How to differentiate and manage a patient with suspected cerebrovascular disease (CVD), presenting with acute neurological symptoms, and a history of cardiovascular disease, diabetes, or anticoagulant use, to determine if it's an ischemic infarct or a hemorrhagic bleed?

Differentiating Ischemic Infarct from Hemorrhagic Bleed in Acute Cerebrovascular Disease

Neuroimaging is absolutely mandatory to differentiate ischemic stroke from intracerebral hemorrhage—clinical features alone have inadequate sensitivity and specificity to guide treatment decisions, and relying on clinical assessment without imaging can lead to catastrophic outcomes if antithrombotic therapy is given to a patient with hemorrhagic stroke. 1, 2

Immediate Diagnostic Approach

Neuroimaging: The Definitive Test

• Non-contrast CT head must be completed within 30 minutes of hospital admission to distinguish ischemic from hemorrhagic stroke 3, 2
• CT is the gold standard for detecting acute hemorrhage and is the most practical first-line imaging modality 2
• MRI with diffusion-weighted imaging (DWI) and gradient echo (GRE) or T2*-susceptibility-weighted sequences are as sensitive as CT for acute blood detection and more sensitive for prior hemorrhage, but time, cost, and availability often preclude emergent MRI 2, 3
• Do not delay imaging to obtain laboratory studies that won't change immediate management 1

Clinical Features That Suggest (But Cannot Confirm) Hemorrhage

While imaging is mandatory, certain clinical features increase suspicion for intracerebral hemorrhage 2:

• Vomiting
• Systolic blood pressure >220 mmHg
• Severe headache
• Coma or decreased level of consciousness
• Symptom progression over minutes to hours

However, none of these findings are specific enough to guide treatment without imaging confirmation 2

Critical Management Decisions Based on Imaging Results

If Ischemic Infarct is Confirmed

• Administer IV rtPA (0.9 mg/kg, maximum 90 mg) if patient presents within 3 hours of symptom onset and has no contraindications 3
• Blood pressure must be <185/110 mmHg before thrombolysis, then maintained <180/105 mmHg for 24 hours post-treatment 3, 2
• Start aspirin 160-300 mg within 48 hours of ischemic stroke onset, but typically after 24 hours if thrombolysis was given 3, 4
• Avoid aggressive BP lowering unless >220/120 mmHg—permissive hypertension may maximize cerebral blood flow 3

If Intracerebral Hemorrhage is Confirmed

• Immediately discontinue and reverse any anticoagulation 4
• For spontaneous ICH with hypertension presenting within 6 hours: reduce systolic BP acutely to target of 140 mmHg (strictly avoiding SBP <110 mmHg) 4, 2
• Consider external ventricular drainage if hydrocefalia with decreased level of consciousness develops 4
• Never administer aspirin, heparin, or any antithrombotic therapy 1

Essential Baseline Studies

Obtain these studies immediately but do not delay imaging or thrombolytic therapy while awaiting results unless there is clinical suspicion of bleeding abnormality, thrombocytopenia, or known anticoagulant use 2:

• Blood glucose (hypoglycemia can mimic stroke) 2, 5
• Complete blood count with platelet count 2
• Prothrombin time/INR and activated partial thromboplastin time 2
• Serum electrolytes and renal function 2
• 12-lead ECG and cardiac biomarkers 2, 3

Neurological Assessment

• Perform NIHSS assessment immediately upon arrival to quantify stroke severity and guide treatment decisions 3, 2
• Patients with NIHSS <15 are optimal candidates for early intervention 3
• Document the exact time of symptom onset or last known well—this determines eligibility for time-sensitive therapies 1, 4

Common Pitfalls to Avoid

• Never assume stroke type based on severity alone—there is substantial overlap between hemorrhagic and ischemic presentations 1
• Never treat empirically with aspirin before imaging—the risk of expanding an intracranial hemorrhage outweighs potential benefits 1
• Do not confuse stroke mimics (seizure, conversion disorder, migraine, hypoglycemia) with actual stroke—history and diagnostic studies usually exclude these 5
• In patients taking warfarin or with suspected coagulopathy, do not give thrombolytics until coagulation studies confirm safety 2

Special Considerations for High-Risk Patients

Patients on Anticoagulants

• Check INR immediately—if elevated and hemorrhage is present, reverse anticoagulation urgently 4
• If INR is therapeutic and ischemic stroke is confirmed, thrombolysis is contraindicated 2

Patients with Diabetes

• Verify blood glucose immediately—hypoglycemia causes focal symptoms mimicking stroke 2, 5
• Hyperglycemia is associated with unfavorable stroke outcomes 2

Patients with Cardiovascular Disease

• Acute myocardial infarction can lead to stroke, and acute stroke can lead to myocardial ischemia 2
• Initiate continuous cardiac monitoring for 24-72 hours to detect atrial fibrillation and arrhythmias 3, 4

Time-Critical Actions

The entire evaluation from door to imaging interpretation to treatment decision must occur within 60 minutes for ischemic stroke patients eligible for thrombolysis 3:

1. Triage as highest priority upon arrival 3
2. Complete non-contrast CT within 30 minutes 3
3. Obtain NIHSS score and verify symptom onset time 3
4. Achieve door-to-needle time ≤30 minutes if thrombolysis indicated 3