In suspected acute stroke, what is the initial step to differentiate ischemic from hemorrhagic etiologies?

In suspected acute stroke, what is the initial step to differentiate ischemic from hemorrhagic etiologies?

• A. Non-contrast CT brain to rule out hemorrhage
• B. Lumbar puncture
• C. MRI brain
• D. CT angiography

Answer: (A)

In suspected acute stroke, the first priority is to distinguish hemorrhage from ischemia quickly, because treatment decisions (like giving thrombolytics) depend on it. A non-contrast CT scan of the brain is the best initial test because it can rapidly rule out intracranial hemorrhage, is widely available, and does not require contrast. If a bleed is seen, thrombolysis is avoided; if no bleed is detected, the patient may be eligible for reperfusion therapy within the approved window. Other options don’t fit as the first step for this purpose: lumbar puncture isn’t useful for acute differentiation, MRI is more sensitive but slower and not as readily available in the emergent setting, and CT angiography adds vascular detail after you’ve ruled out hemorrhage on non-contrast CT.

In suspected acute stroke, the first priority is to distinguish hemorrhage from ischemia quickly, because treatment decisions (like giving thrombolytics) depend on it. A non-contrast CT scan of the brain is the best initial test because it can rapidly rule out intracranial hemorrhage, is widely available, and does not require contrast. If a bleed is seen, thrombolysis is avoided; if no bleed is detected, the patient may be eligible for reperfusion therapy within the approved window.

Other options don’t fit as the first step for this purpose: lumbar puncture isn’t useful for acute differentiation, MRI is more sensitive but slower and not as readily available in the emergent setting, and CT angiography adds vascular detail after you’ve ruled out hemorrhage on non-contrast CT.