Diagnosis and Management of Acute Ischemic Stroke

This chapter will review updates in the various imaging modalities used to diagnose acute ischemic stroke (AIS), how these are used to select patients for intervention, and the different interventions used for management of AIS. The backbone of the AIS diagnostic algorithm remains the computed tomography scan (CT) given its speed of use and sensitivity. CT-angiography (CTA) is crucial in diagnosing large-vessel occlusions (LVOs) and multiphase CTA and CT-perfusion (CTP) can demonstrate the number of collaterals in the area and remaining salvageable tissue. MRI can be used to select patients presenting in an unknown time window for thrombolysis. The primary goal of AIS management is to rescue the ischemic penumbra and the approach to treating AIS has gone from a time-based to tissue-based approach. While tPA is still the agent of choice for thrombolysis in patients with AIS, tenecteplase (TNK) may be just as effective and more efficient to use. Endovascular thrombectomy (EVT) has shown considerable efficacy for alleviating LVOs and using CTP, patients can be selected for hours after symptom-onset if viable tissue remains. It remains unclear if an “EVT-alone” strategy is superior to “tPA + EVT” strategy but this may be dependent on clot, patient, and geographical characteristics