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

Differentiating CVD Infarct vs Bleed

Immediate non-contrast CT of the brain is absolutely mandatory and must be completed within 30 minutes of hospital arrival to distinguish ischemic stroke from intracerebral hemorrhage, as clinical features alone cannot reliably differentiate between the two. 1

Immediate Diagnostic Protocol

Neuroimaging is the only reliable method to differentiate ischemic from hemorrhagic stroke—do not rely on clinical features alone, as they have inadequate sensitivity and specificity. 1

First-Line Imaging: Non-Contrast CT Head

• CT is the gold standard for detecting acute hemorrhage and should be performed within 30 minutes of arrival. 1
• CT demonstrates high density (increased Hounsfield units) in areas of acute blood, which should be new compared to prior imaging or resolve on follow-up CT performed at least 2 weeks later. 2
• Do not delay imaging to obtain laboratory studies that won't change immediate management. 1

Alternative: MRI (if available and doesn't delay treatment)

• 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. 1
• Gradient recalled echo (GRE) sequences demonstrate signal dropout and are particularly helpful for identifying small hemorrhages. 2
• FLAIR sequences should ideally be performed within 2 weeks of symptom onset to demonstrate extracellular methemoglobin. 2
• However, time, cost, and availability often preclude emergent MRI in acute settings. 1

Clinical Features Suggesting Hemorrhage (But Never Diagnostic Alone)

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

• Vomiting at presentation. 1
• Systolic blood pressure >220 mmHg. 1
• Severe headache (especially sudden onset). 1
• Coma or decreased level of consciousness. 1
• Symptom progression over minutes to hours (rather than sudden maximal deficit). 1

Time-Critical Workflow

The entire evaluation from door to imaging interpretation to treatment decision must occur within 60 minutes for patients eligible for thrombolysis. 1

Immediate Actions (Parallel Processing):

1. Triage as highest priority upon arrival. 1
2. Complete non-contrast CT within 30 minutes. 1
3. Obtain NIHSS score immediately to quantify stroke severity. 1
4. Document exact time of symptom onset or last known well—this determines eligibility for time-sensitive therapies. 1
5. Obtain baseline studies (but don't delay imaging): 1
   • Blood glucose (hypoglycemia can mimic stroke)
   • Complete blood count with platelet count
   • PT/INR and aPTT
   • Serum electrolytes and renal function
   • 12-lead ECG and cardiac biomarkers

Management Based on Imaging Results

If Ischemic Infarct Confirmed:

Administer IV rtPA (0.9 mg/kg, maximum 90 mg) if patient presents within 3 hours of symptom onset and has no contraindications. 1

• Blood pressure must be <185/110 mmHg before thrombolysis, then maintained <180/105 mmHg for 24 hours post-treatment. 1
• Start aspirin 160-300 mg within 48 hours of ischemic stroke onset, but typically after 24 hours if thrombolysis was given. 1
• Avoid aggressive BP lowering unless >220/120 mmHg—permissive hypertension may maximize cerebral blood flow. 1
• Consider vascular imaging (CTA, MRA) to evaluate for large vessel occlusion if endovascular therapy is being considered. 2

If Intracerebral Hemorrhage Confirmed:

Immediately discontinue and reverse any anticoagulation. 1

• For spontaneous ICH with hypertension presenting within 6 hours: reduce systolic BP acutely to target of 140 mmHg (strictly avoiding SBP <110 mmHg). 1
• Never administer aspirin, heparin, or any antithrombotic therapy. 1
• Consider external ventricular drainage if hydrocephalus with decreased level of consciousness develops. 1
• Perform CTA to assess for vascular pathologies (aneurysms, arteriovenous malformations) or MRI for vascular malformations and neoplastic pathologies associated with hemorrhage. 2

Critical Pitfalls to Avoid

• Never delay imaging for laboratory results unless there is clinical suspicion of bleeding abnormality, thrombocytopenia, or known anticoagulant use. 1
• Never rely on clinical features alone to differentiate ischemic from hemorrhagic stroke—imaging is mandatory. 1, 3
• Never give thrombolytics without imaging confirmation of ischemic stroke—this is catastrophic if hemorrhage is present. 1
• Never aggressively lower blood pressure in acute ischemic stroke unless >220/120 mmHg, as this may worsen cerebral perfusion. 1
• Patients with NIHSS >15 who are obtunded have poor outcomes with aggressive intervention. 1