Differentiating Ischemic Infarct from Hemorrhagic Bleed in Acute Cerebrovascular Disease

Immediate Diagnostic Approach

Neuroimaging is absolutely mandatory to differentiate ischemic stroke from intracerebral hemorrhage, as clinical features alone have inadequate sensitivity and specificity to guide treatment decisions, according to the American Heart Association 1, 2.
Non-contrast CT head must be completed within 30 minutes of hospital admission to distinguish ischemic from hemorrhagic stroke, as recommended by the American College of Cardiology 3, 4.
CT is the gold standard for detecting acute hemorrhage and is the most practical first-line imaging modality, according to the American Stroke Association 2.
MRI with diffusion-weighted imaging (DWI) and gradient echo (GRE) or T2*-susceptibility-weighted sequences are as sensitive as CT for acute blood detection and more sensitive for prior hemorrhage, but time, cost, and availability often preclude emergent MRI, as noted by the American Heart Association 2, 3.
Do not delay imaging to obtain laboratory studies that won't change immediate management, as advised by the American College of Cardiology 1.

Vom sometime indicates intracerebral hemorrhage, according to the American Stroke Association 2.
Systolic blood pressure >220 mmHg may suggest intracerebral hemorrhage, as noted by the American College of Cardiology 3.
Severe headache sometimes indicates intracerebral hemorrhage, according to the American Heart Association 3.
Coma or decreased level of consciousness may suggest intracerebral hemorrhage, as recommended by the American Academy of Neurology 4.
Symptom progression over minutes to hours can indicate intracerebral hemorrhage, as advised by the American College of Cardiology 3.

Administer IV rtPA (0.9 mg, maximum 90 mg) if patient presents within 3 hours of symptom onset and has no contraindications, as recommended by the American Heart Association 3.
Blood pressure must be <185/110 mmHg before thrombolysis, then maintained <180/105 mmHg for 24 hours post-treatment, according to the American College of Cardiology 3, 4.
Start aspirin 160-300 mg within 48 hours of ischemic stroke onset, but typically after 24 hours if thrombolysis was given, as advised by the American College of Cardiology 3, 5.
Avoid aggressive BP lowering unless >220/120 mmHg—permissive hypertension may maximize cerebral blood flow, according to the American Heart Association 3.

Immediately discontinue and reverse any anticoagulation, as recommended by the American College of Cardiology 5.
For spontaneous ICH with hypertension presenting within 6 hours: reduce systolic BP acutely to target of 140 mmHg (strictly avoiding SBP <110 mmHg), according to the American Heart Association 5, 2.
Consider external ventricular drainage if hydrocephalus with decreased level of consciousness develops, as advised by the American Academy of Neurology 5.
Never administer aspirin, heparin, or any antithrombotic therapy, according to the American College of Cardiology 1.

Perform NIHSS assessment immediately upon arrival to quantify stroke severity and guide treatment decisions, as recommended by the American Academy of Neurology 3, 4.
Patients with NIHSS <15 are optimal candidates for early intervention, according to the American Heart Association 3.
Document the exact time of symptom onset or last known well—this determines eligibility for time-sensitive therapies, as advised by the American College of Cardiology 1, 5.

The entire evaluation from door to imaging interpretation to treatment decision must occur within 60 minutes for ischemic stroke patients eligible for thrombolysis, as recommended by the American Heart Association 3.
Triage as highest priority upon arrival 3.
Complete non-contrast CT within 30 minutes 3.
Obtain NIHSS score and verify symptom onset time 3.
Achieve door-to-needle time ≤30 minutes if thrombolysis indicated 3.