A 72-year-old woman is brought to the emergency department by emergency medical services. Her family reports that she was last seen in her normal state of health at 10:00 PM the previous night. She awoke at 6:00 AM today with profound left-sided hemiparesis, rightward gaze deviation, and severe dysarthria. Her current blood pressure is 170/90 mmHg, and point-of-care blood glucose is 110 mg/dL. The institutional acute stroke code is activated. Arrange the following neuroimaging modalities in the standard step-wise sequence to evaluate this patient's eligibility for and to execute endovascular reperfusion therapy.
- 1Non-contrast computed tomography (NCCT) of the head
- 2Computed tomography angiography (CTA) of the head and neck
- 3Computed tomography perfusion (CTP) of the brain
- 4Digital subtraction angiography (DSA) of the cerebral vasculature
Answer
The correct sequential order is: 1. Non-contrast CT (NCCT), 2. CT Angiography (CTA), 3. CT Perfusion (CTP), 4. Digital Subtraction Angiography (DSA).
The evaluation of an acute wake-up stroke with severe deficits requires a highly standardized step-wise imaging protocol. The absolute first priority is ruling out a hemorrhage with a Non-contrast CT. Once excluded, a CTA is reviewed to detect a large vessel occlusion (LVO). Because the patient is outside the standard 4.5-hour thrombolytic window, advanced imaging with CT Perfusion must then be analyzed to ensure there is a salvageable ischemic penumbra. Finally, if criteria are met, the patient is taken for Digital Subtraction Angiography, which serves as the diagnostic roadmap for endovascular mechanical thrombectomy.
Step-by-Step Solution
Key Concept
Standardized sequential interpretation of neuroimaging in acute extended-window ischemic stroke.
Estimated Time:1m 30s