What is the management approach for a stroke diagnosed on Magnetic Resonance Imaging (MRI)?

Management of Stroke Diagnosed on MRI

The management of a stroke identified on MRI requires immediate brain and vascular imaging, followed by appropriate treatment based on stroke type, time of onset, and clinical presentation. 1

Initial Assessment and Imaging

• All patients with suspected stroke must undergo immediate non-contrast brain CT or MRI to distinguish between ischemic and hemorrhagic stroke 1
• If hemorrhage is detected on MRI, further vascular imaging (CTA) should be performed to evaluate for underlying vascular malformations or aneurysms 1
• For ischemic stroke, vascular imaging with CT angiography (CTA) including extracranial and intracranial arteries should be performed to guide hyperacute care 1
• 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 1

Management of Ischemic Stroke

Thrombolytic Therapy (IV tPA/Alteplase)

• For patients presenting within 0-3 hours of symptom onset:

  • IV tPA (alteplase) is strongly recommended if no contraindications exist 1
  • Presence of intracranial hemorrhage is an absolute contraindication 1
  • Large acute hypodensity on CT is a relative contraindication 1

• For patients presenting within 3-4.5 hours:

  • IV tPA remains beneficial despite increased risk of symptomatic intracranial hemorrhage 1, 2
  • The presence of early ischemic changes on CT (other than frank hypodensity) should not preclude treatment 1

• For patients with unknown time of onset:

  • Advanced imaging (diffusion-perfusion mismatch) can help select patients who might benefit from thrombolysis beyond standard time windows 1, 3

Endovascular Therapy

• For patients with large vessel occlusion:
  • Endovascular thrombectomy should be considered, especially if presenting within 6 hours of symptom onset 1
  • Selected patients may benefit from thrombectomy up to 24 hours based on advanced imaging 1
  • Vascular imaging is necessary as a preliminary step for endovascular interventions 1

Blood Pressure Management

• For patients receiving thrombolytic therapy:

  • Blood pressure should be maintained below 180/105 mmHg to reduce risk of secondary intracranial hemorrhage 1

• For patients not eligible for thrombolytic therapy:

  • Routine treatment of hypertension is not recommended unless extremely elevated (>220/120 mmHg) 1
  • If treatment is needed, reduce blood pressure by approximately 15%, not more than 25% 1

Management of Hemorrhagic Stroke

• If MRI shows intracerebral hemorrhage:
  • Immediate neurosurgical consultation should be obtained 1
  • CTA should be performed to evaluate for underlying vascular abnormalities 1
  • Blood pressure should be carefully managed according to the location and cause of hemorrhage 1

Additional Management Considerations

• Electrocardiogram (ECG) should be performed to assess baseline cardiac rhythm, but should not delay acute treatment decisions 1
• For suspected cardioembolic stroke, prolonged ECG monitoring (up to 30 days) should be considered to detect paroxysmal atrial fibrillation 1
• New onset seizures occurring within 24 hours of stroke should be treated with appropriate short-acting medications if not self-limited 1
• Prophylactic use of anticonvulsant medications is not recommended 1

Monitoring and Care

• Patients should initially be admitted to a monitored stroke unit bed until stabilization (minimum 24 hours) 1
• Frequent neurological checks using standardized scales (preferably NIHSS) should be performed several times per day 1
• Adequate tissue oxygenation should be maintained to prevent hypoxia and potential worsening of brain injury 1

Common Pitfalls to Avoid

• Do not delay emergency treatment to obtain multimodal imaging studies 1
• Do not delay vascular imaging in patients presenting within 3 hours of symptom onset who are eligible for IV thrombolysis 1
• Do not exclude patients from IV tPA based on early ischemic changes on CT (unless frank hypodensity involves more than one-third of the MCA territory) 1
• Do not routinely treat hypertension in acute ischemic stroke patients not receiving thrombolytic therapy 1