Top tips for imaging in hyperacute stroke

Acute ischaemic stroke (AIS) is the second leading cause of death and the third cause of death and disability worldwide. The estimated global cost of stroke is over $720 billion. In the UK, the incidence of stroke is over 110,000 and the prevalence of stroke is predicted to increase by 120% by 2035. Hyperacute stroke is defined as that occurring within 24 hours of symptom onset. Current national UK and Ireland guidelines advise thrombolysis within 4.5 hours of symptom onset (within nine hours with favourable CT perfusion or MRI) and mechanical thrombectomy within six hours.5,6 Recently published thrombectomy trials, such as DAWN, DEFUSE 3, SELECT2, ANGEL-ASPECT and TESLA, included patients presenting within 24 hours of symptom onset and demonstrated improved outcomes with thrombectomy versus best medical management. The 2023 national guidelines recommend thrombectomy in patients presenting within 24 hours if they have favourable non-contrast CT (NCCT) and CT perfusion (CTP) findings. In the UK, an estimated 15,400 (15%) stroke patients are now eligible for thrombectomy. Imaging plays a key role in the diagnosis of stroke and its mimics, while also identifying which patients are suitable for reperfusion therapies. The modalities used in the diagnosis of stroke include NCCT, CT angiography (CTA), CTP and MRI. The following describes the role of each of these modalities in the management of AIS.

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