Imaging.

All patients with suspected stroke should have an emergency unenhanced

CT scan or MRI to differentiate ischemic from hemorrhagic stroke and to identify
tumor or mass effect (suggesting large stroke). Ischemic stroke is the most likely
diagnosis when the CT scan does not show hemorrhage, tumor, or focal infection,
and the history does not suggest migraine, hypoglycemia, encephalitis, or SAH.
1. CT/MRI CT/MRI is used to determine the location, type (ischemia or hemorrhage),
and complications of stroke (edema, mass effect, hydrocephalus). It is also used to
exclude nonvascular causes of neurologic symptoms (tumors, hydrocephalus). MRI
is more sensitive than CT scan for detecting brain infarction within the fi rst 72
hours and for evaluating the posterior fossa (brainstem and cerebellum), but CT can
more easily differentiate hemorrhage from ischemia in acute lesions. Diffusion/
perfusion-weighted MRI is particularly useful in identifying infarcted brain and
underperfused brain regions at risk for infarction if reperfusion does not occur. Using
contrast dye, CT perfusion studies can be done quickly in an emergency setting. The
sensitivity of CT scan for detecting subarachnoid blood drops from 95% on day 1 to
50% at 1 week. LP is required for suspected SAH in patients with normal CT.
2. Doppler ultrasound. Duplex ultrasound is warranted to assess stenosis or
occlusion of the carotid and vertebral arteries in the neck. TCD can be used to
assess the direction and velocity of blood fl ow in the circle of Willis and to identify
stenotic or occlusive vascular lesions in the anterior and posterior circulations. TCD
can also be used to detect silent emboli and right-to-left vascular shunts.
3. MRA and CTA. MRA is used to screen for severe occlusive disease of extracranial
arteries and intracranial large arteries. It is also used to screen for aneurysms in
patients with predisposition (e.g., fi bromuscular dysplasia, polycystic kidneys). CTA
is less prone to artifact from turbulence or complex fl ow patterns than is MRA.
4. Cerebral angiography. Angiography is used to defi ne the nature, location, and
severity of vascular occlusive disease and to identify vascular abnormalities leading
to brain hemorrhage (saccular aneurysm, AVM). Cerebral angiography is best used
in conjunction with brain imaging (CT, MRI) and noninvasive vascular screening
modalities (ultrasound, MRA, CTA).
5. Lumbar puncture. LP is used to diagnose SAH when CT/MRI are unavailable or
negative (i.e., when bleeding is minor or several days old); the absence of blood on
LP excludes the diagnosis of SAH. LP is also important when CNS infection
(meningitis, meningovascular syphilis) is suspected.
6. Echocardiogram. Echocardiography is used to assess the nature and extent of
myocardial/valvular disease when cardiogenic embolism is suspected to be the
etiology of stroke. Transesophageal echo is more sensitive than transthoracic echo
for the detection of aortic atherothrombotic debris, aortic dissection, atrial septal
aneurysms, left atrial clot, infectious endocarditis, and shunts. .
7. Electrocardiography. The ECG is used to detect myocardial ischemia/infarction,
arrhythmias, and chamber enlargement that suggests cardiomyopathy or valvular
heart disease.
8. Holter monitoring. Ambulatory ECG monitoring is used to detect paroxysmal
arrhythmia when suspected as a cause of cardiogenic embolism.

9. Electroencephalography. EEG is useful for suspected seizures but not for clarifi
cation of stroke subtype or stroke severity.