischemic Stroke Who are Candidates for IV Thrombolysis

Treatment options are considered for patients with acute ischemic stroke without intracranial hemorrhage present on imaging. FDA guidelines for the administration of IV thrombolysis include imaging to exclude intracranial hemorrhage and its interpretation by a physician with appropriate expertise. Completion of this initial imaging within 45 min of the patient admission to the emergency department is a CMS Hospital Outpatient Quality Reporting Program measure [4, 5, 6]. There is strong evidence

Imaging Patients With Acute Ischemic Stroke Who are Candidates for Endovascular Revascularization

There is limited evidence supporting the use of intra-arterial thrombolytic agents up to 6 hours after symptom rest. Also, the evidence supporting improved clinical outcomes with first-generation mechanical embolectomy devices up to 8 hours after symptom onset, compared with standard medical care, has recently been challenged by the results of the Mechanical Retrieval and Recanalization of Stroke Clots Using Embolectomy [16], Interventional Management of Stroke III [17], and Intra-Arterial

Imaging Patients With Acute Ischemic Stroke Who are not Candidates for IV or Endovascular Therapy and Patients With Tias

When acute revascularization therapy is not being considered, the role of imaging is focused primarily on diagnosis, prevention of immediate complications, and the identification of potentially treatable causes of future stroke. In patients with TIAs, multimodal MRI is preferred, and NCCT should be performed only if MRI is not available, as NCCT has limited utility in patients whose symptoms have resolved [24]. DWI can demonstrate lesions in approximately 40% of patients with TIAs [25, 26, 27],

Imaging the Cervical Arteries in Patients With Acute Stroke and Tias

In patients with acute stroke, vascular imaging should be performed to evaluate the mechanism of stroke and assess risk for future stroke [1]. Overall, vascular imaging with duplex ultrasound, CTA, MRA, or digital subtraction angiography has good agreement. Concordant results from at least two noninvasive imaging techniques can be used to determine treatment eligibility for revascularization procedures.

Take-Home Points

  • The primary goal of imaging patients with acute stroke symptoms is to distinguish between hemorrhagic and ischemic stroke.

  • Early identification of the stroke etiology or mechanism (carotid atherosclerotic disease or other treatable causes) is critical to treatment decisions and long-term management.

  • In acute stroke patients who are candidates for IV thrombolysis (0-hour to 4.5-hour time window), either noncontrast CT or MRI of the brain is recommended to exclude intracranial hemorrhage and

Acknowledgments

We thank Judy Burleson, MHSA, director of metrics, ACR, and Christine Waldrip, RN, MHA, program manager, ACR Appropriateness Criteria®, for the support they provided in the preparation of this report.

References (31)

  • Tissue plasminogen activator for acute ischemic stroke

    N Engl J Med

    (1995)
  • H.P. Adams et al.

    Guidelines for thrombolytic therapy for acute stroke: a supplement to the guidelines for the management of patients with acute ischemic strokeA statement for healthcare professionals from a special writing group of the Stroke Council, American Heart Association

    Circulation

    (1996)
  • W. Hacke et al.

    Intravenous thrombolysis with recombinant tissue plasminogen activator for acute hemispheric strokeThe European Cooperative Acute Stroke Study (ECASS)

    JAMA

    (1995)
  • W. Hacke et al.

    Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic stroke

    N Engl J Med

    (2008)
  • R. von Kummer et al.

    Sensitivity and prognostic value of early CT in occlusion of the middle cerebral artery trunk

    AJNR Am J Neuroradiol

    (1994)
  • Cited by (64)

    • A review on the association of thrombus composition with mechanical and radiological imaging characteristics in acute ischemic stroke

      2021, Journal of Biomechanics
      Citation Excerpt :

      However, there are currently no guidelines on the preferred use of stent retrievers, aspiration catheters or combined approaches for thrombi based on composition (Powers et al., 2019). The primary imaging techniques currently used in the setting of AIS are non-contrast computed tomography (NCCT), CT angiography (CTA), magnetic resonance imaging (MRI) and digital subtraction angiography (DSA) (Wintermark et al., 2013). These imaging modalities can provide both qualitative and quantitative information on the thrombus.

    • Telestroke

      2018, Neuroimaging Clinics of North America
      Citation Excerpt :

      A critical evaluation for early or evolving subacute ischemic signs is imperative in decision making for IV t-PA. Approximately 60% of all cerebral infarctions are seen on an NCCT in the first 3 hours to 6 hours, with overall sensitivity of 64% and specificity of 85%.38,39 In up to 60%, ischemia in the lentiform nuclei (deep gray-matter nuclei) can be visible in as little as 1 hour of occlusion.

    View all citing articles on Scopus

    The full version of this article appears in the American Journal of Neuroradiology http://www.ajnr.org/content/early/2013/08/01/ajnr.A3690.full.pdf+html.

    1

    Max Wintermark and Pina C. Sanelli are co-first authors of this article.

    View full text