Review Question - QID 105003

This patient is presenting with left-sided body weakness, facial droop and slurred speech, which is concerning for acute stroke. For patients with signs and symptoms concerning for acute stroke that present within 4.5 hours of symptom onset, non-contrast CT scan of the head is the first step in management.

Acute stroke usually presents with focal neurologic deficits that follow a vascular distribution within the brain such as unilateral body weakness, dysarthria, vision loss, or sudden onset confusion. When any patient presents with sudden onset neurological deficits, an immediate non-contrast head CT should be performed to rule out intracranial hemorrhage. While uncommon, hypoglycemia may mimic acute stroke. All patients with suspected stroke should be evaluated with a point of care blood glucose to rule out hypoglycemia prior to work up for stroke. If the patient is presenting within 4.5 hours of symptom onset and an initial non-contrast head CT does not demonstrate a bleed, intravenous alteplase (tPA) can be given if the patient is an appropriate candidate.

Herpich et. al review the management of acute ischemic stroke. They discuss risk factors and pathogenesis as well as presenting features. They detail the initial workup of patients with suspected acute ischemic stroke, and recommend CT scan of the head without contrast as the initial imaging study.

Incorrect Answers:
Answer 1: Aspirin, with or without a statin or other anti-platelet agent may be indicated for patients with acute ischemic stroke that are not eligible for intravenous thrombolytic therapy or mechanical thrombectomy. Aspirin would not be appropriate in this patient prior to non-ontrast CT for exclusion of intracranial hemorrhage.

Answer 3: CT angiogram head and neck may eventually be indicated in this patient to assess for the presence of a large vessel occlusion and determine eligibility for mechanical thrombectomy. However, it is not the best initial imaging study.

Answer 4: Intravenous alteplase may eventually be indicated for this patient. However, a non-contrast CT head must first be obtained to exclude intracranial hemorrhage. In addition, patients must be evaluated for other contraindications (e.g. anticoagulant use, prior hemorrhagic stroke) to tPA prior to administration.

Answer 5: MRI brain may be indicated to more definitively rule out acute stroke or characterize infarction in a patient that presents with neurologic deficits and unremarkable CT imaging. However, it is not the most appropriate initial step in management.


Bullet Summary:
For patient's presenting with focal neurologic deficits concerning for acute stroke, the most appropriate initial imaging study is a CT head without contrast.