Neurovascular Imaging of the Acute Stroke Patient

Neuroimaging is critical to the appropriate management of the acute stroke patient. Numerous noninvasive imaging tools are available to characterize the relevant stroke physiology, and each has its advantages and disadvantages. The most important question is whether the stroke is ischemic or hemorrhagic in nature, as this will influence the diagnostic and therapeutic pathway. For ischemic strokes, IV tPA should be administered rapidly to eligible patients without evidence of intracranial hemorrhage. Vessel status and core infarct size are helpful to decide whether an endovascular approach is indicated. For hemorrhagic strokes, the location of the blood determines whether a vascular cause is likely and what type of lesion is present. Noninvasive vessel imaging is highly accurate for diagnosing aneurysms and arteriovenous malformations, which are amenable to surgical or endovascular treatment. In primary intraparenchymal bleeds, imaging may predict the risk of early hematoma growth and offer a target for future hemostatic therapies.