Management of Stroke Diagnosed on MRI

Initial Assessment and Imaging

The American College of Radiology recommends that all patients with suspected stroke must undergo immediate non-contrast brain CT or MRI to distinguish between ischemic and hemorrhagic stroke 2, 3
If hemorrhage is detected on MRI, further vascular imaging (CTA) should be performed to evaluate for underlying vascular malformations or aneurysms, as recommended by the American College of Radiology 4
For ischemic stroke, vascular imaging with CT angiography (CTA) including extracranial and intracranial arteries should be performed to guide hyperacute care, according to the International Journal of Stroke 2, 3
Advanced imaging such as CT perfusion (CTP) or multiphase/dynamic CTA should be considered to assess cerebral blood flow and collateral vessels, but should not delay treatment, as stated by the International Journal of Stroke 2, 3

The American Heart Association recommends that for patients presenting within 0-3 hours of symptom onset, IV tPA (alteplase) is strongly recommended if no contraindications exist, with a strength of evidence classified as high 1, 5
Presence of intracranial hemorrhage is an absolute contraindication for IV tPA, as stated by the American College of Radiology 1, 4
Large acute hypodensity on CT is a relative contraindication for IV tPA, according to the American College of Radiology 1
For patients presenting within 3-4.5 hours, IV tPA remains beneficial despite increased risk of symptomatic intracranial hemorrhage, with a strength of evidence classified as moderate 1, 5
The American Stroke Association recommends that endovascular thrombectomy should be considered for patients with large vessel occlusion, especially if presenting within 6 hours of symptom onset, with a strength of evidence classified as high 1, 6
Selected patients may benefit from thrombectomy up to 24 hours based on advanced imaging, as stated by the American College of Cardiology 6

The American College of Radiology recommends that if MRI shows intracerebral hemorrhage, immediate neurosurgical consultation should be obtained 4
CTA should be performed to evaluate for underlying vascular abnormalities, as recommended by the American College of Radiology 4
Blood pressure should be carefully managed according to the location and cause of hemorrhage, according to the American College of Radiology 4

The American Heart Association recommends that electrocardiogram (ECG) should be performed to assess baseline cardiac rhythm, but should not delay acute treatment decisions, with a strength of evidence classified as low 2, 3
For suspected cardioembolic stroke, prolonged ECG monitoring (up to 30 days) should be considered to detect paroxysmal atrial fibrillation, as stated by the International Journal of Stroke 2
New onset seizures occurring within 24 hours of stroke should be treated with appropriate short-acting medications if not self-limited, according to the International Journal of Stroke 3
Prophylactic use of anticonvulsant medications is not recommended, as stated by the International Journal of Stroke 2, 3

The American Stroke Association recommends that patients should initially be admitted to a monitored stroke unit bed until stabilization (minimum 24 hours) 9
Frequent neurological checks using standardized scales (preferably NIHSS) should be performed several times per day, as recommended by the American Stroke Association 9
Adequate tissue oxygenation should be maintained to prevent hypoxia and potential worsening of brain injury, according to the American Heart Association 7, 8