IMAGING IN

ACUTE
ISCHEMIC
STROKE

Dr.J S K Chaitanya
Dr.Vijayan K

 Imaging in acute stroke is mainly targeted

towards assessment of 4 Ps

Parenchy
ma

Pipes

Perfusion

Penumbr
a

Parenchyma
CT
MRI

Pipes

USG
CTA
MRA
DSA

Perfusion and
Penumbra
SPECT
XENON CT
CT
PERFUSIO
N
MR
PERFUSIO
N

PARENCHYMA

Parenchyma
Brain tissue.
What has to be seen?
Change in density / intensity of brain tissue.

What are the modalties?

CT / MRI

Why to assess parenchyma?

Exclude hemorrhage.
Detection of ischemic tissue.
Exclude mimics

Exclusion of haemorrhage
CT is the gold standard for
diagnosing haemorrhage.
MR GRE sequence appeared to be at
least as accurate as CT for the
detection of acute ICH.
FLAIR sequences are useful in
identifying SAH and SDH on MRI.

FLAIR

SWI

Does the presence of tiny amounts of hemorrhage seen

on MR but not CT contraindicate the use of a thrombolytic
agent?

Although the presence of old microbleeds

may predict recurrent disabling and fatal
strokes, there was no statistically
significant increase in the risk of
symptomatic ICH when patients with a
small number of microhemorrhages (< 5)
on MR were treated with intravenous
thrombolysis. ( Level B )
The risk in patients with multiple
microbleeds (>5) is underdetermined.

Detection of cerebral ischemia and

exclusion of mimics
CT
MRI
CTA Source images

CT (plain)
Sulcal effacement
Loss of insular ribbon
Blurring of grey white matter
junction
Obscuration of lentiform nucleus
Hyperdense artery sign , indicative of
intravascular thrombus.
Loss of differentiation among basal
ganglion nuclei

HYPER
DENSE
MCA SIGN

SULCAL EFFACEMENT

OBSCURATION OF
LENTIFORM NUCLEUS

INSULAR
RIBBON
SIGN

Loss of
differentiatio
n among
basal
ganglion
nuclei

Quantification-ASPECTS
SCORE
The Alberta Stroke Program Early CT
Score (ASPECTS) was proposed in
2001 as a means of quantitatively
assessing acute ischemia on CT
images by using a 10-point
topographic scoring.
A sharp increase in dependence
and death occurs with an
ASPECTS of 7 or less

ASPECTS SCORE
The normal MCA territory is assigned a total
score of 10. For each area involved in stroke
on the unenhanced CT images, one point is
deducted
from that score.

M1, M2, M3, M4, M5, M6

Caudate nucleus (C)
Lentiform nucleus (L)
Internal capsule (IC), and
insular cortex (I).

M1

M4
C
I

L
IC

M5

M2

M3

ASPECTS Score = 10 M3 = 9

M6

MRI
T1-weighted spin-echo (T1W)
T2- weighted fast spin-echo(T2W)
Fluid attenuated inversion recovery
(FLAIR)
T2*-weighted gradient-echo, and
Diffusion weighed imaging (DWI)
Apparent diffusion coefficient mapping (ADC)

Gadolinium-enhanced T1-weighted spinecho sequences

Principles of MRI
To acquire images RF pulses are applied at
Larmor frequency of hydrogen ( H+ resonant
spin frequency).
The energy from these pulses is absorbed and
then released until the tissue has remitted the
energy absorbed and undergone relaxation.
The energy released occurs over a time
according to T1 ( longitudinal relaxation
constant ) and T2 ( transverse relaxation
constant ) of different tissues.

 ECHO TIME ( TE )
The time the machine waits after applied
RF pulse to receive RF echo from the
patient

REPITITION TIME ( TR )
The time between RF pulses.

Conventional pulse
sequences

T1 WI
GREY MATTER GREY
WHITE MATTER WHITE
CSF BLACK
ARTERIES BLACK
(FLOW VOIDS)

T2 WI
GREY MATTER GREY
WHITE MATTER GREY
CSF WHITE
ARTERIES BLACK
(FLOW VOIDS)

FLAIR
GREY MATTER GREY
WHITE MATTER
GREY
CSF BLACK
ARTERIES BLACK
(FLOW VOIDS)

Advanced stroke imaging

protocols
Diffusion weighted imaging (DWI)
It detects the Brownian movment of water
molecules.
Ischemic brain with reduced water movment will
loose less signal and hence look bright relatively.
As the diffusion coefficient increases (b=0 to 1000)
acutely infarcted region becomes more brighter. i.e.
DIFFUSION RESTRICTION
ADC (Apparent diffusion coefficient ) is calculated
from reduction in signal intensity that occurs with
diffusion weighing. In acute ischemia ischemic
tissues appear bright on DWI and dark on ADC
mapping.

FLAIR

DWI
b=100
0

DWI
b=0

ADC

FLAIR

DWI
b =1000

DWI
b=0

ADC

 Susceptibility Weighted Imaging (SWI)

Here the contrast between tissues
depends on the magnetic susceptibility
differences.
SWI imaging helps in detection of acute
hemorrhage , chronic micro bleeds and
cerebral veins.
One of the best modality available in
detecting bleed.

CT

SWI

Usual findings noted on MR :

Hyper intense signal in white matter,
( T2 ,T2*,DWI ,FLAIR )
Loss of gray matter white matter
differentiation.
Sulcal effacement and mass effect
Loss of the arterial flow voids seen on
T2- weighted images.
Intravascular thrombus can be seen on
MR images as
Low signal-intensity on T2* gradient echo
sequences
High-signal-intensity on FLAIR images

BLOOMING

CTA Source images

CTA-SI appears to be as good as DWI
at detecting acute ischemia, with the
exception of small foci and those in
the posterior fossa. ( LEVEL B )

PIPES

 USG
CAROTID DOPPLER
TCD

CTA
MRA
DSA

TCD Transcranial Doppler

Transcranial Doppler (TCD) was
introduced by Rune Aaslid in 1982
to non-invasively assess cerebral
hemodynamics.
From that TCD has evolved a lot and
with the modern imaging device
brain circulatory physiology is easily
accessible.

 This technique can detect

Intracranial flow velocities,

Direction of flow,
Vessel occlusion,
Presence of emboli, and
Vascular reactivity.

The arteries best evaluated are those at

the base of the brain (MCA, ACA, carotid
siphon, vertebral artery, and basilar
artery) and the ophthalmic artery.

TCD-TIBI
Demchuk et al. developed the
thrombolysis in brain ischemia
(TIBI) flow grading system to predict
the success of intracranial clot lysis
and short-term improvement after
ischemic stroke.

TCD
2 MHz probe
Windows

Temporal
Orbital
Sub occipital
Retro mastoid

 GRADE 0 no flow
GRADE 1 minimal flow
GRADE 2 blunted flow
GRADE 3 dampened
GRADE 4 stenotic
GRADE 5 normal flow

Lt.MCA grade 2 flow

Post lysis Lt.MCA

PRE THROMBOLYSIS

POST THROMBOLYSIS

MRA
2-D TOF ( Time of flight )
3-D TOF
CE MRA

MR Angiography
The vascular signals depend on direction
and velocity of blood flowing in to the
plane of imaging.
A 3-D acquisition ( 3D TOF ) gives higher
spatial resolution for assessing arteries of
circle of Willis and is less prone for signal
loss from turbulent flow.
2D TOF is good for neck vessel assessment
as it is more sensitive for slow flow.

 In diagnosis of arterial dissection ,

Fibromuscular dysplasia, venous
thrombosis, and some cases of
vasculitis.
Detects intracranial aneurysms and
arteriovenous malformations.
CE-MRA provides more accurate
imaging of extracranial vessel
morphology .( Level A )

CT ANGIOGRAPHY
CTA has twice the spatial resolution of MRA.
A study by Berg et al found that CTA was
comparable to DSA for diagnosing significant
carotid disease.
For an acute stroke patient, Lev et al have
demonstrated that the accuracy of CTA for defining
the acute intra-arterial thrombus is close to that of
DSA.
CTA appears superior to 3-dimensional TOF
MRA, with a higher sensitivity and positive predictive
value than MRA for both intracranial stenosis and
occlusion.

CLOT BURDEN SCORE

To detect the intra vascular
thrombus load.
10 points were allotted for noting
contrast opacification in major
arteries of anterior circulation.
2 points each were subtracted for
absence of contrast opacification in
the complete cross-section of any
part of the
Proximal M1 segment,
Distal M1 segment or
Supraclinoid ICA and
1 point each for
M2 branches,
A1 segment and
Infraclinoid ICA

CLOT BURDEN SCORE = 10 distal MCA(2) MCA cortical branches(2) = 6

PERFUSION & PENUMBRA

PENUMBRA
Acute cerebral ischemia may result in a central
irreversibly infarcted tissue core surrounded
by a peripheral region of stunned cells that is
called a penumbra but this region is potentially
salvageable with early recanalization.
It is a dynamic entity

Role of perfusion imaging

Identification of brain regions with extremely low
cerebral blood flow (CBF), i.e core
Identification of patients with at-risk brain regions i.e
penumbra which is salvageable.
Triage of patients with at-risk brain regions to other
available therapies,( induced hypertension or
mechanical clot retrieval )
Disposition decisions regarding intensive monitoring
of patients with large abnormally perfused brain
regions;
Patients who awaken with a stroke for which the
precise time of onset is unknown

SPECT
Xenon CT
CT perfusion
MR perfusion

CT PERFUSION
Important information obtained by
perfusion imaging
Cerebral blood volume (CBV )
Cerebral blood flow (CBF)
Mean transit time (MTT)

 CTA-SI, can specifically detect infarct

core and can therefore be used to
define a worst-case lower limit to
final infarct size (FIV).
In patients with major reperfusion,
mean CBV and CTP-SI infarct size
closely predicted final infarct size ,
indicating its accuracy in identifying
the extent of reversible and
irreversible ischemia.

 Thresholds >66% reduction in CBF for

nonviable penumbra and <50% reduction
in CBF for benign oligemiamay predict
the upper and lower limits of final infarct size.
Visual threshold for identification of the CBV
core corresponded to a 75% reduction in
CBF.
A relative MTT increase of 150% being
accurate for defining the at-risk
penumbra

 50 yr M , presenting within 3 hrs of

Rt hemiplegia with grade 2 power
and aphasia.
NIHSS 18
ASPECT Score - 9

ON THE DAY 3 HRS FROM SYMPTOMS

CEREBRAL BLOOD VOLUME

MEAN TRANSIT TIME

CEREBRAL BLOOD
FLOW

CEREBRAL BLOOD VOLUME

2

MEAN TRANSIT TIME

2

CEREBRAL BLOOD FLOW

2

CEREBRAL BLOOD VOLUME

3

MEAN TRANSIT TIME

3

CEREBRAL BLOOD
FLOW

AFTER 24 HRS

MR Perfusion
2 techniques
Bolus tracking with contrast
Arterial spin labelling ( without contrast ) - newer

Amount of signal loss is proportional to

cerebral blood volume (CBV )
Time taken to peak (TTP) change is
proportional to Mean transit time (MTT)of
blood
Cerebral blood flow (CBF) equals the
ratio of CBV : MTT

PRE THROMBOLYSIS

POST
THROMBOLYSIS

TAKE HOME POINTS

CT

MRI

More readily available

Cheaper modality both
for the patient and
equipment cost
Involves radiation
exposure and contrast
exposure.
Image acquisition is
faster compared to
MRI

No ionizing radiation
More sensitive and
accurate than CT in early
imaging.
Non contrast alternatives
for vascular and
perfusion assesment
available .
Cost,availability,feasibilit
y
Contraindications

Technique selection for evaluation of

acute stroke with CT and MRI

CT

MRI

Parenchy
ma
Pipes

CT PLAIN

FLAIR , DWI ,

CT ANGIOGRAPHY

MR ANGIOGRAPHY

Perfusion

CT PERFUSION
IMAGING

PERFUSION
WEIGHED IMAGING

Penumbra Cerebral blood flow DWI PWI

and cerebral blood mismatch
volume (CBF
CBV ) mismatch

Multi modal CT imaging

Sulcal effacement
Loss of insular ribbon
Blurring of grey white matter junction
Obscuration of lentiform nucleus
Hyperdense artery sign , indicative of intravascular
thrombus.
Arterial occlusion on CTA
Reduction or absence of contrast on CTA source
images
Reduction or absence of perfusion on CT Perfusion
parameter maps

MRI
Hyperintensity on DWI with minimal or no changes on T2WI
or FLAIR.
Hypointensity on ADC
Hypointense artery sign on Gradient recalled echo ( GRE )
sequences, suggestive of acute intravascular thrombus
BLOOMING
Arterial occlusion on MRA
Absence of arterial flow void on T2WI ,FLAIR
Hyperintense vessel sign on FLAIR , indicative of slow or
collateral flow .
Reduction or absence of contrast on dynamic PWI source images
Reduction or absence of perfusion on PWI perfusion
parameter maps.

The main advantages of

TCD are
Bedside testing
Real time assessment
of hemodynamics
Ascertaining stroke
pathogenesis
Continuous monitoring
Aid therapies

ASPECTS score

Clot burden score

DWI
b=

DWI
b =500

DWI
b
=100
0