What is the preferred initial imaging to evaluate suspected acute stroke?

• A. MRI brain with contrast
• B. Non-contrast CT head
• C. CT angiography
• D. Ultrasound of carotids

Answer: (D)

In acute stroke, the priority is to quickly determine whether there is intracranial hemorrhage so treatment decisions (like giving thrombolytics) can be made safely. A non-contrast CT scan of the head is the best initial imaging because it can be performed rapidly, is widely available in emergency settings, and without contrast can reliably detect acute bleeding to guide urgent management. MRI can be more sensitive for early ischemia but takes longer and isn’t as universally accessible in the hyperacute window. CT angiography and carotid ultrasound have important roles later in the workup (to assess vessels or carotid disease), but they’re not the first test in the emergency evaluation of suspected stroke.