Acute Ischemic Stroke

Acute Ischemic Stroke - Early Management

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ÎÎA noninvasive intracranial vascular study is strongly recommended during the initial imaging evaluation of the acute stroke patient if either intra-arterial fibrinolysis or mechanical thrombectomy is being considered for management but should not delay IV rtPA if indicated (I-A). ÎÎIn IV fibrinolysis candidates, the brain imaging study should be interpreted within 45 minutes of patient arrival in the ED by a physician with expertise in reading CT and MRI studies of the brain parenchyma (I-C). ÎÎCT perfusion and MRI perfusion and diffusion imaging, including measures of infarct core and penumbra, may be considered for the selection of patients for acute reperfusion therapy beyond the time windows for IV fibrinolysis (IIb-B). Note: These techniques provide additional information that may improve diagnosis, mechanism, and severity of ischemic stroke and allow more informed clinical decision making. ÎÎFrank hypodensity on non–contrast-enhanced CT may increase the risk of hemorrhage with fibrinolysis and should be considered in treatment decisions. If frank hypodensity involves more than one third of the middle cerebral artery territory, IV rtPA treatment should be withheld (III-A). For patients with cerebral ischemic symptoms that have resolved: ÎÎNoninvasive imaging of the cervical vessels should be performed routinely as part of the evaluation of patients with suspected TIAs (I-A). ÎÎNoninvasive imaging by means of CT angiography or magnetic resonance angiography of the intracranial vasculature is recommended to exclude the presence of proximal intracranial stenosis and/or occlusion (I-A) and should be obtained when knowledge of intracranial steno-occlusive disease will alter management. Note: Reliable diagnosis of the presence and degree of intracranial stenosis requires the performance of catheter angiography to confirm abnormalities detected with noninvasive testing. ÎÎPatients with transient ischemic neurological symptoms should undergo neuroimaging evaluation within 24 hours of symptom onset or as soon as possible in patients with delayed presentations (I-B). Note: MRI, including diffusion-weighted imaging, is the preferred brain diagnostic imaging modality. If MRI is not available, head CT should be performed. 9

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