IMAGING ASSESSMENT OF ACUTE ISCHAEMIC STROKE: A REVIEW

Aubrey George Smith, BSc, MBBS, MRCS, FRCR and Chris Rowland Hill, BA, MBBS, MRCP, FRCR

PERCEPTOR
Dr. Noflih Sulistia, Sp.Rad

OLEH:
Atika Landani
Ria Andriana JOURNAL READING
Vika Annisa
William Bahagia

KEPANITERAAN KLINIK RADIOLOGI

FAKULTAS KEDOKTERAN UNIVERSITAS LAMPUNG
RSUD Dr. H. ABDUL MOELOEK PROVINSI LAMPUNG
2019
ABSTRACT

Acute ischaemic stroke Current evidence Imaging plays a crucial

is the second largest
cause of death
worldwide and a cause
of major physical and
psychological morbidity.
based treatment
includes intravenous
thrombolysis (IVT) and
mechanical
thrombectomy (MT)
role identifying patients
who may benefit from
MT or IVT whilst
excluding those that may
be harmed

The optimum pathway is a balance between diagnostic information, local resources,

specialization and the time taken to acquire, process and interpret the data.
INTRODUCTION (1)
The incidence in the UK
ranges from 115 to 150
per 100,000 population
Strokes are divided into two
large groups: ischemic or
hemorrhagic. Ischemic
strokes are much more
common (85%)
They are three-compartment
model of brain parenchyma
following vascular occlusion
(infarct core, ischaemic
penumbra, oligaemia)
“Time is brain” is phrase in acute
stroke. In 1 min, 1.9 million neurons die
with the brain ageing approximately 3.6
years each hour without treatment
Current guidelines recommend that IVT (if
within 4.5 h) and MT (if within 6 h) may be
performed for large arterial occlusion in the
anterior circulation after symptom onset
Rapid imaging plays an essential part in
assessing and selecting
patients and determining their treatment
course
INTRODUCTION (2)
IVT Imaging role (exclude): Hyperacute
Hyperacute stroke
stroke trials
trials listing
listing treatment
treatment and
and imaging
imaging protocols
protocols
used
used
• Haemorrhage
• Stroke mimics
• Provide an estimate of
the volume of non-viable
brain tissue

MT Imaging role:
• Identify the presence,
location and
morphology of
occlusive thrombus
• Identify tandem lesions
• Assess the collateral
circulation.

CTA, CT angiography; DWI, diffusion weighted imaging; PWI, perfusion-weighted imaging

UNENHANCED CT
Acute infarction  relative reduction
in the attenuation of grey matter
owing due to cytotoxic oedema and
an overall increase in water content.
Associated swelling of the
infarcted parenchyma produces
focal sulcal effacement. (If 2.
swelling without cytotoxic edema
 early ischaemic change)
Sensitivity of approximately 52% in
assessment of abnormal
parenchymal changes indicative of
ischaemia.
Unenhanced CT is best viewed as
series comprising thick and thin
1. 4. slices, typically 5 and 0.5 mm
Reviewing images in reformatted
coronal and sagittal planes is
useful in accurate localization of
5. infarction and confirming
suspicion of abnormality in axial
plane
Sensitivity to parenchymal changes in
3. 6. acute ischaemic stroke has been
shown to improve by utilizing stroke
windows (centre 40, width 40)
Loss of definition of the basal ganglia from the adjacent capsules
and loss of distinction of cortex from underlying white matter 
insular ribbon sign
Thick slices  good appreciation of the Thin slices  increased spatial
brain parenchyma, detection of resolution for resolving partial volume
haemorrhage and assessment of grey averaging and detecting very small
white matter differentiation infarcts
 The Alberta Stroke Program Early CT
Score (ASPECTS)  a simple
topographic scoring system for
assessment of the extent of early
ischaemic changes in middle cerebral
artery territory on unenhanced CT.

The MCA territory is divided into 10

regions (Scores 1 = normal ; 0=
abnormal)

Score < 8 is associated with a poorer

neurological outcome
Isolated linear hyperdensity on CT can represent organized
thrombus in the context of acute ischaemic stroke (attenuation
~80 HU)  dot sign
Limitations of Unenhanced CT

Not accurately indicate the infarct core or provide information

about the ischaemic penumbra

In ASPECTS, assessment of early change within 90 min of

stroke onset is less reliable and small core infarction may not
be picked up

Patient factors that reduce sensitivity to ischaemia include

cerebral atrophy and leukoariosis.

Poor sensitivity for detection of posterior fossa infarcts.

e. Other pitfalls  assessing acute thrombus include variability

in slice thickness, vessel wall calcification and increased
haematocrit.
 Summary Unenhanced CT
• Unenhanced CT can provide sufficient information to
select patients for IVT according to current guidelines.

• It is highly sensitivity for acute haemorrhage. Detectable

changes of early infarction correlate with outcome and
the risk of treatment related haemorrhage.
 CT ANGIOGRAPHY (CTA)

Presence, location and Rapid and provides The source data The arch and The sensitivity of
size of occlusive excellent spatial can be vessels is CTA in the detection
thrombus and may resolution in reformatted into essential to of significant stenosis
provide information on assessment of the 2D and 3D identify tandem or thrombotic
collateral supply to the intra and multiplanar lesions occlusion of large
ischaemic territory extracranial images. intracranial and
vasculature extracranial
vessels is 95 to 99%.
CTA of the arch and vessels is essential to identify tandem lesions such as an ICA stenosis or
arterial dissection and to aid planning of access to the intracranial circulation

Acute stenting of tandem lesions of the extracranial ICA results in a high recanalization rate (87 vs
48% p = 0.001), favourable outcome (68 vs 15% p = 0.001) and lower mortality (18 vs 41% p =
0.048).
Utilizing assessment of the collateral supply can be
enhanced by using a multiphase CTA technique

Comprare two additional low-dose CT scans of the

head only, acquired sequentially at approximately 5 and
10 s after the initial arch to vertex acquisition.

Multiphase CTA involves a lower radiation dose than

CTP and no additional intravenous contrast is required.
CTA allows visualization of the distal pial arteries after the occlusive
thrombus, the number of which is consistent with the number of
collaterals

There are multiple collateral scores published in the literature, none of

which are standardized
Limitations of CTA

As efforts to speed up imaging and optimize

arterial opacification  result in overestimation
of infarct size

Early arterial phase CTA may underestimate

thrombus length

Collateralization scores have not been standardized

Renal disease and patients with low GFR can be relatively

contraindicated to have CTA assessment
 Summary CT Angiography
• Effective method for rapid assessment of the extra and
intracranial arterial vasculature and assisting with
preprocedural planning (MT)

• Assessment of collateral circulation can be used as a

positive predictor of patient outcome
CT PERFUSION (CTP)
The data can be applied to the
three compartment model of
acute infarction and provide an
estimate of the infarct core
Provide data for cerebral blood Preservation of or an increase in
volume (CBV), cerebral blood 3. regional blood volume in the
flow (CBF) and presence of reduced flow is
mean transit time (MTT) thought to be an indicator of
2. 4. salvageable brain tissue

1. 5.

Produces high spatial resolution Able to help predict

quantitative perfusion–blood haemorrhagic transformation
volume mapping. in ischaemic stroke and
recognize
stroke mimics.
Normal cerebral blood flow is defined as 45–110 ml100 g-1 min-1

Potentially salvageable brain tissue  CBF >25 ml100 g–1 min–1)

Irreversible infarctionCBF <10 ml100 g–1 min–1

Limitations of CTP

Increases imaging acquisition time, radiation dose

and contrast dose

Interpretation requires specialist training,

experience and is time-consuming (22 min)

Sensitive to patient motion artefact resulting

in misregistration and unreliable

Reduced perfusion may also be seen in those

patients who have seizures that mimic strokes
and vasospasm.
 Summary CT Perfusion
•• CTP
CTP provides
provides high
high spatial
spatial resolution
resolution data
data on
on blood
blood flow
flow and
and volume
volume

•• As
As supplement
supplement the
the information
information from
from plain
plain CT
CT and
and CTA
CTA to to optimize
optimize selection
selection for
for
treatment (especially
treatment (especially in
in subjects
subjects who
who present
present late
late after
after symptom
symptom onset)
onset)

•• Provides
Provides quantitative
quantitative and
and qualitative
qualitative data
data on
on the
the infarct
infarct core
core and
and ischaemic
ischaemic penumbra
penumbra and
and is
is
particularly useful
particularly useful in
in those
those patients
patients who
who present
present 33 hh after
after symptom
symptom onset
onset

•• Useful
Useful in
in predicting
predicting haemorrhagic
haemorrhagic risk
risk of
of reperfusion
reperfusion therapy
therapy and
and recognize
recognize stroke
stroke mimics
mimics in
in CTA
CTA
negative studies
negative studies
Magnetid Resonance Imaging (MRI)
●
MRI presents practical difficulties for hyperacute stroke patients but can be a
valuable contributor to patient work-up, particularly beyond 3 h post-symptom
onset.

The goals in MRI and CT scanning are identical. Assessment of the brain parenchyma can be performed on
●

T2W FSE () and FLAIR (fluid attenuated inversion recovery) imaging, with assessment of haemorrhage and
microhaemorrhage with gradient echo and susceptibility-weighted imaging (SWI)

●
Although there is no significant difference in patient outcome, when utilizing
unenhanced CT and MR within the first 3 h post-symptom onset, use of MRI may
reduce the rate of symptomatic intracerebral haemorrhage
MRI of left PICA territory infarct

(a) High FLAIR signal

clearly identifies the
region of oedema
(e) Gradient echo related to the
sequences infarct.
demonstrates low
signal confirming
the presence of
haemorrhage.

(b) ADC
map

(d) Sagittal
T2
demonstrates
high signal.
(c) DWI
demonstrates
restricted diffusion
confirming the
acute nature of the
pathology.
 An added benefit of DWI is optimized
posterior circulation evaluation. Between
6 and 10% of ischaemic strokes involve the
basilar artery with patients having a poor
prognosis and mortality rate of up to 85%.
DWI can identify small volume
infarction that may not be 3. DWI is also valuable in the diagnosis
appreciated on unenhanced CT
alone and locates infarct
of stroke mimics particularly as a
position relative to region negative finding in Todd’s Paraesis.
eloquence accurately. 2. 4.

1. 5.
Diffusion-weighted imaging (DWI)
SWI is very sensitive to cerebral
provides the most accurate
microhaemorrhages, which may be
measure of infarct core volume associated with an increased risk of
and is an independent predictor of symptomatic intracerebral
clinical outcome in many trials. haemorrhage after thrombolysis
therapy.
Limitations Of MRI
remote location of scanners from the acute
stroke assessment areas and well-known
safety issues that are exacerbated in the
However, PWI/ DWI mismatchacutely unwell patient, especially if
modelling
should be considered superior for intubated.
selecting patients for reperfusion therapy
where thrombus level has not been
accounted for.

DWI is not totally specific for

irreversible infarction and DWI
positive lesions have been reversed
with early vessel recanalization.

PWI may help to provide delayed

treatment to those potential
candidates who have late presentation
with slow progressive strokes.

MRA is less able to provide accurate

assessment of the collateral circulation
distal to an occlusions compared with CTA
or as accurate assessment of luminal
stenosis.
Summary MRI
●
MRI provides comprehensive multiparametric assessment of the brain parenchyma and circulation in acute
stroke. It is superior to CT in many respects particularly the provision of DWI in demonstration of the infarct
core.
●
DWI can be directly compared with PWI, other sequences and clinical status to assess tissue salvageability.

●
SWI is very sensitive to microhaemorrhage, which may have
proved to be significant in determining treatment. It is
considerably superior to CT in posterior circulation strokes.

The MR Witness trial findings presented at the International Stroke Conference 2016 has
●

demonstrated that FLAIR/DWI mismatch may be utilized in initial assessment safely within
4.5 h of symptom discovery and with a median time of >11 h of last being seen well to the
initialization of tPA.
Discussion
• Whichever imaging modality and techniques
are utilized, they must be able to accurately
and safely identify those patients likely to
• Nevertheless, any
benefit from treatment and exclude those who
are not, especially those at risk of greater harm
•1 •4 additional time taken
than benefit. This must be done with the
greatest possible speed but not at the expense
. . to acquire and
of safety.
interpret imaging
• For MT work-up, • MRI
must be can
balanced
provide all
•2 •5
against the needimaging
the required to
the minimum
requirement of . . institute
data and in
plain CT for • treatment
particular more
as rapidly
definitive imaging of
as possible.
• IVT is no longer • However, MRIcore,
the infarct can
•sufficient
Basic CT and
and CTA •3 •6 present
therebygreater logistic
providing
must
maybebe . . challenges and in the to
more information UK
supplemented
supplementedatby at least it ispatients
identify likely that CT
least by single-
multiphase CTA andwhoCTA,could
± CTPbenefit
will be
phase CTA from thefor
mainstay
IVT of
Conclusion
• the evidence for MT is excellent. The number needed to treat of 2.619 is much fewer
than for primary coronary intervention. It is highly likely that the current limit of 6 h
from symptom onset for consideration of MT is excluding patients who may benefit.
• A recent meta-analysis of five randomized trials demonstrated that MT is effective up to
7.3 h after symptom onset with functional independence gained in 64% of patients at 3
h and 46% of patients at 8 h.79 The DEFUSE III trial (NCT02586415) is assessing patients
with large artery occlusion that have presented 6–16 h after symptom onset and uses
multimodal CT and MRI
• prior to randomization to thrombectomy and best medical therapy versus best medical
therapy alone.
• It is known that the growth rate of infarct cores is highly variable80 supporting the
concept that in future optimum stroke treatment will be individualized based on clinical
and imaging data.
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