ACR Appropriateness Criteria ® Cerebrovascular Disease

Abstract

Diseases of the cerebral vasculature represent a heterogeneous group of ischemic and hemorrhagic etiologies, which often manifest clinically as an acute neurologic deficit also known as stroke or less commonly with symptoms such as headache or seizures. Stroke is the fourth leading cause of death and is a leading cause of serious long-term disability in the United States. Eighty-seven percent of strokes are ischemic, 10% are due to intracerebral hemorrhage, and 3% are secondary to subarachnoid hemorrhage. The past two decades have seen significant developments in the screening, diagnosis, and treatment of ischemic and hemorrhagic causes of stroke with advancements in CT and MRI technology and novel treatment devices and techniques. Multiple different imaging modalities can be used in the evaluation of cerebrovascular disease. The different imaging modalities all have their own niches and their own advantages and disadvantages in the evaluation of cerebrovascular disease. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

ACR Appropriateness Criteria® Headache

“…If intracranial hemorrhage is identified, or if there is also a new neurologic deficit, imaging should be guided by the ACR Appropriateness Criteria Ò topic on "Cerebrovascular Disease" [4].…”

“…This document acknowledges that some patients may be assessed at the time of noncontrast CT as to the need to proceed with the angiographic portion of the examination, and there may be institutional practices that have implications for clinical decision support. However, this document is for the initial imaging test, and appropriateness of imaging once SAH is identified is guided by the ACR Appropriateness Criteria Ò topic on "Cerebrovascular Disease" [4].…”

“…There is no relevant literature to support the use of MR angiography (MRA) in the initial imaging evaluation of a patient in this setting. Imaging once SAH is identified is guided by the ACR Appropriateness Criteria Ò topic on "Cerebrovascular Disease" [4].…”

“…Given the frequent coexistence of headache and other neurologic, traumatic, infectious, and vascular processes, it is important to acknowledge the overlap of symptoms with other conditions referenced in independent ACR Appropriateness Criteria documents, and others beyond the scope of this document. To avoid delay of appropriate care, any patient with a new neurologic deficit suggesting transient ischemic attack or stroke should have imaging guided by the ACR Appropriateness Criteria Ò topic on "Cerebrovascular Disease" [4]. Headache accompanying clinical signs of meningitis should be managed by appropriate clinical guidelines.…”

Available Therapeutics after a Stroke: Current and Promising Options

“…The differential diagnosis for stroke includes transient ischemic attacks, seizure, syncope, migraine, and brain tumors [33]. To establish a correct and timely diagnosis and to determine the best course of action, the clinician must rely on laboratory testing [34] (blood glucose is usually high, total cholesterol, LDL, HDL, AST, CPK-MB), and although the gold standard for diagnosis is a cerebral angiography, clinicians try to avoid it by choosing different methods such as imaging testing, including the first-line non-contrast CT scans, CT angiography, MRI, and MRI angiography [32, 35,36]. In the earliest stages of acute stroke, CT scans are less useful for ischemic stroke diagnosis but can rule out hemorrhagic stroke [36].…”