In suspected acute stroke, what is the initial imaging to rule out hemorrhage?

• A. CT head with contrast
• B. MRI brain
• C. PET scan
• D. CT head without contrast

Answer: (D)

In suspected acute stroke, the priority is to quickly distinguish hemorrhagic from ischemic stroke so that treatment can be chosen safely. The best initial test is a non-contrast CT scan of the head. Without contrast, acute blood appears clearly as hyperdense areas, allowing rapid detection or exclusion of intracranial hemorrhage. This is essential before any thrombolytic therapy, since giving IV tPA in the presence of bleeding would be dangerous. CT without contrast is fast, widely available, and minimizes risks from contrast agents, making it the preferred first imaging in this scenario. MRI can detect ischemia more sensitively but is slower and less readily available in emergencies, while PET is not used for acute stroke evaluation.