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to determine prognosis.177–179 In patients whose symptoms started <8 hours ago, these tests may be helpful in selecting candidates for intervention. A variety of ancillary tests are available to help clinicians reach accurate pathophysiological and etiologic stroke diagnoses and provide information that can be critical for effective prevention of recurrent stroke.180,181 Vascular imaging is a key component of the evaluation. The selection of tests needs to be tailored to the individual patient and clinical setting.C. Conclusions and RecommendationsBrain imaging remains a required component of the emergency assessment of patients with suspected stroke. Both CT and MRI are options for imaging the brain, but for most cases and at most institutions, CT remains the most practical initial brain imaging test. A physician skilled in assessing CT or MRI studies should be available to examine the initial scan. In particular, the scan should be evaluated for evidence of early signs of infarction. Baseline CT findings, including the presence of ischemic changes involving more than one third of a hemisphere, have not been predictors of responses to treatment with rtPA when the agent is administered within the 3-hour treatment window. Information about multimodal CT and MRI of the brain suggests that these diagnostic studies may help in the diagnosis and treatment of patients with acute stroke. Imaging of the intracranial or extracranial vasculature in the emergency assessment of patients with suspected stroke is useful at institutions providing endovascular recanalization therapies. The usefulness of vascular imaging for predicting responses to treatment before intravenous administration of thrombolytic agents has not been demonstrated. Class I Recommendations 1. Imaging of the brain is recommended before initiating any specific therapy to treat acute ischemic stroke (Class I, Level of Evidence A). This recommendation has not changed from the previous guideline. 2. In most instances, CT will provide the information to make decisions about emergency management (Class I, Level of Evidence A). This recommendation has not changed from the previous guideline. 3. The brain imaging study should be interpreted by a physician with expertise in reading CT or MRI studies of the brain (Class I, Level of Evidence C). This recommendation has been added since the previous guideline. 4. Some findings on CT, including the presence of a dense artery sign, are associated with poor outcomes after stroke (Class I, Level of Evidence A). This recommendation has not changed from the previous guideline. 5. Multimodal CT and MRI may provide additional information that will improve diagnosis of ischemic stroke (Class I, Level of Evidence A). This recommendation has been added since the previous guideline. Class II Recommendations 1.Nevertheless, data are insufficient to state that, with the exception of hemorrhage, any specific CT finding (including evidence of ischemia affecting more than one third of a cerebral hemisphere) should preclude treatment with rtPA within 3 hours of onset of stroke (Class IIb, Level of Evidence A). This recommendation has not changed from the previous guideline. 2. Vascular imaging is necessary as a preliminary step for intra-arterial administration of pharmacological agents, surgical procedures, or endovascular interventions (Class IIa, Level of Evidence B). This recommendation has not changed from the previous guideline. Class III Recommendations 1. Emergency treatment of stroke should not be delayed in order to obtain multimodal imaging studies (Class III, Level of Evidence C). This recommendation has been added since the previous guideline. 2. Vascular imaging should not delay treatment of patients whose symptoms started <3 hours ago and who have acute ischemic stroke (Class III, Level of Evidence B). This recommendation has been added since the previous guideline. V. GENERAL SUPPORTIVE CARE AND TREATMENT OF ACUTE COMPLICATIONS A. Airway, Ventilatory Support, and Supplemental Oxygen Maintaining adequate tissue oxygenation is important in the setting of acute cerebral ischemia. The goals are to prevent hypoxia and potential worsening of the brain injury.
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