What is the best initial management approach for an older adult patient with a history of hypertension, diabetes, and hyperlipidemia presenting with symptoms of a stroke, to differentiate between an infarct (cerebral infarction) and a bleed (cerebral hemorrhage)?

Immediate Brain Imaging is Mandatory to Differentiate Stroke Type

Non-contrast CT scan of the brain must be performed immediately upon presentation, as clinical features alone cannot reliably distinguish ischemic stroke from hemorrhagic stroke, and this distinction is absolutely critical before any treatment can be initiated. 1, 2

Why Imaging is Non-Negotiable

• Clinical examination, symptom severity, and patient characteristics have inadequate sensitivity and specificity to differentiate between cerebral infarction and intracerebral hemorrhage 2
• Administering antithrombotic therapy (aspirin, heparin, or thrombolytics) to a patient with hemorrhagic stroke can be catastrophic and potentially fatal 2
• The American Heart Association guidelines explicitly state that brain imaging is essential before treatment decisions can be made 1

Optimal Imaging Protocol and Timing

The non-contrast CT scan should ideally be completed within 25 minutes of emergency department arrival and interpreted within 45 minutes. 1

What the CT Scan Reveals:

• If NO hemorrhage is visible: The patient may be a candidate for fibrinolytic therapy (rtPA) if within the appropriate time window and meets other eligibility criteria 1
• If hemorrhage IS visible: The patient is absolutely excluded from fibrinolytic therapy and requires neurosurgical consultation 1
• During the first few hours of ischemic stroke, the CT may not show obvious signs of brain ischemia, but the absence of hemorrhage is sufficient to proceed with thrombolytic consideration 1

Critical Concurrent Evaluations

While imaging is being obtained, these assessments should occur in parallel (not sequentially): 1

Essential Laboratory Tests:

• Blood glucose (hypoglycemia can mimic stroke) 1
• Complete blood count with platelet count 1
• PT/INR and aPTT (critical for bleeding risk assessment) 1
• Serum electrolytes and renal function 1
• Cardiac enzymes and 12-lead ECG (acute MI can cause stroke; stroke can cause MI) 1, 3

Important caveat: Thrombolytic therapy should NOT be delayed while awaiting laboratory results unless there is clinical suspicion of bleeding abnormality, thrombocytopenia, or known anticoagulant use 1

Neurological Assessment:

• Document the exact time of symptom onset or last known well—this is the single most critical piece of historical information 1, 2
• Perform the National Institutes of Health Stroke Scale (NIHSS) to quantify deficit severity 1
• Assess airway, breathing, circulation, and oxygen saturation 1

Blood Pressure Management Differs by Stroke Type

This is why imaging MUST come first—blood pressure targets are completely opposite depending on whether the stroke is ischemic or hemorrhagic:

For Ischemic Stroke (Potential rtPA Candidate):

• Blood pressure must be reduced to <185/110 mmHg before rtPA can be administered 1
• Use labetalol 10 mg IV or nicardipine IV infusion to achieve this target 1

For Ischemic Stroke (NOT rtPA Candidate):

• Only consider lowering BP if systolic >220 mmHg or diastolic >120 mmHg 1
• Target reduction of 15-25% within the first day 1

For Hemorrhagic Stroke:

• Different BP targets apply (typically more aggressive reduction) to prevent hematoma expansion 1

Common Pitfalls to Avoid

• Never assume stroke type based on severity alone—there is substantial overlap in presentation between hemorrhagic and ischemic strokes 2
• Never administer aspirin, heparin, or any antithrombotic therapy before imaging excludes hemorrhage 2
• Do not delay transfer to obtain laboratory studies that won't change immediate management if your facility lacks CT capability 2
• Do not perform lumbar puncture unless subarachnoid hemorrhage is suspected and CT is negative for blood 1

Special Considerations for Rural/Limited Resource Settings

• If CT is unavailable at your facility, immediately activate emergency medical services for transfer to the nearest stroke center 2
• Notify the receiving facility in advance to activate their stroke team 2
• Consider air medical transport if ground transport exceeds 60 minutes 2
• Do NOT treat empirically with aspirin before imaging—the risk of expanding an intracranial hemorrhage outweighs potential benefits 2

Advanced Imaging Considerations

• MRI performs as well as CT for identifying acute hemorrhage and is superior for detecting chronic hemorrhage and vascular malformations 1
• However, MRI may not be feasible in 20% of acute stroke patients due to contraindications, impaired consciousness, or hemodynamic instability 1
• Advanced imaging (CT perfusion, CT angiography, MRI) should NOT delay rtPA administration in eligible patients 1