Should CT Angiography be a Routine Component of Acute Stroke Imaging?

摘要

For over a decade, the standard of care for patients with acute ischemic stroke has been intravenous tissue plasminogen activator (IV tPA). Although only a noncontrast head computed tomography (CT) is required to rule out hemorrhage in order to administer IV tPA to eligible patients, many stroke centers have long used CT angiography (CTA) as an adjunctive study to diagnose carotid stenosis, intracranial atherosclerosis, and large vessel occlusions at the time of presentation. Some of these investigations are a critical part of the stroke workup to inform secondary prevention strategies, but until recently an evidence-based indication for emergently diagnosing large vessel occlusion is lacking. Therefore, one might question the routine use of CTA at the time of presentation, especially if it might delay administration of IV tPA. This changed with the publication of several large randomized controlled trials demonstrating improved outcomes when endovascular throm-bectomy was added to IV tPA in patients with large vessel occlusion. These pivotal studies will change the landscape of acute stroke treatment, and the stakes are suddenly much higher for accurate identification of patients who may benefit from endovascular therapy. Does this mean that every patient with stroke should be evaluated with CTA? Are there drawbacks to this approach? In the following editorial, Dr Shamy and Dr Bhattacharya outline the arguments for and against the use of routine CTA in acute ischemic stroke.