Advanced Brain Imaging Studies Should Be Performed in Patients With Suspected Stroke Presenting Within 4.5 Hours of Symptom Onset

The Case:A 70-year-old woman presents within 4 hours of acute onset of loss of consciousness and right-sided weakness. NIHSS score is 17. Plain, non-contrast, head CT scan (NCCT) shows no ICH or early signs of ischemia. She meets all eligibility criteria for intravenous thrombolysis (IV tPA). The Questions: The Controversy:should advanced brain imaging studies be performed in patients with suspected stroke presenting within 4.5 hours of symptom onset.This case, on superficial glance, is a classic example of a patient who should receive intravenous tissue-type plasminogen activator (IV tPA). Indeed, for the “lumpers,” who worship at the altar of evidence-based medicine, this would be the only appropriate course of action. On the other hand, the “splitters” believe that stroke treatment should be individually tailored and guided by tissue pathophysiology. Since the 1980s, the more devout splitters have been searching for what they believe to be the “Holy Grail” of stroke, the ischemic penumbra. They argue that unless we use the now widely available modern imaging techniques in the routine assessment of patients with acute stroke, we will never gain a sophisticated understanding of …