Management of Acute Cerebrovascular Accident (CVA) Typing

Initial Diagnostic Approach

The American College of Cardiology recommends rapid neuroimaging with non-contrast CT to differentiate hemorrhagic from ischemic stroke, which must be completed within 45 minutes of emergency department arrival 1, 2
Non-contrast CT is the gold standard initial imaging modality for acute stroke typing because it rapidly excludes intracranial hemorrhage and provides necessary information for emergency management decisions 1, 2, 3, 4
The brain imaging study must be interpreted within 45 minutes of patient arrival by a physician with expertise in reading CT and MRI studies of the brain parenchyma 1

The American College of Cardiology states that acute hemorrhage appears as hyperdense foci on NCCT, and absence of such foci virtually excludes intracranial hemorrhage 4, 6
Intravenous fibrinolytic therapy is recommended even in the presence of early ischemic changes on CT, regardless of their extent, unless there is frank hypodensity involving more than one-third of the middle cerebral artery territory 1

Visualizing a vessel occlusion confirms the diagnosis of acute ischemic stroke, and its location guides treatment decisions, according to the American College of Cardiology 4, 6
Large vessel occlusions are less likely to recanalize with alteplase alone and should be considered for endovascular therapy 4
Time-consuming imaging methods and overly selective treatment selection criteria should be avoided because every 30-minute delay in recanalization decreases the chance of good functional outcome by 8-14% 3, 4

Clinical characteristics alone should not be relied upon to differentiate hemorrhagic from ischemic stroke, as symptoms such as vomiting and severe headache are not specific 5
A negative plain CT or MRI does not rule out cerebral venous thrombosis, and a venographic study must be performed if clinical suspicion remains 7

Every emergency department must be prepared to treat patients with acute stroke or have a plan for rapid transfer to a tertiary care center with neurology, neuroradiology, neurosurgery, and critical care facilities 5
Advance notice by emergency medical services to the emergency department significantly shortens time to CT scanning, and critical pathways for acute stroke management allow for more efficient care 5