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Further recommendations for imaging

The Nice Guidelines CG68 5 Stroke: Diagnosis and initial management of acute stroke and transient ischaemic attack (TIA) (2008) recommend the following imaging criteria for stroke and TIA.

Brain imaging for the early assessment of people with acute stroke

Brain imaging should be performed immediately for those with acute stroke who have any of the following:

  • indications for thrombolysis or early anticoagulation treatment

  • anticoagulant therapy

  • a known bleeding tendency

  • a depressed level of consciousness (Glasgow Coma Score below 13)

  • unexplained progressive or fluctuating symptoms

  • papilloedema, neck stiffness or fever

  • severe headache at onset of stroke symptoms.

For all people with acute stroke without indications for immediate brain imaging, scanning should be performed as soon as possible.

Suspected TIA – referral for urgent brain imaging

People who have had a suspected TIA (that is, whose symptoms and signs have completely resolved within 24 hours) should be assessed by a specialist within one week of symptom onset and before a decision on brain imaging is made.

People who have had a suspected TIA who are at high risk of stroke (for example, an ABCD2* score of 4 or above, or with crescendo TIA) in whom the vascular territory or pathology is uncertain, should undergo urgent brain imaging, preferably diffusion-weighted MRI.

People who have had a suspected TIA who are at lower risk of stroke (for example, an ABCD2 score of less than 4) in whom the vascular territory or pathology is uncertain, should undergo brain imaging, preferably diffusion-weighted MRI.

Type of brain imaging for people with suspected TIA

People who have had a suspected TIA who need brain imaging (that is, those in whom vascular territory or pathology is uncertain) should undergo diffusion-weighted MRI except where contraindicated in which case CT scanning should be used.

Early carotid imaging in people with acute non-disabling stroke or TIA

All people with suspected non-disabling stroke or TIA who, after specialist assessment, are considered as candidates for carotid endarterectomy should have carotid imaging within one week of the onset of symptoms.

*The ABCD2score is a risk assessment tool designed to improve the prediction of short-term stroke risk after a transient ischemic attack (TIA).  The ABCD2 score is calculated by summing up points for five independent factors; Age, Blood Pressure, Clinical Features, Duration and Diabetes.6

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