What is the first imaging order for a patient presenting with acute-onset left-sided weakness and facial droop, suspected of having a stroke?

Medical Advisory BoardAll articles are reviewed for accuracy by our Medical Advisory Board
Educational purpose only • Exercise caution as content is pending human review
Article Review Status
Submitted
Under Review
Approved

Last updated: November 17, 2025 • View editorial policy

Personalize

Help us tailor your experience

Which best describes you? Your choice helps us use language that's most understandable for you.

Initial Imaging for Acute Stroke with Focal Neurological Deficits

The first imaging order should be C: CT head without contrast and CTA head and neck 1, 2.

Rationale for Combined CT and CTA Approach

For a 78-year-old patient presenting with acute-onset left-sided weakness and facial droop, immediate non-contrast CT head followed by CT angiography of the head and neck from aortic arch to vertex is the standard of care 1, 2. This combined approach should be completed within 25 minutes of arrival to guide time-critical treatment decisions 2.

Why Non-Contrast CT First

  • Non-contrast CT head is essential to immediately exclude intracranial hemorrhage before any thrombolytic therapy can be considered 2.
  • CT rapidly assesses for hemorrhagic stroke, mass lesions, and early ischemic changes, though sensitivity for acute infarction is limited in the first few hours 1, 3.
  • The speed of CT acquisition is critical in the hyperacute setting where "time is brain" 1.

Why Add CTA Immediately

  • CTA head and neck must be performed at the time of initial brain CT to rapidly identify large vessel occlusion requiring mechanical thrombectomy 1, 2.
  • Within the 6-hour window from symptom onset, non-contrast CT followed by multiphase CTA is sufficient for treatment decisions without need for perfusion imaging 1.
  • CTA provides critical information about posterior circulation vasculature and procedural planning for potential endovascular intervention 1.

Why Other Options Are Inadequate

Option A (CT Head Without Contrast Only)

  • Never rely solely on non-contrast CT without vascular imaging, as this may miss large vessel occlusions requiring endovascular therapy 1.
  • This approach delays critical treatment decisions and requires a second trip to the scanner 2.

Option B (CT Head and Neck)

  • This option is ambiguous and doesn't specify whether it includes angiography, which is essential for detecting vessel occlusion 1, 2.

Option D (MRI Brain Without Contrast)

  • While MRI with diffusion-weighted imaging is the gold standard for detecting acute ischemia with higher sensitivity than CT, never delay treatment for advanced imaging 1.
  • MRI takes significantly longer to acquire and may not be immediately available in the emergency setting 1.
  • MRI is appropriate only when it can be performed without delaying treatment 1.

Critical Time-Sensitive Considerations

  • The presence of large vessel occlusion requires urgent intervention, making immediate vascular imaging mandatory 1.
  • For patients presenting beyond 6 hours or with unknown onset time, advanced perfusion imaging (CT perfusion or MRI perfusion) becomes necessary for treatment selection, but this is a secondary consideration after initial CT/CTA 1, 2.

Common Pitfalls to Avoid

  • Do not order CT head alone and wait for results before ordering CTA - this causes dangerous delays in identifying candidates for thrombectomy 1, 2.
  • Do not substitute MRI in the acute setting unless it is immediately available and will not delay potential intervention 1.
  • Do not skip vascular imaging in elderly patients assuming they are not thrombectomy candidates - age alone is not a contraindication 2.

References

1
Guideline

Imaging for Suspected Acute Cerebellar Stroke

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2025

2
Guideline

Initial Hospital-Based Workup for Cerebrovascular Accident (CVA)

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2025

Related Questions

Should a CT scan for a patient with headaches be ordered with or without contrast?
What labs and imaging should be ordered for a patient with a history of significant head injury presenting with acute onset of aphasia, choking, and lower back tightness?
What are examples of CT scan usage in medical practice?
For a 13-year-old with concerns for intracranial bleeding, should a CT scan or MRI of the brain be performed initially?
Does a patient with a history of loss of consciousness (LOC), nausea, disorientation, initial inability to feel arms, and current numbness after a 50-pound package fell on their head, and an unremarkable computed tomography (CT) scan, require a magnetic resonance imaging (MRI) of the neck and brain?
Does dextroamphetamine affect sperm quality and production?
What lab test should an Adult-Gerontology Acute Care Nurse Practitioner (AGACNP) order when monitoring serum phenytoin levels in a patient admitted for seizures?
What causes bradycardia (low heart rate) with concurrent hypertension (elevated blood pressure)?
Does Adderall (dextroamphetamine/amphetamine) affect sperm quality?
What is the most appropriate initial test for an asymptomatic 22-year-old female with genetically confirmed Turner syndrome?
Is PND (Piperacillin/Nafcillin/Dexamethasone) otic drops safe for a perforated tympanic membrane?

Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

Have a follow-up question?

Our Medical A.I. is used by practicing medical doctors at top research institutions around the world. Ask any follow up question and get world-class guideline-backed answers instantly.

Ask Question