Optimal Imaging at the Primary Stroke Center

Bruce C.V. Campbell, MBBS (Hons), BMedSc, PhD, FRACP


Stroke. 2020;51(7):1932-1940. 

In This Article

Abstract and Introduction


Primary stroke centers remain the workhorses for stroke care in most systems worldwide. Until recently, the immediate role of the primary stroke center was to deliver thrombolysis as rapidly as possible within 4.5 hours of stroke onset. With evolving evidence, these centers now have the opportunity to use more advanced imaging to fast-track patients with large vessel occlusion to an endovascular-capable center and potentially deliver thrombolysis beyond 4.5 hours. This review will discuss the optimal imaging strategy to achieve a fast, accurate diagnosis and rapidly deliver reperfusion therapies within the resource constraints of a primary stroke center (Table 1).

Computed tomography (CT)–based imaging is almost universal in primary stroke centers as urgent magnetic resonance imaging (MRI) access is not practical and many patients cannot have MRI due to agitation or safety screening difficulties in the acute stroke context. The current practice for imaging of suspected stroke patients at most US primary stroke centers, and in many other countries, is to obtain a noncontrast CT brain and perhaps a CT angiogram, often as a separate imaging session at a later time. Thrombolysis is generally administered on the basis of the noncontrast CT brain. Patients with suspected large vessel occlusion based on hyperdense artery or severe clinical presentation are often transferred to comprehensive stroke centers without having a CT angiogram to prove the occlusion. They are then reimaged on arrival at the comprehensive stroke center, usually with another noncontrast CT brain and CT angiogram. Increasingly, CT perfusion is also performed at the comprehensive center, particularly when the patient arrives >6 hours after stroke onset.[1]