Original articleImaging 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
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
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The primary goal of imaging patients with acute stroke symptoms is to distinguish between hemorrhagic and ischemic stroke.
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Early identification of the stroke etiology or mechanism (carotid atherosclerotic disease or other treatable causes) is critical to treatment decisions and long-term management.
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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.
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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.
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Max Wintermark and Pina C. Sanelli are co-first authors of this article.