Suspected acute ischaemic stroke with possible large-vessel occlusion — MRCEM SBA MCQ

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EasyProcedures, imaging and diagnosticsSuspected acute ischaemic stroke with possible large-vessel occlusionMRCEM SBA

A 72-year-old man arrives in the emergency department 100 minutes after suddenly developing aphasia and right-sided weakness. He was previously independent. His NIHSS score is 14, capillary blood glucose is 6.2 mmol/L, and he takes no anticoagulant. He is haemodynamically stable. CT is available immediately; MRI would take two hours to arrange. The stroke team is assessing him for reperfusion treatment, including possible thrombectomy. Which imaging strategy is most appropriate now?

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Correct answer: B — Arrange immediate non-enhanced CT brain followed by CT angiography.

The sudden, disabling focal deficit within 100 minutes of onset requires immediate imaging to guide reperfusion treatment. Non-enhanced CT brain comes first to assess for haemorrhage. His severe anterior-circulation syndrome also makes a proximal arterial occlusion—and therefore thrombectomy—plausible, so CT angiography should follow to identify an occlusion. NICE recommends this sequence when thrombectomy might be indicated. ([nice.org.uk](https://www.nice.org.uk/guidance/ng128/chapter/Recommendations)) A is attractive because non-enhanced CT is the essential first scan, but CT alone does not establish whether there is an arterial target for thrombectomy; it would suffice as the initial imaging strategy if thrombectomy were not being considered. C assesses the vessels but omits the initial non-enhanced scan needed to evaluate for haemorrhage. D adds perfusion rather than angiography: perfusion imaging helps assess potentially salvageable tissue when thrombectomy is considered beyond six hours, but does not replace the recommended angiographic assessment here. E could be considered in an appropriate MRI-based stroke pathway, but waiting two hours for MRI is inappropriate when CT can be performed immediately in this time-critical presentation. ([nice.org.uk](https://www.nice.org.uk/guidance/ng128/chapter/Recommendations))

Reference: NICE NG128: Stroke and transient ischaemic attack in over 16s — Recommendations (Last updated 13 April 2022) — https://www.nice.org.uk/guidance/ng128/chapter/Recommendations NICE NG128: Stroke and transient ischaemic attack in over 16s — Rationale and impact (Last updated 13 April 2022) — https://www.nice.org.uk/guidance/ng128/chapter/Rationale-and-impact