Approach to Diagnosis

The goal of imaging in a patient with

acute stroke are:
Exclude hemorrhage
Differentiate between irreversibly
affected brain tissue and reversibly
impaired tissue (dead tissue vs. tissue
at risk or the penumbra)
Identify stenosis or occlusion of major
extra- and intracranial arteries

Approach to Diagnosis

CT Scan
MRI
Angiography
CBC
Electrocardiogram
Other laboratory parameter

CT Scan
CT has the advantage of being available 24
hours a day and is the gold standard for
hemorrhage.
First tests done in a stroke evaluation,
particularly during an acute stroke in the
emergency room.
Distinguish between ischemic and
hemorrhagic stroke
Normal CT in patient with <3 hrs of
symptoms can begin rtPA therapy if no other
contraindications

CT Scan
Used when MRI is not available or
contraindicated, or in emergency
settings when hemorrhage,stroke, or
traumatic brain injuryare suspected.
The overall sensitivity of CT to
diagnose stroke is 64% and the
specificity is 85%.

CT Scan
Acute Ischemic Stroke:
Result from thrombo-embolic
occlusion of intracranial arteries
Various patterns can be seen on CT
scan in early & late stages

CT Scan
Middle Cerebral Artery:
75% of all ischemic events
Sxs vary between minor sensory or
motor deficits
More patients are scanned earlier to
rule out hemorrhage and large
infarcts due to thrombolytic therapy

CT Scan
Hyperdense MCA sign:
Clot is visible as hyperdense in MCA
Most evident along the horizontal part
Appears as vessel segment of higher
density than other parts of same vessel,
contralateral MCA and BA
Not an unequivocal sign of occlusion
Does not represent ischemic change in
parenchyma

CT early signs of ischemia

hypo attenuaing brain tissue

obscuration of lentiform nucleus
dense MCA sign
insular ribbon sign
loss of sulcal effacement

MCA Infarction
hypodense with in 6 hours

Insular Ribbon Signs

This refers to hypodensity and swelling of the insular cortex.
It is a very indicative and subtle early CT-sign of infarction in
the territory of the middle cerebral artery.
This region is very sensitive to ischemia because it is the
furthest removed from collateral flow.

Insular Ribbon Sign of MCA

CT Scan
Day 3 after Acute Ischemic Stroke

Dense MCA sign

due to thrombus or embolus

CT Perfusion (CTP)
With CT and MR-diffusion we can get a good
impression of the area that is infarcted, but we
cannot preclude a large ischemic penumbra (tissue
at risk).
With perfusion studies we monitor the first pass of
an iodinated contrast agent bolus through the
cerebral vasculature.
Perfusion will tell us which area is at risk.
Approximately 26% of patients will require a
perfusion study to come to the proper diagnosis.
The limitation of CT-perfusion is the limited
coverage.

CT Perfusion (CTP)

Magnetic Resonance
Imaging (MRI)
useful for detecting a wide variety of brain
and blood vessel abnormalities, and can
usually determine the area of the brain
that is damaged by an ischemic stroke.
MRA: inject intravenous dye (gadolinium)
into the blood vessels to view arteries and
veins and highlight blood flow

Left MCA Infarct (Superior

division)

Diffusion Weighted Imaging (DWI)

It is the most sensitive sequence for stroke
imaging.
It is sensitive to restriction of Brownian
motion of extracellular water due to
imbalance caused by cytotoxic edema.
Normally water protons have the ability to
diffuse extracellularly and loose signal.
High intensity on DWI indicates restriction
of the ability of water protons to diffuse
extracellularly.

Diffusion Weighted Imaging (DWI)

Angiography
Provide high resolution images of the extraintra cranial cerebral vasculature
Involves entering a catheter into the body
to inject a dye (a contrast medium) into the
carotid arteries, the vessels of the neck that
lead to the brain.
Useful for:
Occluded or stenotic vessel - Arterial dissection
Aneurysm - AVM
Vasculitic narrowing - Venous sinus thrombosis

CT Findings in Cerebral
Acute: 12-24 hrs
Infarction

Hyperacute: <12 hrs

Normal 50-60%
Onset 4-6hours
Hyperdense artery
(dense MCA sign)
Obscuration of the
lenticular nucleus
loss of gray-white
interfaces (insular
ribbon sign

Low density basal

ganglia
sulcal effacement

1 to 3 Days:
Increasing mass
effect
Wedge-shaped low
density area
involving gray and
white matter
Possible
hemorrhagic

MR Findings in Cerebral
Infarction
Immediate
Hyperintense on DWI
(low apparent diffusion
coefficient, ADC)
IV contrast enhancement
perfusion alterations
<12 hrs
Sulcal effacement, gyral
edema, loss of graywhite interfaces on T1

12 to 24 hrs
Hyperintensity on T2
Meningeal enhancement
adjacent to infarct
Mass effect
1 to 3 days
IV and meningeal
enhancement begin
decline
Signal abnormalities
striking on T1WI, T2WI
Possible hemorrhagic
transformation

Complete Blood Count

(CBC)
Serves as a baseline study and may reveal
a cause for the stroke (eg, polycythemia,
thrombocytosis, thrombocytopenia,
leukemia) or provide evidence of
concurrent illness (eg, anemia).
Serves as a baseline study and may reveal
a stroke mimic (eg, hypoglycemia,
hyponatremia) or provide evidence of
concurrent illness (eg, diabetes, renal
insufficiency).

Electrocardiogram
The first sign of arrhythmia or a MI is often the
occurrence of cerebral embolism; consequently it
is advisable that an ECG and Echocardiogram be
obtained in all patient with stroke of uncertain
origin
Sometimes the only method of detecting
irregularities in heart rhythm such as atrial
fibrillation that can lead to the forming of blood
clots that can later get flow to the brain. These
blood clots can cause stroke by forming in the
heart, coming loose and then getting lodged in a
small artery of the brain.
http://www.strokecenter.org
http://
eradiology.bidmc.harvard.edu/LearningLab/central/Hoki.pdf

Underlying Disease
Cardiovascular:
- Like MI, atrial fibrillation, valvular
disease etc.
- ECG
- Chest X-ray
- Echocardigraphy
- Transesophageal ultrasound
- Blood Cultures

 Serum lipids for hyperlipidemia

MR Angiography (arterial dissection)
PT, aPTT, Platelet count for bleeding
d/o
Protein C & S for hypercuagulability
Random blood sugar (RBS)