Stroke diagnostic pathway and patient
selection
A neurological examination is performed on
all patients with suspected hyperacute
stroke. National Institutes of Health Stroke
Scale (NIHSS) score is performed at the time
of admission by the stroke team. Patients
presenting with NIHSS ≥6 and within six
hours of symptom onset for anterior
circulation stroke or 12 hours for posterior
circulation strokes are considered for
mechanical thrombectomy.
As per the NCCCC guidelines, 9 plain CT of
the brain is performed immediately to exclude
patients with contraindications to treatment,
such as acute haemorrhage or significant
established ischaemia. For middle cerebral artery
territory symptoms, the Alberta Stroke Program
Early CT Score (ASPECTS) is performed to assess
the degree of established ischaemia. Patients with
a lack of extensive early ischaemic change (those
with ASPECTS more than 5 on plain CT) are
selected. 8
If there are no contraindications to treatment,
then a CT angiogram is performed from aortic
arch to the vertex. This helps to delineate the
vascular anatomy and assess the patency of the
intracranial arterial system, as well as the degree
of collateral supply. In patients with uncertain
time of symptom onset, brain perfusion imaging
(CT or MRI) may be employed. 8 The decision to
proceed with mechanical thrombectomy is
made in conjunction with a stroke physician
considering the patient’s clinical condition,
age and co-morb