Stroke Imaging

Author: Vinodkumar Velayudhan, DO; Chief

Editor: L Gill Naul, D
Overview
Background
Stroke, or !ere"ro#a$!ular a!!ident %CVA&, i$ a !lini!al term that de$!ri"e$ a
$udden lo$$ of neurologi! fun!tion 'er$i$ting for more than () hour$ that i$ !au$ed
"y an interru'tion of the "lood $u''ly to the "rain %$ee the image$ "elo*&+ It i$ the
third leading !au$e of death in the ,nited State$ and the $e!ond mo$t !ommon
!au$e of death *orld*ide, *ith !on$idera"le di$a"ility among $ur#i#or$+
-., (/
A0ial non!ontra$t !om'uted tomogra'hy %NCC1& demon$trate$ diffu$e
hy'oden$ity in the right lentiform nu!leu$, *ith ma$$ effe!t u'on the frontal horn
of the right lateral #entri!le+ 1he 'atient i$ a 234year4old female *ith hi$tory of
left4$ided *eakne$$ for $e#eral hour$ duration+

5I *a$ $u"$e6uently o"tained in the $ame 'atient+ An a0ial 1( 7LAI5 image
%left& demon$trate$ high $ignal in the lentiform nu!leu$ *ith ma$$ effe!t+ 1he a0ial
diffu$ion4*eighted image %middle& demon$trate$ high $ignal in the $ame area *ith
!orre$'onding lo* $ignal on the a''arent diffu$ion !oeffi!ient %ADC& ma'$,
!on$i$tent *ith true re$tri!ted diffu$ion and an a!ute infar!tion+ a0imum
inten$ity 'ro8e!tion from a 9D time4of4flight 5A %right& demon$trate$ o!!lu$ion
of the di$tal middle !ere"ral artery %CA& trunk %red !ir!le&+
1he etiologie$ of $troke are #aried "ut !an "roadly "e !ategori:ed into i$!hemi! or
hemorrhagi! infar!tion$+ A''ro0imately ;34;2< of $troke$ are from i$!hemi!
infar!tion due to throm"oti! or em"oli! !ere"ro#a$!ular o!!lu$ion+ =emorrhagi!
1
infar!tion$ !om'ri$e mo$t of the remainder of $troke$ *ith a $maller num"er due
to aneury$mal $u"ara!hnoid hemorrhage+
-., 9, ), >/
7urthermore, (34)3< of 'atient$ *ith i$!hemi! infar!tion may de#elo'
hemorrhagi! tran$formation *ithin one *eek after i!tu$+
-?, 2/
Differentiating
"et*een the$e different ty'e$ of $troke i$ an e$$ential 'art of the initial *orku' of
the$e 'atient$ "e!au$e the $u"$e6uent management of ea!h 'atient i$ #a$tly
different+ 1he $!o'e of thi$ arti!le mainly fo!u$e$ on i$!hemi! and hemorrhagi!
$troke+
Neuroimaging 'lay$ a #ital role in the *orku' of a!ute $troke "y 'ro#iding
information e$$ential to a!!urately triage 'atient$, e0'edite !lini!al de!i$ion
making *ith regard$ to treatment, and im'ro#e out!ome$ in 'atient$ 're$enting
*ith a!ute $troke+
-;/
5a'id and a!!urate diagno$i$ i$ !ru!ial $in!e the only drug
!urrently a''ro#ed "y the 7DA for treatment of a!ute i$!hemi! $troke i$
intra#enou$ ti$$ue 'la$minogen a!ti#ator %t@A& admini$tered *ithin 9 hour$ of
$troke on$et+
-A/
Pathophysiology
Ischemic stroke
A!ute i$!hemi! $troke$ are the re$ult of #a$!ular o!!lu$ion $e!ondary to
throm"oem"oli! di$ea$e+ I$!hemia re$ult$ in !ell hy'o0ia and de'letion of !ellular
adeno$ine tri'ho$'hate %A1@&+ Bithout A1@, energy failure re$ult$ in an ina"ility
to maintain ioni! gradient$ a!ro$$ the !ell mem"rane and !ell de'olari:ation+
Influ0 of $odium and !al!ium ion$ and 'a$$i#e inflo* of *ater into the !ell
en$ue$, re$ulting in !ytoto0i! edema+ 7urther, !ell de'olari:ation lead$ to the
relea$e of glutamate and free radi!al$, mito!hondrial mem"rane di$ru'tion, and a
!a$!ade that ultimately lead$ to a'o'toti! !ell death+
->, ;, .3/
I$!hemia al$o dire!tly re$ult$ in dy$fun!tion of the !ere"ral #a$!ulature, *ith
"reakdo*n of the "lood4"rain "arrier o!!urring *ithin )4? hour$ after infar!tion+
7ollo*ing "reakdo*n of the "lood4"rain "arrier, 'rotein$ and *ater flood into the
e0tra!ellular $'a!e, leading to #a$ogeni! edema+ Va$ogeni! edema 'rodu!e$
greater le#el$ of "rain $*elling and ma$$ effe!t that 'eak at 94> day$ and re$ol#e$
o#er the ne0t $e#eral *eek$ *ith re$or'tion of *ater and 'rotein$+
-.., .(/
Infar!tion re$ult$ in the death of a$tro!yte$ a$ *ell a$ the $u''orting
oligodendroglia and mi!roglia !ell$+ 1he infar!ted ti$$ue e#entually undergoe$
li6uefa!tion ne!ro$i$ and i$ remo#ed "y ma!ro'hage$ *ith the de#elo'ment of
'aren!hymal #olume lo$$+ A *ell4!ir!um$!ri"ed region of !ere"ro$'inal4fluidlike
lo* den$ity i$ e#entually $een, !on$i$ting of en!e'halomala!ia and !y$ti! !hange+
1he e#olution of the$e !hroni! !hange$ may "e $een in the *eek$ to month$
follo*ing the infar!tion+
Ischemic penumbra
2
I$!hemi! ti$$ue !an "e fun!tionally di#ided into the irre#er$i"ly damaged infar!t
!ore and the i$!hemi! 'enum"ra $urrounding it+ 1he infar!t !ore i$ the !entral
:one of dead or dying ti$$ue in an i$!hemi! area+ Surrounding the infar!t !ore i$
ti$$ue *ith le$$ $e#ere redu!tion in "lood flo* that may "e $al#aged *ith early
re'erfu$ion, termed i$!hemi! 'enum"ra, and oligemi! ti$$ue at the 'eri'hery+
Bithout re'erfu$ion, the :one of infar!t !ore may e0tend to in#ol#e the 'enum"ra+
1he goal$ of modern i$!hemi! $troke diagno$i$ and thera'y lie in identifying the
infar!t !ore and determining if any $ignifi!ant $al#agea"le ti$$ue e0i$t$+
-.9/
Ischemic stroke classification
I$!hemi! $troke$ may "e di#ided into 9 ma8or $u"ty'e$, "a$ed on the 1OAS1
!la$$ifi!ation $y$tem, ado'ted from the $y$tem of !ategori:ing $troke de#elo'ed in
the multi!enter 1rial of Org .3.2( in A!ute Stroke 1reatment+
-.)/
1he$e in!lude
large artery infar!tion, $mall4#e$$el or la!unar infar!tion, and !ardioem"oli!
infar!tion$+
Large vessel occlusive disease
Large artery o!!lu$ion ty'i!ally re$ult$ from em"oli:ation of athero$!leroti!
de"ri$ originating from the !ommon or internal !arotid arterie$ or from a !ardia!
$our!e+ A $maller num"er of large artery o!!lu$ion$ may ari$e from 'la6ue
ul!eration and in $itu throm"o$i$+ Large4#e$$el i$!hemi! $troke$ more !ommonly
affe!t the middle !ere"ral artery territory, *ith the anterior !ere"ral artery territory
affe!ted to a le$$er degree %$ee the image$ "elo*&+

Non!ontra$t C1 in thi$ >(4year4old male *ith hi$tory of *or$ening right4$ided
*eakne$$ and a'aha$ia demon$trate$ diffu$e hy'oden$ity and $ul!al effa!ement
in#ol#ing the left anterior and middle !ere"ral artery territorie$ !on$i$tent *ith
a!ute infar!tion+ S!attered !ur#ilinear area$ of hy'erden$ity are $ugge$ti#e of
de#elo'ing 'ete!hial hemorrhage in thi$ large area of infar!tion+

5A in the $ame 'atient %left& demon$trate$ o!!lu$ion of the left 're!a#ernou$
$u'ra!linoid internal !arotid artery %ICA, red !ir!le&, o!!lu$ion or high4grade
$teno$i$ of the di$tal middle !ere"ral artery %CA& trunk and attenuation of
multi'le ( "ran!he$+ 1he diffu$ion4*eighted image %right& demon$trate$ high
$ignal !onfirmed to "e true re$tri!ted diffu$ion on the ADC ma' !on$i$tent *ith
a!ute infar!tion+

1hi$ ?34year4old female under*ent NCC1 after an e'i$ode of left u''er e0tremity
*eakne$$+ NCC1 demon$trate$ !orti!al and $u"!orti!al hy'oden$ity in#ol#ing the
right mid to anterior tem'oral lo"e+

I@ image from a C1A demon$trate$ a filling defe!t or high4grade $teno$i$ at the
"ran!hing 'oint of the right CA trunk %red !ir!le&, $u$'i!iou$ for throm"u$ or
3
em"olu$+ C1A i$ highly a!!urate in dete!ting large #e$$el $teno$i$ and o!!lu$ion$,
*hi!h !om'ri$e a''ro0imately one third of i$!hemi! $troke$+
Lacunar infarction
La!unar infar!tion$ are $mall infar!t$ re$ulting from o!!lu$ion of dee',
'enetrating end arterie$ %$ee the image "elo*&+ 1hey may "e !au$ed "y $mall
#e$$el athero$!lero$i$ and li'ohyalino$i$ related to hy'erten$ion or em"oli!
o!!lu$ion+ Ce!au$e of the limited area $u''lied "y the$e 'erforating end arterie$,
their o"$tru!tion re$ult$ in a $mall area of infar!tion ranging from a"out > mm in
diameter u' to a''ro0imately .> mm+ 1he mo$t !ommon lo!ation$ for la!unar
infar!tion$ in!lude the "a$al ganglia, internal !a'$ule, thalamu$, and the !orona
radiata+
-.>, .?, .2/

A0ial non!ontra$t C1 demon$trate$ a fo!al area of hy'oden$ity in the left
'o$terior lim" of the internal !a'$ule in thi$ ?34year4old male *ith ne* on$et of
right4$ided *eakne$$+ 1he le$ion demon$trate$ high $ignal on the 7LAI5 $e6uen!e
%middle image& and DBI %right image&, *ith lo* $ignal on the ADC ma'$,
indi!ating an a!ute la!unar infar!tion+ La!unar infar!t$ are ty'i!ally no more than
.+> !m in $i:e and !an o!!ur in the dee' gray matter $tru!ture$, !orona radiata,
"rain$tem, and !ere"ellum+
Cardioembolic infarction
Cardiogeni! em"oli are a !ommon $our!e of re!urrent $troke %$ee the image
"elo*&+ 1hey may !om'ri$e u' to (3< of a!ute $troke and ha#e "een re'orted to
ha#e the highe$t .4month mortality+ 5i$k fa!tor$ in!lude atrial fi"rillation and
re!ent !ardia! $urgery+ Cardioem"oli! $troke$ may "e i$olated, multi'le and in a
$ingle hemi$'here or $!attered and "ilateral; the latter t*o of *hi!h indi!ate
multi'le #a$!ular di$tri"ution$ and are more $'e!ifi! for !ardioem"oli$m+ ulti'le
and "ilateral infar!t$ !an "e the re$ult of em"oli! $ho*er$ or re!urrent em"oli+
Other 'o$$i"ilitie$ for $ingle and "ilateral hemi$'heri! infar!tion$ in!lude em"oli
originating from the aorti! ar!h and diffu$e throm"oti! or inflammatory 'ro!e$$e$
that !an lead to multi'le $mall #e$$el o!!lu$ion$+
-.;, .A/

Cardioem"oli! $troke: A0ial diffu$ion4*eighted image$ demon$trate $!attered fo!i
of high $ignal in the $u"!orti!al and dee' *hite matter "ilaterally in a 'atient *ith
a kno*n !ardia! $our!e for em"oli:ation+ An area of lo* $ignal in the left
ganglio!a'$ular region may "e $e!ondary to 'rior hemorrhage or $u"a!ute to
!hroni! la!unar infar!t+ 5e!urrent $troke$ are mo$t !ommonly $e!ondary to
!ardioem"oli! 'henomenon+
Watershed infarction
Va$!ular *ater$hed or "order4:one infar!tion$ o!!ur at the mo$t di$tal area$
"et*een arterial territorie$ %$ee the image "elo*&+ 1hey are "elie#ed to "e
4
$e!ondary to em"oli! 'henomenon or due to $e#ere hy'o'erfu$ion, $u!h a$ in
!arotid o!!lu$ion or 'rolonged hy'oten$ion+
-(3, (., ((/

5I *a$ o"tained to e#aluate thi$ ?(4year4old hy'erten$i#e and dia"eti! male
*ith hi$tory of tran$ient e'i$ode$ of right4$ided *eakne$$ and a'ha$ia+ 1he
7LAI5 image %left& demon$trate$ 'at!hy area$ of high $ignal arranged in a linear
fa$hion in the dee' *hite matter, "ilaterally+ 1hi$ !onfiguration i$ ty'i!al for dee'
"order:one or *ater$hed infar!tion; in thi$ !a$e, the anterior and 'o$terior middle
!ere"ral artery %CA& *ater$hed area$+ 1he left4$ided infar!t$ ha#e !orre$'onding
lo* $ignal on the ADC ma' %right&, $ignifying a!uity+ An old left 'o$terior 'arietal
infar!t i$ noted a$ *ell+
Hemorrhagic transformation of ischemic stroke
=emorrhagi! tran$formation re're$ent$ the !on#er$ion of a "land infar!tion into
an area of hemorrhage+ @ro'o$ed me!hani$m$ for hemorrhagi! tran$formation
in!lude re'erfu$ion of i$!hemi!ally in8ured ti$$ue, either from re!anali:ation of an
o!!luded #e$$el or from !ollateral "lood $u''ly to the i$!hemi! territory or
di$ru'tion of the "lood "rain "arrier+ Bith di$ru'tion of the "lood4"rain "arrier,
red "lood !ell$ e0tra#a$ate from the *eakened !a'illary "ed, 'rodu!ing 'ete!hial
hemorrhage or more frank intra'aren!hymal hematoma+
->, (9, ()/
=emorrhagi! tran$formation of an i$!hemi! infar!t o!!ur$ *ithin (4.) day$ 'o$t
i!tu$, u$ually *ithin the fir$t *eek+ It i$ more !ommonly $een follo*ing
!ardioem"oli! $troke$ and i$ more likely *ith larger infar!t $i:e+
->, 2, A/
=emorrhagi!
tran$formation i$ al$o more likely follo*ing admini$tration of t@A and *ith
non!ontra$t C1 demon$trating area$ of hy'oden$ity %$ee the image "elo*&+
-.9, (>, (?/

Non!ontra$t C1 %left& o"tained after thi$ 2>4year4old male *a$ admitted for CVA;
$!an demon$trate$ a large right middle !ere"ral artery di$tri"ution infar!tion *ith
linear area$ of de#elo'ing hemorrhage+ 1he$e "e!ome more !onfluent on day ( of
ho$'itali:ation %middle image&, *ith in!rea$ed ma$$ effe!t and midline $hift+
a$$i#e hemorrhagi! tran$formation o!!ur$ "y day ? %right& *ith in!rea$ed
left*ard midline $hift and $u"fal!ine herniation+ O"$tru!ti#e hydro!e'halu$ i$ al$o
noted *ith dilatation of the lateral #entri!le$, likely due to !om're$$ion of the
foramen of onroe+ Intra#entri!ular hemorrhage i$ al$o noted, layering in the left
o!!i'ital horn+ Larger infar!tion$ are more likely to undergo hemorrhagi!
tran$formation and are one !ontraindi!ation to throm"olyti! thera'y+
Hemorrhagic stroke
1he mo$t !ommon etiology of 'rimary hemorrhagi! $troke %intra!ere"ral
hemorrhage& i$ hy'erten$ion, *ith at lea$t t*o4third$ of 'atient$ *ith 'rimary
intra'aren!hymal hemorrhage re'orted to ha#e 're4e0i$ting or ne*ly diagno$ed
hy'erten$ion+ =y'erten$i#e $mall #e$$el di$ea$e re$ult$ from tiny li'ohyalinoti!
aneury$m$ that $u"$e6uently ru'ture and re$ult in intra'aren!hymal hemorrhage+
5
1y'i!al lo!ation$ in!lude the "a$al ganglia, thalami, !ere"ellum, and 'on$ %$ee the
image$ "elo*&+ 1he remaining !a$e$ of $'ontaneou$ intra'aren!hymal
hemorrhage may "e $e!ondary to #a$!ular malformation$ %eg, arterio#enou$
malformation$ and !a#ernou$ malformation$& or amyloid angio'athy+
->, .), (2, (9, (;/

A0ial non!ontra$t C1 $!an of the "rain in a ?34year4old male *ith hi$tory of a!ute
on$et of left4$ided *eakne$$ demon$trate$ ( area$ of intra!ere"ral hemorrhage in
the right lentiform nu!leu$ *ith $urrounding edema and effa!ement of the
ad8a!ent !orti!al $ul!i and right $yl#ian fi$$ure+ a$$ effe!t i$ 're$ent u'on the
frontal horn of the right lateral #entri!le *ith intra#entri!ular e0ten$ion of
hemorrhage+

Non!ontra$t C1 of the "rain %left& demon$trate$ an a!ute hemorrhage in the left
ganglio!a'$ular region *ith $urrounding *hite matter hy'oden$ity !on$i$tent *ith
#a$ogeni! edema+ 1(4*eighted a0ial 5I %middle image& demon$trate$ the
hemorrhage *ith $urrounding high4$ignal edema+ 1he !oronal gradient e!ho
image %right& demon$trate$ $u$!e'ti"ility related to the hematoma *ith markedly
lo* $ignal ad8a!ent the left !audate head+ Gradient e!ho image$ are highly
$en$iti#e for "lood 'rodu!t$+
Subarachnoid hemorrhage
1he mo$t !ommon !au$e of atraumati! hemorrhage into the $u"ara!hnoid $'a!e i$
ru'ture of an intra!ranial aneury$m+ Aneury$m$ are fo!al dilatation$ of arterie$,
*ith the mo$t fre6uently en!ountered intra!ranial ty'e "eing the "erry aneury$m
or $a!!ular aneury$m$+ Aneury$m$ may le$$ !ommonly "e related to altered
hemodynami!$ related to arterio#enou$ malformation$, !ollagen4#a$!ular di$ea$e,
'oly!y$ti! kidney di$ea$e, $e'ti! em"oli, and neo'la$m$+
Nonaneury$mal 'erime$en!e'hali! $u"ara!hnoid hemorrhage may al$o "e $een
and i$ thought to ari$e from !a'illary or #enou$ ru'ture+ It ha$ a le$$ $e#ere
!lini!al !our$e and, in general, "etter 'rogno$i$+
Cerry aneury$m$ are mo$t !ommonly i$olated le$ion$ that form due to a
!om"ination of hemodynami! $tre$$e$ and a!6uired or !ongenital *eakne$$ in the
#e$$el *all+ Sa!!ular aneury$m$ ty'i!ally o!!ur at #a$!ular "ifur!ation$, *ith
more than A3< o!!urring in the anterior !ir!ulation+ 1he$e in!lude the 8un!tion of
the anterior !ommuni!ation arterie$ and anterior !ere"ral arterie$ mo$t !ommonly,
the middle !ere"ral artery "ifur!ation, the $u'ra!linoid internal !arotid artery at
the origin of the 'o$terior !ommuni!ating artery, and the "ifur!ation of the ICA+
1he 'athologi! effe!t$ of SA= on the "rain are multifo!al+ SA= re$ult$ in
ele#ated intra!ranial 're$$ure and im'air$ !ere"ral autoregulation+ 1hi$, in
!om"ination *ith a!ute #a$o!on$tri!tion, mi!ro#a$!ular 'latelet aggregation, and
lo$$ of mi!ro#a$!ular 'erfu$ion, re$ult$ in 'rofound redu!tion in "lood flo* and
!ere"ral i$!hemia %$ee the image$ "elo*&+
-(A/
6

Non!ontra$t C1 $!an *a$ 'erformed emergently in thi$ 2.4year4old male *ho
're$ented *ith a!ute on$et of $e#ere heada!he and under*ent ra'id neurologi!
deterioration re6uiring intu"ation+ 1he non!ontra$t C1 %left image& demon$trate$
diffu$e, high4den$ity $u"ara!hnoid hemorrhage in the "a$ilar !i$tern$ and "oth
Syl#ian fi$$ure$+ Diffu$e lo$$ of gray4*hite differentiation i$ 're$ent+ 1he 7LAI5
image demon$trate$ high $ignal throughout the !orti!al $ul!i, "a$ilar !i$tern$, and
in the de'endent 'ortion$ of the #entri!le$+ 7LAI5 i$ highly $en$iti#e to a!ute
$u"ara!hnoid hemorrhage "e!au$e of the $u''re$$ion of high CS7 $ignal lending
to greater !on$'i!uity of SA= !om'ared *ith !on#entional 5I $e6uen!e$+
1hi$ 'atient $u"$e6uently under*ent a C1A and $u"$e6uent !ere"ral angiogra'hy+
ulti'le aneury$m$ *ere identified, in!luding a A4mm aneury$m at the 8un!tion of
the anterior !ere"ral and 'o$terior !ommuni!ating arterie$ $een on thi$ lateral
#ie* of an internal !arotid artery %ICA& in8e!tion+ Calloon4a$$i$ted !oil
em"oli:ation *a$ 'erformed+

Lateral #ie* of a $ele!ti#e in8e!tion of the left internal !arotid artery demon$trate$
a mi!ro!atheter 'a$$ing di$tal to the aneury$m ne!k+ 1hi$ lateral #ie* from an
angiogram 'erformed during "alloon4a$$i$ted !oil em"oli:ation demon$trate$
$ignifi!antly dimini$hed filling of the aneury$m+
Frequency
United States
Ea!h year in the ,nited State$, a''ro0imately 2A>,333 'eo'le e0'erien!e ne* or
re!urrent $troke+ Of the$e, a''ro0imately ?.3,333 re're$ent initial atta!k$, and
.;>,333 re're$ent re!urrent $troke$+ 1he in!iden!e of $troke #arie$ de'ending on
age, gender, ethni!ity, and $o!ioe!onomi! $tatu$+ A''ro0imately ;2< of $troke$ in
the ,nited State$ are i$!hemi!, .3< are $e!ondary to intra!ere"ral hemorrhage,
and another 9< may "e $e!ondary to $u"ara!hnoid hemorrhage+
-., (/
International
1he glo"al in!iden!e of $troke ha$ at lea$t mode$t #ariation from nation to nation,
$ugge$ting the im'ortan!e of geneti!$ and en#ironmental fa!tor$, $u!h a$
di$'aritie$ in a!!e$$ to health!are for de#elo'ing !ountrie$+ A!!ording to the
Borld =ealth Organi:ation, .> million 'eo'le $uffer $troke *orld*ide ea!h year+
1he age4ad8u$ted in!iden!e of total $troke$ 'er .333 'er$on4year$ for 'eo'le >>
year$ or older ha$ "een re'orted in the range of )+(D?+>+ 1he highe$t in!iden!e$
ha#e "een re'orted in 5u$$ia, ,kraine, and Ea'an+
O#erall, the in!iden!e of a!ute $troke ha$ demon$trated a !on$tant de!line o#er the
'a$t $e#eral de!ade$, mo$t nota"ly during the .A23$D.AA3$, although in re!ent
year$ thi$ trend ha$ "egun to 'lateau+ 1he in!rea$ed $ur#i#al among $troke #i!tim$
'la!e$ an in!rea$ed demand on health!are $y$tem$ glo"ally+
->, 93/
7
Stroke $u"ty'e$ al$o #ary greatly in different 'art$ of the *orld+ 7or e0am'le, the
'ro'ortion of hemorrhagi! $troke$ may "e e#en higher in !ertain 'o'ulation$, $u!h
a$ in China, *hi!h *a$ re'orted to "e u' to 9A+)<, and u' to 9;+2< in Ea'an+
-93, 9./
Mortality/Morbidity
Mortality
Stroke remain$ the $e!ond leading !au$e of death *orld*ide, $ur'a$$ed only "y
i$!hemi! heart di$ea$e, and i$ the third mo$t !ommon !au$e of death in de#elo'ed
nation$, in!luding the ,nited State$+ It a!!ount$ for a''ro0imately A< of death$
around the *orld+ 1he mortality a''roa!he$ >34.33 death$ 'er .33,333 'eo'le 'er
year *orld*ide "ut #arie$ $ignifi!antly regionally+ ortality i$ highe$t in many
de#elo'ing nation$, likely due to geneti! and $o!ioe!onomi! fa!tor$, 're#alen!e of
modifia"le ri$k fa!tor$, and differen!e$ in a#aila"le health!are re$our!e$ for
diagno$i$ and treatment+
A''ro0imately a 6uarter of i$!hemi! $troke$ are fatal *ithin a month, nearly one
third "y ? month$, and a half "y . year+ Stroke mortality i$ e#en higher for tho$e
*ith 'rimary intra!ere"ral hemorrhage and $u"ara!hnoid hemorrhage, *hi!h
a''roa!h >3< mortality "y one month+
->, 93/
7or $u"ara!hnoid hemorrhage, the mortality i$ a''ro0imately 9>< after the initial
"leed+
-9(/
Va$o$'a$m i$ the leading !au$e of death in tho$e *ho $ur#i#e the initial
hemorrhage,
-99/
*ith the 'eak in!iden!e o!!urring >4.( day$ after the aneury$m
ru'ture+ 5e"leeding i$ al$o a$$o!iated *ith a $ignifi!antly in!rea$ed mortality of
a''ro0imately 23< in $ur#i#or$ of the initial "leed+
-(A/
Morbidity
E$timate$ of 'o'ulation4"a$ed $tudie$ ha#e $ho*n that a''ro0imately >33 'er
.33,333 li#e *ith the !on$e6uen!e$ of $troke *ith the age4ad8u$ted 're#alen!e for
'eo'le aged ?> year$ or more ranging from )?+. to 29+9 'er .333 'o'ulation+ It
ha$ "een e$timated that $troke4related di$a"ility i$ the $i0th mo$t !ommon !au$e
of redu!ed di$a"ility4ad8u$ted life4year$+
->/
Race
A!!ording to data 'u"li$hed "y the Ameri!an =eart A$$o!iation, "la!k$ ha#e a
ri$k of fir$t4e#er $troke that i$ nearly dou"le that for *hite$+ 1he age4ad8u$ted
in!iden!e of fir$t i$!hemi! $troke 'er .33,333 *a$ ;; in *hite$, .A. in "la!k$, and
.)A in =i$'ani!$, a!!ording to data from the Northern anhattan Study
%NOAS& of $troke and $troke ri$k fa!tor$+
8
A$ 're#iou$ly de$!ri"ed, differen!e$ in $troke $u"ty'e may al$o "e $een "et*een
different ra!e$+ 7or e0am'le, an in!rea$ed 'ro'ortion of intra!ere"ral hemorrhage
and la!unar infar!t$ ha#e "een re'orted in A$ia; in the ,nited State$, the A=A
re'orted in one $tudy, re$ear!her$ found that "la!k$ had a 94fold higher
multi#ariate4ad8u$ted ri$k ratio of la!unar $troke than *hite$+
-./
Sex
Stroke i$ an im'ortant health i$$ue in *omen "e!au$e their in!iden!e of $troke
e0!eed$ that in men at older age$+ 1hi$ may in 'art "e $e!ondary to the greater
life$'an of *omen !om'ared to men and the effe!t$ of hormone $tatu$ on
!ardio#a$!ular di$ea$e follo*ing meno'au$e+ Bomen )>4>) year$ are re'orted to
"e more than t*i!e a$ likely a$ men to $uffer a $troke+ O#erall, >>,333 more
*omen than men ha#e a $troke annually in the ,nited State$+
-./
Age
Stroke i$ a di$ea$e of in!rea$ing im'ortan!e in the elderly 'o'ulation, *ith
a''ro0imately 2>< of $troke$ o!!urring in tho$e older than ?>+ Numerou$ $tudie$
ha#e demon$trated that the age4$'e!ifi! in!iden!e of $troke in!rea$e$ *ith ea!h
de!ade of life+
Anatoy
Arterial distributions
Fno*ledge of !ere"ro#a$!ular arterial anatomy and the territorie$ $u''lied "y
ea!h i$ u$eful in determining *hi!h #e$$el or #e$$el$ are in#ol#ed in a!ute $troke+
Aty'i!al 'attern$ that do not !onform to a #a$!ular di$tri"ution may indi!ate
another diagno$i$, $u!h a$ #enou$ infar!tion+
1he !ere"ral hemi$'here$ are $u''lied "y 9 'aired ma8or arterie$: the anterior,
middle, and 'o$terior !ere"ral arterie$+ 1he anterior and middle !ere"ral arterie$
!om'ri$e the anterior !ir!ulation and ari$e from the $u'ra!linoid internal !arotid
arterie$+ 1he anterior !ere"ral artery $u''lie$ the medial 'ortion of the frontal and
'arietal lo"e$ and anterior 'ortion$ of "a$al ganglia and anterior internal !a'$ule+
1he middle !ere"ral artery $u''lie$ the lateral 'ortion$ of the frontal and 'arietal
lo"e$ and the anterior and lateral 'ortion$ of the tem'oral lo"e$ and gi#e$ ri$e to
'erforating "ran!he$ to the glo"u$ 'allidu$, 'utamen, and internal !a'$ule+
1he 'o$terior !ere"ral arterie$ ari$e from the "a$ilar artery and form the 'o$terior
!ir!ulation+ 1he 'o$terior !ere"ral artery gi#e$ ri$e to 'erforating "ran!he$ that
$u''ly the thalami and "rain$tem and !orti!al "ran!he$ to the 'o$terior and medial
tem'oral lo"e$ and o!!i'ital lo"e$+ 1he !ere"ellar hemi$'here$ are $u''lied
inferiorly "y the 'o$terior inferior !ere"ellar artery %@ICA& ari$ing from the
#erte"ral artery, and $u'eriorly "y the $u'erior !ere"ellar artery and anterolaterally
"y the anterior inferior !ere"ellar artery %AICA& from the "a$ilar artery,
re$'e!ti#ely %$ee the image$ "elo*&+
9

7rontal #ie* of a !ere"ral angiogram *ith $ele!ti#e in8e!tion of the left internal
!arotid artery illu$trate$ the anterior !ir!ulation+ 1he anterior !ere"ral artery
!on$i$t$ of the A. $egment 'ro0imal to the anterior !ommuni!ating artery *ith the
A( $egment di$tal to it+ 1he CA !an "e di#ided into ) $egment$: the .
%hori:ontal $egment& e0tend$ to the limen in$ulae and gi#e$ off lateral
lenti!ulo$triate "ran!he$, the ( %in$ular $egment&, 9 %o'er!ular "ran!he$& and
) %di$tal !orti!al "ran!he$ on the lateral hemi$'heri! !on#e0itie$&+

Lateral #ie* of a !ere"ral angiogram illu$trate$ the "ran!he$ of the anterior
!ere"ral artery and Syl#ian triangle+ 1he 'eri!allo$al artery ha$ "een de$!ri"ed to
ari$e di$tal to the anterior !ommuni!ating artery or di$tal to the the origin of the
!allo$omarginal "ran!h of the anterior !ere"ral artery %ACA&+ 1he $egmental
anatomy of the ACA ha$ "een de$!ri"ed a$ follo*$: the A. $egment e0tend$ from
the internal !arotid artery %ICA& "ifur!ation to the anterior !ommuni!ating artery;
A( e0tend$ to the 8un!tion of the ro$trum and genu of the !or'u$ !allo$um; A9
e0tend$ into the "end of the genu of the !or'u$ !allo$um; A) and A> e0tend
'o$teriorly a"o#e the !allo$al "ody and $u'erior 'ortion of the $'lenium+ 1he
Syl#ian triangle o#erlie$ the o'er!ular "ran!he$ of the middle !ere"ral artery
%CA&, *ith the a'e0 re're$enting the Syl#ian 'oint+

7rontal 'ro8e!tion from a right #erte"ral artery angiogram illu$trate$ the 'o$terior
!ir!ulation+ 1he #erte"ral arterie$ 8oin to form the "a$ilar artery+ 1he 'o$terior
inferior !ere"ellar arterie$ %@ICA& ari$e from the di$tal #erte"ral arterie$+ 1he
anterior inferior !ere"ellar arterie$ %AICA& ari$e from the 'ro0imal "a$ilar artery+
1he $u'erior !ere"ellar arterie$ %SICA& ari$e di$tally from the "a$ilar artery 'rior
to it$ "ifur!ation into the 'o$terior !ere"ral arterie$+
he vascular territory of the anterior circulation !carotid"
1he anterior !ere"ral artery $u''lie$ the follo*ing $tru!ture$:
Corti!al "ran!he$ 4 edial frontal and 'arietal lo"e
edial lenti!ulo$triate "ran!he$ 4 Caudate head, glo"u$ 'allidu$, anterior
lim" of the internal !a'$ule
1he middle !ere"ral artery $u''lie$ the follo*ing $tru!ture$:
Corti!al "ran!he$ 4 Lateral frontal and 'arietal lo"e$, lateral and anterior
tem'oral lo"e
Lateral lenti!ulo$triate "ran!he$ 4 Glo"u$ 'allidu$ and 'utamen, internal
!a'$ule
1he anterior !horoidal artery $u''lie$ the follo*ing $tru!ture$:
O'ti! tra!t$
edial tem'oral lo"e
10
Ventrolateral thalamu$
Corona radiata
@o$terior lim" of the internal !a'$ule
he vascular territory of the posterior circulation
1he 'o$terior !ere"ral artery $u''lie$ the follo*ing $tru!ture$:
Corti!al "ran!he$ 4 O!!i'ital lo"e$, medial and 'o$terior tem'oral and
'arietal lo"e$
@erforating "ran!he$ 4 Crain$tem, 'o$terior thalamu$, and mid"rain
1he 'o$terior inferior !ere"ellar artery $u''lie$ the follo*ing $tru!ture$:
Inferior #ermi$
@o$terior and inferior !ere"ellar hemi$'here$
1he anterior inferior !ere"ellar artery $u''lie$ the follo*ing $tru!ture:
Anterolateral !ere"ellum
1he $u'erior !ere"ellar artery $u''lie$ the follo*ing $tru!ture$:
Su'erior #ermi$
Su'erior !ere"ellum %$ee the image "elo*&

1he $u'ratentorial #a$!ular territorie$ of the ma8or !ere"ral arterie$ are
demon$trated $u'erim'o$ed on a0ial %left& and !oronal %right& 1(4*eighted
image$ through the le#el of the "a$al ganglia and thalami+ 1he middle
!ere"ral artery %CA; red& $u''lie$ the lateral a$'e!t$ of the hemi$'here$,
in!luding the lateral frontal, 'arietal and anterior tem'oral lo"e$, in$ula,
and "a$al ganglia+ 1he anterior !ere"ral artery %ACA; "lue& $u''lie$ the
medial frontal and 'arietal lo"e$+ 1he 'o$terior !ere"ral artery %@CA;
green& $u''lie$ the thalami and o!!i'ital and inferior tem'oral lo"e$+ 1he
anterior !horoidal artery %yello*& $u''lie$ the 'o$terior lim" of the
internal !a'$ule and 'art of the hi''o!am'u$ e0tending to the anterior and
$u'erior $urfa!e of the o!!i'ital horn of the lateral #entri!le+
Image$ illu$trating #a$!ular di$tri"ution$

Va$!ular di$tri"ution$: iddle !ere"ral artery %CA& infar!tion+ Non!ontra$t C1
$!an demon$trate$ a large a!ute infar!tion in the CA territory in#ol#ing the
lateral $urfa!e$ of the left frontal, 'arietal, and tem'oral lo"e$ a$ *ell a$ the left
11
in$ular and $u"in$ular region$ *ith ma$$ effe!t and right*ard midline $hift+ 1he
!audate head i$ $'ared, and at lea$t 'art of the lentiform nu!leu$ and internal
!a'$ule, *hi!h re!ei#e "lood $u''ly form the lateral lenti!ulo$triate "ran!he$ of
the . $egment of the CA+ Note the la!k of in#ol#ement of the medial frontal
lo"e %anterior !ere"ral artery territory&, thalami and 'aramedian o!!i'ital lo"e
%'o$terior !ere"ral artery territory&+

Va$!ular di$tri"ution$: anterior !ere"ral artery %ACA& infar!tion+ Diffu$ion4
*eighted image on the left demon$trate$ high $ignal in the 'aramedian frontal and
high 'arietal region$+ 1he o''o$ite diffu$ion4*eighted image in a different 'atient
demon$trate$ re$tri!ted diffu$ion in a larger ACA infar!tion in#ol#ing the left
'aramedian frontal and 'o$terior 'arietal region$+ Infar!tion of the lateral
tem'oro'arietal region$ "ilaterally %"oth CA di$tri"ution$& al$o e0i$t$; it i$
greater on the left, indi!ating multi#e$$el in#ol#ement $ugge$ting em"oli+

Va$!ular di$tri"ution$: 'o$terior !ere"ral artery %@CA& infar!tion+ 1he non!ontra$t
C1 image$ demon$trate @CA di$tri"ution infar!tion in#ol#ing the right o!!i'ital
and inferomedial tem'oral lo"e$+ 1he image on the right demon$trate$ additional
in#ol#ement of the thalamu$, al$o 'art of the @CA territory+

Va$!ular di$tri"ution$: Anterior !horoidal artery infar!tion+ 1he diffu$ion4
*eighted image %left& demon$trate$ high $ignal *ith a$$o!iated $ignal dro'out on
the a''arent diffu$ion !oeffi!ient %ADC& ma' in#ol#ing the 'o$terior lim" of the
internal !a'$ule+ 1hi$ i$ the ty'i!al di$tri"ution of the anterior !horoidal artery, the
la$t "ran!h of the internal !arotid artery "efore "ifur!ating into the anterior and
middle !ere"ral arterie$+ 1he anterior !horoidal artery may al$o ari$e from the
middle !ere"ral artery %CA&+
Stroke in the young patient
A num"er of different di$ea$e$ !an re$ult in i$!hemi! $troke in the young 'atient+
1he$e in!lude !ardioem"oli! di$ea$e, di$$e!tion, inherited $tru!tural and
meta"oli! a"normalitie$, throm"o'hilia$, 'regnan!y, and drug u$e+
->, 9)/
Cardioem"oli! $troke$ !an "e $een in 'atient$ *ith ri$k fa!tor$ $u!h a$
arrhythmia$, !ongenital $tru!tural defe!t$, $u!h a$ 'atent foramen o#ale,
and #al#ular heart di$ea$e, in!luding "oth nati#e and 'ro$theti! #al#e$+
Di$$e!tion !an "e $een *ith trauma and !onne!ti#e ti$$ue di$order$, $u!h
a$ arfan and Ehler4Danlo$ $yndrome+
Inherited a"normalitie$ in!lude inherited form$ of hy'erli'idemia, $u!h a$
auto$omal dominant hy'er!hole$terolemia, !ere"ral auto$omal dominant
arterio'athy *ith $u"!orti!al infar!t$, and leukoen!e'halo'athy
%CADASIL&, and numerou$ other !ongenital meta"oli! a"normalitie$+
12
=ematologi! di$order$ in!lude defi!ien!ie$ of 'rotein C and S,
antithrom"in III defi!ien!y, anti'ho$'holi'id anti"ody $yndrome,
hy'er#i$!o$ity $yndrome$, and $i!kle !ell anemia+
Va$!ulitide$, in!luding lu'u$ and CehGet di$ea$e !an al$o 'rodu!e
i$!hemi! infar!tion+
@regnan!y !reate$ a hy'er!oagula"le $tate "y in!rea$ing the amount$ of
!ertain !lotting fa!tor$, *ith $troke and hy'erten$i#e en!e'halo'athy "eing
'otential !om'li!ation$ of 'regnan!y indu!ed hy'erten$ion and e!lam'$ia+
Drug$, "oth 're$!ri"ed and illi!it %e$'e!ially !o!aine&, may re$ult in
i$!hemi! infar!tion+
Radiography
Findings
Con#entional $kull radiogra'hy i$ not u$eful for the diagno$i$ of a!ute $troke+
"oputed #oography
Findings
#oncontrast C

On non!ontra$t C1 $!an, early finding$ %*ithin ? hour$& in!lude $u"tle lo$$

of gray4*hite differentiation !orre$'onding to in!rea$ed *ater !ontent
from early !ytoto0i! edema+
-9>, 9?/
Lo$$ of definition of !orte0 and
o"$!uration of dee' gray matter $tru!ture$ may e0i$t+

In middle !ere"ral artery infar!tion, o"$!uration of lateral margin$ of the

in$ula, %the in$ular ri""on $ign& and lo$$ of den$ity of the "a$al ganglia
nu!lei, $u!h a$ the lentiform nu!leu$ %#ani$hing "a$al ganglia $ign&, may
e0i$t %$ee image$ "elo*&+
-92, 9;/

Non!ontra$t C1 *a$ o"tained to e#aluate thi$ ?)4year4old male *ho
a*oke *ith a'ha$ia and right4$ided *eakne$$+ Lo$$ of the normal gray4
*hite differentiation "et*een the normally den$er in$ular !orte0 and the
le$$ attenuating $u"in$ular *hite matter i$ $een; thi$ i$ !on$i$tent *ith lo$$
of the Hin$ular ri""on+H

7ollo*4u' non!ontra$t C1 $!an o"tained a''ro0imately .( hour$ after the
initial $tudy in the $ame 'atient demon$trate$ further e#olution of the
13
infar!tion, *hi!h i$ no* e0ten$i#e and $'an$ mo$t of the left middle
!ere"ral artery %CA& territory+

Non!ontra$t C1 $!anning *a$ 'erformed to e#aluate thi$ 234year4old
female *ith a hi$tory of a!ute on$et of right4hand *eakne$$ and a'ha$ia+
Lo$$ of gray4*hite differentiation in the left in$ular !orte0 and in the
immediately ad8a!ent !orti!al and $u"!orti!al 'ortion$ of the left tem'oral
o'er!ulum i$ $een; thi$ i$ $trongly $ugge$ti#e of an a!ute infar!tion+

=y'erattenuation of #e$$el$ may "e $een %den$e #e$$el $ign or dot $ign&;
the$e are "elie#ed to re're$ent a!ute throm"u$ or em"olu$ and ha$ "een
de$!ri"ed in the CA, "a$ilar artery, and #enou$ $inu$e$ %$ee the image$
"elo*&+
-9A, )3/

Non!ontra$t C1 $!an in an ;34year4old female *ho 're$ented *ith a!ute
on$et of right4$ided *eakne$$+ 1he left middle !ere"ral artery %CA&
trunk a''ear$ highly attenuated %the den$e CA $ign&, $u$'i!iou$ for
a!ute throm"o$i$ or em"oli$m+ A follo*4u' non!ontra$t C1 demon$trated
an e#ol#ing infar!t of the lentiform nu!leu$+

Den$e middle !ere"ral artery %CA& $ign: Non!ontra$t C1 in another
'atient *ith $trokelike $ym'tom$ demon$trate$ a hy'erden$e a''earan!e
of the right CA *ith $u"tle lo$$ of gray4*hite differentiation of the
anterior right tem'oral lo"e+

Den$e "a$ilar artery: A0ial non!ontra$t C1 $!an demon$trate$ a
hy'erden$e "a$ilar artery in a 'atient *ith 'ontine infar!tion *ho *a$ later
found to ha#e "a$ilar artery throm"o$i$+ Other large #e$$el$ "e$ide$ the
middle !ere"ral artery %CA& !an 'rodu!e a den$e #e$$el $ign *hen
o!!luded+
14

After a''ro0imately .(4() hour$, a more *ell4defined area of hy'oden$ity,

*hi!h may ha#e a$$o!iated ma$$ effe!t *ith $ul!al or #entri!ular
effa!ement, may "e $een+ 1he hy'oden$ity i$ u$ually irre#er$i"le and i$
felt to !orrelate *ith minimum final infar!t $i:e+
-A, .9/

a$$ effe!t ty'i!ally 'eak$ "y a"out > day$ 'o$t i!tu$ and di$a''ear$ o#er
the ne0t $e#eral *eek$+
-A/

In roughly one half of !a$e$, the infar!t may !hange from hy'oden$e to
i$oden$e+ 1hi$ ha$ "een termed the Hfogging effe!tH on C1 and i$ u$ually
$een (49 *eek$ 'o$t i!tu$ during the $u"a!ute 'ha$e of infar!tion and
$hould re$ol#e on $u"$e6uent imaging+ IV !ontra$t may make the infar!t
more !on$'i!uou$+ 1he 'henomenon i$ "elie#ed to "e due to influ0 of
li'id4laden ma!ro'hage$, de!rea$ed *ater !ontent, 'roliferation of
!a'illarie$, re'erfu$ion, and 'ete!hial hemorrhage %$ee the image "elo*&+
-)., )(/

C1 fogging effe!t: A0ial non!ontra$t C1 $!an demon$trate$ fo!al lo*
den$ity, lo$$ of gray4*hite differentiation, and mild $ul!al effa!ement in
the right 'arietal region %left image, arro*& in a ?(4year4old female
're$enting *ith a!ute $troke+ A follo*4u' non!ontra$t C1 $!an o"tained .3
day$ later demon$trate$ dimini$hed $ul!al effa!ement and i$oden$ity *ith a
near4normal a''earan!e %middle image&, thought to "e $e!ondary to the
C1 Hfogging effe!tH that may "e $een during the e#olution of an infar!t+
1he a0ial diffu$ion4*eighted image %right& !onfirm$ the right 'arietal
infar!t+

After a''ro0imately ?4; *eek$, a *ell4defined !a#ity may "e $een,

!orre$'onding to en!e'halomala!ia+ E#iden!e of #olume lo$$, $u!h a$ e04
#a!uo dilatation of the ad8a!ent #entri!le, may e0i$t+ Corti!al laminar
ne!ro$i$ may "e $een in !hroni! infar!t$ *ith gyriform !orti!al
!al!ifi!ation %$ee the image$ "elo*&+

Non!ontra$t C1 of the "rain in a 'atient *ith hi$tory of remote CVA
demon$trate$ lo* den$ity in the right frontal and anterior tem'oral region$
in the CA di$tri"ution+ E#iden!e of 'aren!hymal #olume lo$$ *ith e04
#a!uo dilatation of the right lateral #entri!le i$ 're$ent, indi!ating
!hroni!ity infar!tion+

Chroni! infar!tion: Non!ontra$t C1 $!an demon$trate$ a *ell4defined area
of #olume lo$$ in the right tem'oral lo"e *ith a lo*4den$ity a''earan!e
!on$i$tent *ith en!e'halomala!ia+ No ma$$ effe!t e0i$t$+
15

La!unar infar!t$ a''ear a$ $mall, >4.> mm area$ of lo* den$ity initially+

After a''ro0imately ) *eek$, la!unar infar!t$ $hould a''ear a$ *ell4
defined, !y$ti! lo*4den$ity area$+ 1y'i!al lo!ation$ in!lude the $u"in$ular
region$, "a$al ganglia, thalami and !a'$ular region$, and !orona radiata+
$uantification of %one of ischemia

Non!ontra$t C1 $!anning !an "e u$ed to e$timate the area of i$!hemi!

ti$$ue in order to guide thera'y+ 1hi$ !on!e't i$ 'o$tulated on e#iden!e4
"a$ed guideline$ that $tate that larger infar!t$, $'e!ifi!ally greater than one
third of the CA di$tri"ution, are more likely to hemorrhage follo*ing
throm"olyti! thera'y+
-.9, (>, )9/

One !la$$ifi!ation $y$tem, the Al"erta Stroke @rogramme Early C1 S!ore

%AS@EC1S& u$e$ a .34'oint $!oring $y$tem to 6uantify a!ute i$!hemia on
non!ontra$t C1 "a$ed u'on degree of in#ol#ement of the CA territory+
1he AS@EC1S $y$tem di#ide$ the CA territory into .3 region$ and
dedu!t$ a 'oint for ea!h region in#ol#ed+ 1hu$, a normal CA territory
*ould re!ei#e a $!ore of .3, and diffu$e CA in#ol#ement *ould re!ei#e
a $!ore of 3+ Lo*er $!ore$ !orrelated *ith *or$e $troke $e#erity and higher
ri$k of $ym'tomati! hemorrhage %$ee the image$ "elo*&+
-/

AS@EC1S 6uantitati#e $troke $!oring $y$tem: 7or AS@EC1S $!oring, the
middle !ere"ral artery %CA& territory i$ allotted . 'oint for ea!h of .3
$e'arate region$: ., (, 9, ), >, ?, the !audate nu!leu$ %C&,
lentiform nu!leu$ %L&, in$ular !orte0 %I&, and internal !a'$ule %IC&+ S!oring
i$ "a$ed on a $e!tion at the le#el of the "a$al ganglia and thalami and
another $e!tion a"o#e the le#el at the "a$al ganglia+ One 'oint i$ $u"tra!ted
for ea!h area demon$trating $ign$ of early i$!hemi! !hange, $u!h a$ fo!al
'aren!hymal hy'oattenuation or edema+ A normal $!an *ould "e $!ored a
.3, and diffu$e edema in#ol#ing all 'oint$ *ould "e $!ored 3+

Non!ontra$t C1 $!an 'erformed in a ?34year4old male *ho 're$ented *ith
a!ute $troke demon$trate$ the u$e of the AS@EC1S+ Diffu$e hy'oden$ity i$
noted throughout the middle !ere"ral artery %CA& di$tri"ution in#ol#ing
the .4? region$ and in$ula+ Se#en 'oint$ are then $u"tra!ting from the
.34'oint AS@EC1S, yielding a $!ore of 9+ C I !audate nu!leu$, L I
lentiform nu!leu$, I I in$ular !orte0, and IC I internal !a'$ule+

Another !la$$ifi!ation in$trument, the Co$ton A!ute Stroke Imaging S!ale

%CASIS&, !an al$o hel' 'redi!t 'atient out!ome+ CASIS u$e$ data a"out
the 'aten!y of #a$!ulature on C1A or 5A and 're$en!e of early i$!hemi!
'aren!hymal !hange$ on non!ontra$t C1 or 5I to !la$$ify $troke a$
ma8or or minor+ Large #e$$el o!!lu$ion$ or $ignifi!ant i$!hemi! !hange$
are !la$$ified a$ ma8or $troke; if "oth !hange$ are a"$ent, then the $troke i$
16
!la$$ified a$ minor+ Sur#i#or$ of ma8or $troke, a$ !la$$ified "y CASIS,
ha#e "een found to ha#e $ignifi!antly longer ho$'ital $tay$ and are
$u"$e6uently mu!h more likely to "e di$!harged to a reha"ilitation fa!ility
rather than home+
-)?/
Contrast&enhanced C
Contra$t enhan!ement follo*ing "rain infar!tion i$ ty'i!ally $een in a"out
t*o third$ of !a$e$, u$ually during the $e!ond or third *eek 'o$t i!tu$+
Common 'attern$ of enhan!ement in!lude 'at!hy, gyriform, ring4like, and
homogenou$+ Earlier !ontra$t enhan!ement !orre$'ond$ to infar!t$ *ith
larger #olume and ma$$ effe!t and i$ $e!ondary to di$ru'tion of the "lood4
"rain "arrier *ith in!rea$ed #a$!ular 'ermea"ility andJor re'erfu$ion from
re!anali:ation or !ollateral !ir!ulation+ Early !ontra$t enhan!ement
'ortend$ an in!rea$ed ri$k of hemorrhagi! tran$formation+
C angiography

1he mo$t im'ortant 'ur'o$e of C1A in a!ute $troke i$ to dete!t #e$$el

throm"o$i$ or o!!lu$ion+ C1A $our!e image$ $hould al*ay$ "e a$$e$$ed, in
addition to multi'lanar re!on$tru!tion %5@& and ma0imum inten$ity
'ro8e!tion %I@& image$+

@ro'er inter'retation re6uire$ attention to luminal enhan!ement to a$$e$$

#e$$el 'aten!y, intimal fla'$ to e0!lude di$$e!tion, filling defe!t$ and
#e$$el *all !al!ifi!ation$ to a$$e$$ $teno$i$, and o!!lu$ion$ and fo!al
out'ou!hing$ $ugge$ti#e of aneury$m or '$eudoaneury$m %$ee the image
"elo*&+

I@ and $urfa!e #olume rendered image$ of the !ir!le of Billi$ from a
C1A in a 234year4old female *ith a!ute on$et right4$ided *eakne$$+ A
high4grade $teno$i$ of the di$tal left middle !ere"ral artery %CA& trunk
%red !ir!le$& i$ $een, *ith filling of the remainder of the CA territory #ia
an anterior "ran!h near the "ifur!ation+

In addition to #a$!ular anatomy, region$ of 'aren!hymal hy'o'erfu$ion

!an al$o "e a$$e$$ed *ith C1A+ 5egion$ of dimini$hed flo* on C1A
$our!e image$ ha#e al$o "een $ho*n to !orrelate *ell *ith the infar!t !ore
%$ee the image "elo*&+
-.9, )2/

C1A $our!e data !an al$o "e u$eful to a$$e$$ for area$ of hy'o'erfu$ion
and 'oor enhan!ement that may !orre$'ond to area$ of greate$t i$!hemia+
1hi$ C1A $our!e image from the 'atient in the 're#iou$ !a$e demon$trate$
$ignifi!antly dimini$hed enhan!ement in#ol#ing the !audate head,
lentiform nu!leu$, and !a'$ular region$+ =igh den$ity noted !entrally in
17
thi$ 'oorly enhan!ing region re're$ent$ an area of hemorrhagi!
tran$formation+
C perfusion
@erfu$ion ma'$ !an u$ually "e !om'ared #i$ually to 6ualitati#ely look for area$ of
gro$$ or $u"tle a$ymmetry+ Kuantitati#e CC7 #alue$ !an al$o "e e0amined *ith
thre$hold$ for i$!hemi! and infar!ted ti$$ue in mind+ A lo* CCV a"normality "e$t
!orrelate$ *ith the infar!t !ore+
-.9, );/
1he mi$mat!h "et*een a"normal CCV and a"normal CC7 e$timate$ the
'enum"ra+
-)A, >3/
Another method to !la$$ify i$!hemi! ti$$ue in#ol#e$ mea$uring the CC7 in the
!ontralateral normal "rain 'aren!hyma and !om'aring it to the CC7 in the area of
'erfu$ion a"normality to !reate a CC7 ratio %$ee the image$ "elo*&+
->./
Shaefer et
al found the follo*ing thre$hold ratio #alue$ "et*een the a"normal i$!hemi!
region and normal !ontralateral $ide relating to the i$!hemi! !ore and 'enum"ra
and mean CC7 ratio$ %'L 3+3>&:
Infar!t !ore: 3+.A MJ4 3+3?
@enum"ra likely to go on to infar!tion: 3+9) MJ4 3+3?
Sal#agea"le 'enum"ra: 3+)? MJ4 3+3?

+
@la!ement of 5OI !ur#e$ on arterial and #enou$ 'i0el$ %image on right& are
needed to generate time4!on!entration !ur#e$ for 'erfu$ion imaging+ 1he$e
!ur#e$ !an then "e u$ed to generate 'erfu$ion ma'$+

After $ele!ting the a''ro'riate arterial and #enou$ in'ut fun!tion$, the
!om'uter $oft*are i$ a"le to generate 'erfu$ion ma'$ of different
'arameter$ %CC7 I !ere"ral "lood flo*, CCV I !ere"ral "lood Volume,
11 I mean tran$it time, 11@ I time to 'eak enhan!ement&+ 5egion$ of
intere$t !an then "e 'la!ed o#er the$e ma'$ for 6uantitati#e information+ In
thi$ 'atient *ith o!!lu$ion of the di$tal left CA trunk, ele#ated 11 and
dimini$hed CC7 e0i$t$ in the left "a$al ganglia, in$ular and o'er!ular
region$+ 1he CCV i$ mildly in!rea$ed in thi$ $ame region, *hi!h i$
"elie#ed to "e due to autoregulatory #a$odilation in re$'on$e to i$!hemia+
$egree o% con%idence
#oncontrast C
18

7inding$ on NCC1 during the hy'era!ute 'ha$e may "e e0tremely $u"tle,
and a high inde0 of $u$'i!ion $hould "e maintained *hen inter'reting the
e0amination+ 1he !hara!teri$ti! finding$, namely 'aren!hymal
hy'oden$ity, o"$!uration of gray4*hite differentiation and $ul!al
effa!ement are $trongly $ugge$ti#e+

1he 're#iou$ly held !on!e'tion that mo$t $tudie$ o"tained *ithin ?4.(
hour$ are generally negati#e *a$ likely related to the limited !a'a"ilitie$ of
early e6ui'ment+ In one $tudy, imaging done *ithin )4? hour$ of a!ute
$troke on$et $ho*ed !hange$ of early infar!t in a''ro0imately 23< of
'atient$+
->(/
Another $tudy 'erformed on 'atient$ *ithin > hour$ of
angiogra'hi!ally 'ro#en a!ute CA o!!lu$ion $ho*ed e#iden!e of
infar!tion in ;.<+
->9/

Soft !o'y image re#ie* u$ing #aria"le *indo* *idth and !enter le#el
$etting$ may further fa!ilitate dete!tion of 'aren!hymal hy'oden$ity,
a!utely i$!hemi! ti$$ue+
->)/
C angiography

C1A ha$ "een demon$trated to "e highly relia"le for the dete!tion or
e0!lu$ion of large intra!ranial #e$$el$, $u!h a$ the ICA and CA trunk u'
to the ( $egment and "a$ilar arterie$+

,$ing modern multidete!tor C1 *ith #o0el $i:e$ *ell "elo* . mm and

'o$t'ro!e$$ing tool$, C1A i$ highly a!!urate in mea$uring #e$$el
diameter$ ad8a!ent to $teno$i$ and i$ $u'erior for grading of intra!ranial
$teno$i$ !om'ared *ith 9D 1O7 5A te!hni6ue+
->>/

C1A ha$ the ad#antage o#er 5A and DSA of dete!ting mural

!al!ifi!ation$ in relation to $teno$i$+

In addition to #a$!ular o!!lu$ion$, C1A $our!e image$ are a"le to

demon$trate hy'o'erfu$ed "rain 'aren!hyma in a!ute $troke $imilar to
DBI image$+
'erfusion C

In the early $tage$ of $troke, the e0tent of regionally a"normal 11 ha$

"een found to e0!eed that of a"normal CCV and CC7, making it the mo$t
$en$iti#e 'arameter for dete!ting de!rea$ed 'erfu$ion and i$!hemia+
@rolonged 11, ho*e#er, ha$ "een found to o#ere$timate final infar!t
$i:e+
->?, >2, >;/

CCV and CC7 ma'$ generally $ho* $maller area$ of a"normality than
11 and are therefore more $'e!ifi! for area$ of i$!hemia and infar!tion+
False positives/negatives
#oncontrast C
19
7al$e4'o$iti#e area$ of hy'oattenuation may "e $een due to "eam
hardening artifa!t from "one along the !ere"ral !on#e0itie$ from the
ad8a!ent !al#aria and in the 'o$terior fo$$a due to the $kull "a$e+ Streak
artifa!t$ may al$o !au$e 'aren!hymal hy'oden$ity ad8a!ent to aerated
$inu$e$+ 1he ty'i!al lo!ation and a''earan!e, linearity, and e0ten$ion
"eyond "rain 'aren!hyma $hould all hel' to identify the$e artifa!t$+
Artifa!tual hy'oden$ity may "e $een *hen the !orte0 i$ #olume4a#eraged
*ith ad8a!ent !ere"ro$'inal fluid in a $ul!u$, fi$$ure, or !i$tern+
Variou$ other le$ion$ may 'rodu!e fo!al area$ of hy'oden$ity "oth *ith
and *ithout ma$$ effe!t, in!luding 'eri#a$!ular $'a!e$, infiltrati#e tumor$
*ith #a$ogeni! edema, and en!e'haliti$+
1he C1 NfoggingO effe!t de$!ri"ed 're#iou$ly may tran$iently 'rodu!e
i$oden$ity of an infar!t that al*ay$ re$ol#e$ on follo*4u' imaging+
C angiography
,$e of #aried *indo* $etting i$ re6uired to a$$e$$ luminal 'aten!y *ithin
the #e$$el *hen it i$ $urrounded "y !al!ified throm"u$+
'erfusion C

1he high $en$iti#ity of 11 for de!rea$ed 'erfu$ion may make it le$$

$'e!ifi! in dete!ting !lini!ally $ignifi!ant i$!hemia+ One $tudy re'orted
ele#ated 11 in an a$ym'tomati! 'atient *ith 'ro0imal o!!lu$ion of the
!arotid artery "ut likely good !ollateral $u''ly and in another 'atient *ho
had re#er$i"le i$!hemi! $ym'tom$ and a negati#e C1A+
->?/

Although the regional a"normality in CCV ha$ "een $aid to "e$t e$timate
infar!t #olume, CCV may al$o "e normal or ele#ated in a!ute $troke+ 1hi$
may "e $e!ondary to autoregulatory !hange$ and !ollateral flo* to
i$!hemi! "rain ti$$ue+ CCV had "een re'orted in the $ame $tudy a"o#e to
"e normal in (>< of 'atient$ *ith a!ute $troke+
->?/
Magnetic Resonance &aging
Findings
Conventional M(I

=igh $ignal inten$ity may "e $een on 1(BI and 'roton den$ityD*eighted
image$ "eginning a''ro0imately ; hour$ after on$et !orre$'onding to a
#a$!ular di$tri"ution+ 1.BI may take $ignifi!antly longer to demon$trate
lo* $ignal+
->A, ?3/

7LAI5 image$ demon$trate a"normal $ignal $ooner than 1(BI and ha#e
"een $ho*n to "e u$eful in dete!ting infar!t$ *ithin 9 hour$ after on$et of
a!ute $troke+
-?./
20

7LAI5 image$ may al$o demon$trate intra4arterial $ignal that i$

hy'erinten$e or i$ointen$e to gray matter+ 1hi$ i$ "elie#ed to o!!ur
immediately after o!!lu$ion, $imilar to the den$e #e$$el $ign $een on C1+
-?./

7LAI5 image$ !an demon$trate high $ignal in the $u"ara!hnoid $'a!e$

*ith SA= %$ee the image "elo*&+

A0ial 7LAI5 image demon$trate$ intra4arterial high $ignal in the left
middle !ere"ral artery %CA& of thi$ 'atient *ith early $troke+ 1he intra4
arterial high $ignal ha$ "een 'o$tulated to "e $e!ondary to different fa!tor$,
in!luding $ta$i$, $lo* or re#er$ed flo*, and throm"u$+
)iffusion&*eighted imaging

A!utely i$!hemi! le$ion$ demon$trate high $ignal of DBI and lo* $ignal
on ADC ma'$ *ithin minute$+
-?(/

A"normal $ignal of DBI ha$ "een re'orted to normali:e in a$ little a$ .)

day$,
-?9/
although more re!ent data ha$ o"$er#ed normali:ation at an
a#erage of a''ro0imately >? day$+
-?)/
=o*e#er, DBI $ignal a"normality
ha$ "een re'orted to la$t u' to 2( day$+ 1hi$ i$ large 'art due to H$hine4
throughH effe!t$ of the 1(4*eighting of DBI+
-?)/

In !ontra$t, the ADC a"normality ty'i!ally 'eak$ "y 9 day$ and

'$eudonormali:e$ during the $u"a!ute 'eriod "et*een the 2
th
and ..
th
day
after infar!tion and i$ a mu!h more a!!urate a$$e$$ment of infar!t age+
-?)/

1o !onfirm *hether high $ignal on DBI re're$ent$ a!ute infar!tion, one

mu$t mat!h the high $ignal on the DBI to lo* $ignal on ADC ma'$ %$ee
the image$ "elo*&+

Non!ontra$t C1 $!an and 5I of the "rain *ith DBI *a$ 'erformed to
e#aluate thi$ ;24year4old male *ith hi$tory of re!urrent $troke$ and ne*
!hange in mental $tatu$+ Non!ontra$t C1 $!an demon$trate$ a right @CA
di$tri"ution hy'oden$ity, and a hy'oden$ity at the #erte0 on the right near
the CAJACA "order:one+ Coth of the$e a"normalitie$ are age
indeterminate on the C1 $!an+

5I *a$ o"tained to further !larify the finding$ on a non!ontra$t C1 $!an+
=igh $ignal on the DBI and !orre$'onding lo* $ignal on the ADC ma'$
in the right frontal #erte0 "order:one area are $een+ 1hi$ $ignifie$ true
re$tri!ted diffu$ion and an a!ute infar!tion+

21
1he right 'o$terior !ere"ral artery %@CA& di$tri"ution infar!tion i$ mo$t
likely !hroni!+ 1he high $ignal on the DBI ha$ no !orre$'onding lo*
$ignal on the ADC ma' %red !ir!le&+ 1he ADC ma' demon$trate$ $lightly
ele#ated $ignal in thi$ !a$e+ 1he fal$ely 'er$i$tent high $ignal on DBI in
the a"$en!e of re!ent infar!tion i$ felt to "e related to the 'artial 1(4effe!t$
of DBI and i$ referred to a$ H1( $hine through+H
Contrast&enhanced M(I

Intra4arterial !ontra$t enhan!ement may "e $een $e!ondary to $lo* flo*

during the fir$t or $e!ond day after on$et of infar!tion and ha$ "een
!orrelated *ith in!rea$ed infar!t #olume $i:e+
-?>/

Early 'aren!hymal enhan!ement on 5I "y the end of the fir$t *eek ha$
"een re'orted a$ an e0'e!ted finding from di$ru'tion of the "lood4"rain
"arrier and de#elo'ment of granulation ti$$ue later+ It i$ !orrelated *ith an
in!rea$ed ri$k of hemorrhagi! tran$formation "ut no ri$k of in!rea$ed
infar!t $i:e %$ee the image "elo*&


A0ial 1.4*eighted 'o$t!ontra$t image o"tained in a 'atient *ith re!ent
$troke demon$trate$ arterial enhan!ement *ithin the left middle !ere"ral
artery %CA& a$ *ell a$ !orti!al and $u"!orti!al enhan!ement in the
ad8a!ent in$ular and o'er!ular region$+ 1he arterial enhan!ement i$
"elie#ed to "e due to $lo* flo* and underlying im'aired hemodynami!$+
Early 'aren!hymal enhan!ement may indi!ate good !ollateral $u''ly+
Magnetic resonance angiography
1hree different te!hni6ue$ !an "e u$ed to 'rodu!e 5A, a$ follo*$:
1ime of flight %1O7&: 1O7 take$ ad#antage of the higher $ignal from
'roton$ in flo*ing "lood, !om'ared *ith 'roton$ in $tationary ti$$ue that
"e!ome 'artially $aturated and lo$e $ignal *hen e0'o$ed to a
radiofre6uen!y %57& 'ul$e+ Area$ of $ignal lo$$ and narro*ing !orre$'ond
to $teno$i$ and o!!lu$ion$+
@ha$e !ontra$t %@C&: @C in#ol#e$ tagging the $'in$ of mo#ing 'roton$
u$ing "idire!tional gradient$ and marking their !hange$ in 'o$ition *hen
ea!h gradient i$ a''lied+ @C i$ e06ui$itely $en$iti#e to flo*, *hi!h the
o'erator !an !hoo$e the #elo!ity thre$hold for, and gi#e$ e0!ellent
"a!kground $u''re$$ion+
Contra$t4enhan!ed 5A %CE5A&: CE5A u$e$ the intraluminal $ignal
'rodu!ed "y a timed "olu$ of 'aramagneti! !ontra$t material to e#aluate
#e$$el 'aten!y+ Image$ may "e $ingle 'ha$e %ie, arterial& or time re$ol#ed+
A$ 're#iou$ly di$!u$$ed, the mo$t *idely u$ed #a$!ular 5I te!hni6ue$ are
9D1O7 and gadolinium enhan!ed 5A %$ee the image$ "elo*&+
22

1O7 5A demon$trate$ an o!!lu$ion or high4grade $teno$i$ at the mid to di$tal
right middle !ere"ral artery %CA& trunk+ 5A i$ highly a!!urate at hel'ing to
e#aluate large intra!ere"ral #e$$el $teno$i$, although le$$ relia"le than C1
$!anning at hel'ing to grade $teno$i$+

9D time4of4flight %1O7& of the ne!k a0ial and I@ image$ demon$trate$ a (4!m
lo*4$ignal !ur#ilinear di$$e!tion fla' in the mid right #erte"ral artery+ 1hi$ 'atient
ha$ a hi$tory of fi"romu$!ular dy$'la$ia and 'rior !arotid artery di$$e!tion+
'erfusion M(I
1he mo$t !ommonly u$ed te!hni6ue for 5 'erfu$ion imaging i$ dynami!
$u$!e'ti"ility, *hi!h in#ol#e$ generating ma'$ of "rain 'erfu$ion "y monitoring
the fir$t 'a$$ of a ra'id "olu$ in8e!tion of !ontra$t through the !ere"ral
#a$!ulature+ Su$!e'ti"ility related 1( effe!t$ !reate $ignal lo$$ in !a'illary "lood
#e$$el$ and 'aren!hyma 'erfu$ed "y !ontra$t that !an "e mea$ured and i$
'ro'ortional to the !ere"ral "lood #olume %$ee the image "elo*&+

5egion$ of intere$t are $ele!ted for arterial and #enou$ in'ut %image on left& for
dynami! $u$!e'ti"ility4*eighted 'erfu$ion 5I+ Signal4time !ur#e$ %image on
right& o"tained from the$e 5OI demon$trate tran$ient $ignal dro' follo*ing the
admini$tration of intra#enou$ !ontra$t+ 1he information o"tained from the
dynami! 'aren!hymal $ignal !hange$ 'o$t !ontra$t are u$ed to generate ma'$ of
different 'erfu$ion 'arameter$+
Area$ of 'rolonged mean tran$it time %11& !orre$'ond to area$ of i$!hemia and
area$ of dimini$hed !ere"ral "lood #olume !orrelate "e$t *ith the area$ of
irre#er$i"le i$!hemi! !hange+ 1he differen!e "et*een the 'erfu$ion a"normality
and diffu$ion a"normality refle!t$ the i$!hemi! 'enum"ra around the infar!t !ore
%$ee the image$ "elo*&+

Left internal !arotid artery %ICA& o!!lu$ion: A0ial 7LAI5 image$ demon$trate
high $ignal in the !entrum $emio#ale in the dee' "order:one region *ith
!orre$'onding re$tri!ted diffu$ion, indi!ating infar!tion+ I@ from a time4of4flight
5A of the !ir!le of Billi$ demon$trate$ no flo* in the left ICA or anterior
!ir!ulation on the right+

Left internal !arotid artery %ICA& o!!lu$ion: 5 'erfu$ion imaging demon$trate$
glo"al and marked ele#ation in mean tran$it time %image on left& in mo$t of the
left !ere"ral hemi$'here, $'aring only 'art of the 'o$terior !ir!ulation+ 1hi$
demon$trate$ ho* 11 i$ e0tremely $en$iti#e to a"normalitie$ in 'erfu$ion+ 1he
CCV %image on right& i$ markedly de're$$ed more !entrally in the dee' and
$u"!orti!al *hite matter, !on$i$tent *ith the infar!tion noted on DBI+
$egree o% con%idence
23
Conventional M(I
7LAI5 image$ ha#e "een $ho*n to "e more $en$iti#e to dete!t a!ute $troke than
$tandard 1(BI, *ith a $en$iti#ity of greater than A3< and in a$ little a$ ;3
minute$ in one $tudy+ 1hi$ i$ likely due to higher 1( *eighting !a'a"ility of
7LAI5 !om'ared to $tandard 1(BI+
->A, ?3/
1he 7LAI5 intra4arterial $ign ha$ "een re'orted to ha#e an e0tremely high degree
of dete!ta"ility for o!!luded #e$$el$ *ithin ? hour$ after $troke+
-?./
7LAI5 image$ are highly $en$iti#e for $u"ara!hnoid hemorrhage, a''roa!hing
.33< for large #olume$ of hemorrhage+
-??/
G5E %1( image$& are likely the mo$t $en$iti#e for dete!ting "lood 'rodu!t$+
-?2, ?;, ?A/
)iffusion&*eighted imaging
Diffu$ion4*eighted image$ are !on$idered to "e the mo$t relia"le marker of
i$!hemi! !ore and !an dete!t i$!hemia *ithin 93 minute$+
-.9, 23, 2./
'erfusion M(
A large amount of data e0i$t$ !onfirming the $en$iti#ity of !om"ining diffu$ion
and 'erfu$ion *eighted 5I to dete!t the i$!hemi! 'enum"ra and al$o 'redi!t the
'otential final infar!t $i:e *ithout treatment+
-.9/
1he $en$iti#ity of ea!h 5
'erfu$ion ma' #arie$ in it$ a"ility to de'i!t area$ of i$!hemia, $imilar to C1
'erfu$ion 'arameter$+
False positives/negatives
Conventional M(I
Con#entional 5I may take hour$ to 'rodu!e di$!erni"le finding$, *ell after the
diffu$ion4*eighted image$ ha#e "e!ome 'o$iti#e+ 7or thi$ rea$on, many !enter$
al*ay$ in!lude diffu$ion4*eighted image$ in their $tandard "rain 5I 'roto!ol+
)iffusion&*eighted M(I
A$ de$!ri"ed 're#iou$ly, DBI may demon$trate high $ignal for $e#eral *eek$+
1hi$ i$ due to 1(4*eighted effe!t$ 'redominating o#er the a''arent diffu$ion in
early and $u"a!ute infar!tion$+
-?)/
Confirmation *ith the ADC ma' for a
!orre$'onding area of $ignal lo$$ i$ needed to !onfirm the a"normal DBI to a#oid
the 'ro"lem of 1( N$hine through+O
7al$ely negati#e and re#er$i"le area$ on diffu$ion image$ !an "e $een if only #ery
mild i$!hemia e0i$t$, if the area of i$!hemia i$ #ery $mall, or if it i$ #ery early in
the !our$e of the i$!hemi! e#ent+
24
'erfusion M(I
a'$ of time to 'eak %11@& or mean time to enhan!ement %1E& are #ery
$en$iti#e to alteration$ in "lood flo*, $imilar to 11 C1 'erfu$ion ma'$+
=o*e#er, the$e ma'$ may al$o o#ere$timate the amount of $ignifi!antly i$!hemi!
ti$$ue+
CCV al$o may "e artifi!ially ele#ated in re$'on$e to hy'o'erfu$ion due to
!om'en$atory autoregulatory me!hani$m$+
Magnetic resonance angiography
1he flo*4related enhan!ement on 1O7 image$ i$ a 1. effe!t+ Similarly, !lot4
!ontaining methemoglo"in may al$o !reate intra#a$!ular high $ignal that i$
indi$tingui$ha"le from $ignal related to flo*+ @ha$e !ontra$t image$ are not
$u$!e'ti"le to thi$ 'ro"lem+
Signal lo$$ may "e $een *hen image$ #e$$el$ are imaged in the 'lane of the $!an+
Su$!e'ti"ility effe!t$ may !au$e $ignal lo$$ in !a#ernou$ 'ortion of the internal
!arotid artery ad8a!ent to the $'henoid $inu$+
'ltrasonography
Findings
Carotid ultrasound
Do''ler ultra$ound i$ the mo$t !ommon imaging e0amination 'erformed for the
diagno$i$ of !arotid $teno$i$ *orld*ide+ 1he 're#alen!e of $ignifi!ant %>3<&
$tenoti! di$ea$e in $ym'tomati! 'atient$ i$ $tated a$ "eing in the range of .;4(3<,
*hile the 're#alen!e in a$ym'tomati! 'atient$ *ith !lini!al marker$ for
$ignifi!ant athero$!leroti! di$ea$e *ho are referred for !arotid imaging i$ .)<+
-)9,
)), )>, 2(/
All $onogra'hi! e0amination$ of the !arotid arterie$ $hould "e 'erformed u$ing
gray$!ale, !olor Do''ler ultra$ound, and $'e!tral Do''ler ultra$ound analy$i$ to
dete!t luminal 'aten!y, 're$en!e of 'la6ue, di$$e!tion fla'$, #elo!ity, and
dire!tion of "lood flo*+
Gray$!ale image$ 'ro#ide a gro$$ analy$i$ of luminal 'aten!y and a$$e$$ment of
!al!ified or $oft 'la6ue and intimal thi!kening+ Color and 'o*er Do''ler
ultra$ound mea$urement$ !an de'i!t re$idual lumen in !a$e$ of high4grade
$teno$i$ to "etter ad#antage than gray$!ale image$+ S'e!tral Do''ler 'ro#ide$
#elo!ity mea$urement$ that are u$ed to $'e!ifi!ally grade $teno$i$+
25
1he !on$en$u$ 'anel of the So!iety of 5adiologi$t$ in ,ltra$ound ha$ $tratified
degree$ of !arotid $teno$i$ u$ing the follo*ing ma8or !riteria:
-2(/
.+ No narro*ing i$ re'orted if the ICA 'eak $y$toli! #elo!ity i$ "elo* .(>
!mJ$ *ith no 'la6ue or intimal thi!kening+
(+ Le$$ than >3< $teno$i$ i$ re'orted *hen ICA @SV i$ le$$ than .(> !mJ$
"ut 'la6ue or intimal thi!kening i$ #i$i"le $onogra'hi!ally+
9+ 7ifty to 23< $teno$i$ i$ re'orted *hen ICA @SV i$ .(>4(93 !mJ$ e0i$t$
*ith #i$i"le 'la6ue+
)+ ore than 23< $teno$i$ "ut le$$ than near o!!lu$ion i$ re'orted *hen ISA
@SV i$ more than (93 !mJ$ *ith #i$i"le 'la6ue and $ignifi!ant "ut not near
!om'lete luminal narro*ing+
>+ Near !om'lete o!!lu$ion i$ diagno$ed "y demon$trated marked narro*ing
on !olor Do''ler or 'o*er Do''ler ultra$ound+ @SV i$ le$$ relia"le in thi$
!a$e+
?+ 1otal o!!lu$ion i$ 're$ent *hen no 'atent lumen i$ identified on gray$!ale
image$ or on !olor, $'e!tral, or 'o*er Do''ler ultra$ound+ 1otal o!!lu$ion
need$ to "e !onfirmed *ith C1A, 5A, or !on#entional angiogra'hy+
If a di$$e!tion i$ identified, the 'ro0imal and di$tal e0tent$ need to "e identified+
1hi$ may re6uire further imaging *ith C1 or 5I %$ee the image$ "elo*&+

Color Do''ler ultra$ound of the left internal !arotid artery *a$ o"tained in a >24
year4old male *ith hi$tory of tran$ient i$!hemi! atta!k$+ A large amount of 'la6ue
i$ $een in the 'ro0imal left internal !arotid artery 'rodu!ing a high4grade $teno$i$+
=o*e#er, !olor flo* i$ noted di$tal to the $teno$i$+

@ul$ed Do''ler *a#eform$ in the $ame 'atient demon$trate a markedly ele#ated
'eak $y$toli! #elo!ity in the 'ro0imal internal !arotid artery %ICA& of (>( !mJ$+
1he $e!ond *a#eform, o"tained more di$tally in the $ame $teno$i$, demon$trate$ a
#elo!ity of greater than )33 !mJ$+ 1he $teno$i$ i$ more than 23 and, "a$ed on gray
$!ale and !olor flo* a$$e$$ment, a''ear$ near o!!lu$i#e+ 1hi$ illu$trate$ the
im'ortan!e of !arefully $am'ling along the !our$e of a $teno$i$ for the highe$t
'eak $y$toli! #elo!ity+

Digital $u"tra!tion angiogram 'erformed in the $ame 'atient a$ 're#iou$ 'hoto
!onfirm$ the near o!!lu$ion *ith a H$tring $ignH in the 'ro0imal left internal
!arotid artery+
ranscranial )oppler
1ran$!ranial Do''ler image$ are o"tained "y 'la!ing a lo*4fre6uen!y 'ro"e in the
tem'oral area a"o#e the :ygomati! ar!h+ 1ran$or"ital #ie*$ !an al$o "e u$ed to
e#aluate the o'hthalmi! artery, and tran$foraminal #ie*$ through the foramen
26
magnum !an "e u$ed to e#aluate the #erte"ro"a$ilar arterial $y$tem+ 1he !ere"ral
arterie$ !an "e lo!ali:ed "a$ed u'on de'th mea$urement$ and !olor flo* image$
%$ee the image "elo*&+

1ran$!ranial Do''ler demon$trate$ 'ul$atile flo* in the right4middle !ere"ral
artery in a )34year4old 'atient follo*ing $u"ara!hnoid hemorrhage and
#a$o$'a$m+ At a de'th of >; mm %near the origin of the middle !ere"ral artery
-CA/&, a markedly ele#ated 'eak $y$toli! flo* #elo!ity of a''ro0imately (>.
!mJ$ and a mean #elo!ity of a''ro0imately .?) !mJ$ indi!ate$ $e#ere CA
$teno$i$+ Normal 'eak and mean CA flo* #elo!itie$ are a''ro0imately .33 !mJ$
and >3 !mJ$, re$'e!ti#ely+
$egree o% con%idence
Du'le0 ultra$ound i$ an e0!ellent tool for $!reening the le#el of $teno$i$ in the
ICA a"o#e or "elo* a $ingle degree of $e#erity+ =o*e#er, it i$ le$$ a!!urate in
$'e!ifi!ally 6uantifying the degree of $teno$i$ in a gi#en !arotid artery+ Do''ler
ultra$ound i$ lea$t a!!urate in diagno$ing moderate degree$ of $teno$i$ %>34?A<&,
often o#ere$timating the amount of $teno$i$ in thi$ !ategory+
-29, 2)/
1ran$!ranial Do''ler ultra$onogra'hy ha$ 'ro#en to "e a #ery u$eful "ed$ide
method to e#aluate !ere"ral "lood flo* nonin#a$i#ely+ 1hi$ te!hni6ue i$ of
'arti!ular #alue for the dete!tion of #a$o$'a$m follo*ing $u"ara!hnoid
hemorrhage, for e#aluating the !ere"ral !ir!ulation in o!!lu$i#e di$ea$e of the
!arotid and #erte"ral arterie$, and for e#en a$$e$$ing #a$!ular malformation$+
-2>, 2?,
22/
False positives/negatives

,ltra$ound i$ an o'erator4de'endent modality, and error$ may o!!ur *ith

im'ro'er te!hni6ue+ 7or e0am'le, ina!!urate Do''ler *a#eform$ and
#elo!itie$ may "e o"tained *ith im'ro'er a''lied angle$ of in$onation+
aintaining a !on$tant angle of ?3< i$ "elie#ed to yield the mo$t a!!urate
re$ult$+
-2(/

A"normal #elo!itie$ may "e $een from $teno$i$ "eyond the area$ that !an
u$ually "e e#aluated *ith ultra$ound, namely the intra!ranial internal
!arotid artery, aorti! ar!h, and !ommon !arotid artery origin+ Although the
aorti! ar!h !an "e a$$e$$ed *ith $tandard ultra$ound, it$ e#aluation i$ not
'art of routine !arotid ultra$ound e0amination$+

Near4!om'lete o!!lu$ion may 'rodu!e #elo!itie$ that are high, lo*, or

undete!ta"le+
-2(/
Al$o, identifi!ation of re$idual 'atent lumen not
a''re!ia"le on gray$!ale image$ re6uire$ !areful !olor Do''ler and 'o*er
Do''ler $onogra'hi! analy$i$+

Ele#ated #elo!itie$ *ithout !orre$'onding le#el$ of $teno$i$ may "e $een

in 'atient$ *ith high4grade $teno$i$ in the !ontralateral !arotid $y$tem or
27
in 'atient$ *ith hy'erdynami! !ardia! $tate$+ Similarly, lo* #elo!itie$ may
"e $een *ith more 'ro0imal flo* limiting $teno$i$ or in 'atient$ *ith lo*
!ardia! out'ut+

=igh4grade internal !arotid $teno$e$ may 'rodu!e an a"normal high

re$i$tan!e and lo*4end dia$toli! flo* *a#eform in the !ommon !arotid
due to e0ternal !arotid artery $hunting+
(uclear &aging
Findings
7un!tional imaging *ith 'o$itron emi$$ion tomogra'hy %@E1& and $ingle 'hoton
emi$$ion !om'uted tomogra'hy %S@EC1& are a"le to re#eal !arotid 'la6ue
#ulnera"ility for ru'ture and hel' in e#aluating "rain #ia"ility "y 6uantifying the
'enum"ra region+ Different agent$ !an "e u$ed in @E1 imaging, in!luding
.;
7,
..
C,
.9
N, and
.>
O+
-2;/
@E1 imaging !an "e u$ed to 6uantify area$ of altered !ere"ral "lood flo* and
a"normal glu!o$e and o0ygen meta"oli$m+ 1hi$ !an "e u$ed to elu!idate area$ of
i$!hemi! 'enum"ra and infar!ted ti$$ue, a$ follo*$:

5egional "lood flo*, o0idati#e meta"oli$m, and relati#e o0ygen e0tra!tion

and !ere"ral meta"oli! rate for o0ygen %C5O
(
& !an "e mea$ured after
infu$ion of
.>
O "ound to *ater to dete!t area$ of ongoing i$!hemia and
ne!ro$i$+

Area$ of i$!hemi! 'enum"ra !orre$'ond to region$ *here !ere"ral "lood

flo* i$ de!rea$ed "ut o0ygen e0tra!tion i$ in!rea$ed+

Ne!roti! area$ may "e $een *hen C5O

(
fall$ "elo* ?> PmolJ.33
gmJmin+
-2A/
5edu!ed #a$!ular re$er#e !an al$o "e mea$ured *ith S@EC1 u$ing an
a!eta:olamide !hallenge+ 5ea!ti#ity in 'atient$ *ith !arotid $teno$i$ i$ related to
$troke ri$k
-2;, ;3/
and !an 'redi!t de#elo'ment of i$!hemi! le$ion$ in 'atient$
undergoing !arotid endartere!tomy+
1he #ulnera"ility of a !arotid 'la6ue to ru'ture !an "e dete!ted "y u$ing
.;
74
fluorodeo0yglu!o$e %7DG& @E1+ 7DG i$ kno*n to a!!umulate in inflammatory
le$ion$ *ith inflammation "eing a key feature of athero$!lero$i$+
-2;/
Other $'e!ifi! feature$ of the #ulnera"le 'la6ue, $u!h a$ o0idi:ed LDL
a!!umulation and a'o'to$i$, !an "e dete!ted *ith radiola"eled !ytokine$ and
li'id$ u$ing S@EC1+
-2;/
$egree o% con%idence
28
@E1 ha$ "een de$!ri"ed a$ the !riterion $tandard for 6uantifying o0ygen and
glu!o$e meta"oli$m in the "rain and for identify the 'enum"ra in human$+
-2;/
S@EC1 i$ al$o u$eful in dete!ting area$ of a"normal "lood flo*+ =o*e#er, @E1 i$
!o$tly and neither modality i$ routinely a#aila"le for u$e in mo$t a!ute !lini!al
$etting$+
Angiography
Findings
Angiogra'hy finding$ are a$ follo*$:

Arterial o!!lu$ion$ are 're$ent in at lea$t 2>< of 'atient$ 're$ent *ith

a!ute i$!hemi! $troke *ho undergo angiogra'hy *ithin ?4; hour$ of on$et
of $ym'tom$ %$ee the image "elo*&+

iddle !ere"ral artery %CA& o!!lu$ion: 1hi$ 'atient *a$ a ?)4year4old male *ho
're$ented *ithin 9 hour$ of on$et of a'ha$ia and right4$ided *eakne$$+ 7rontal
#ie* from a $ele!ti#e in8e!tion of the left internal !arotid artery during a !ere"ral
angiogram demon$trate$ filling of the anterior !ere"ral artery *ith an a"ru't !ut4
off at the middle third of the . $egment of the left CA *ith no di$tal filling+

Arterial o!!lu$ion$ are found in the #a$t ma8ority of 'atient$ *ith NI=SS
$!ore$ of .3 or higher %moderate and $e#ere $troke&, re'ortedly u' to A2<
in one re!ent $tudy+
-;./

In 'atient$ 're$enting *ith a!ute $troke, mo$t le$ion$ are intra!ranial

o!!lu$ion$, in!luding the !arotid $i'hon, !om'ared *ith e0tra!ranial
o!!lu$ion$, *hi!h !om'ri$e (>493<+
-;(/
Nearly half of intra!ranial
o!!lu$ion$ are $e!ondary to CA o!!lu$ion+

Intra!ranial o!!lu$ion$ are mo$tly due to em"oli! 'henomena from a

!ardia! $our!e or the !arotid arterie$+ 1he relati#e la!k of intra!ranial
athero$!leroti! and atherothrom"oti! le$ion$ in auto'$y $tudie$ further
'oint$ to em"oli "eing the ma8or etiology+
-;(/

In the !arotid arterial $y$tem, $ignifi!ant !orrelation$ a''ear to o!!ur

"et*een the $i:e of the infar!tion on C1 and the e0tent of the #e$$el
$teno$i$ $een on angiogram$+ 7urthermore, the likelihood of defi!it
re!o#ery i$ in#er$ely 'ro'ortional to the degree of 'athology $een in C1,
5I, or angiogra'hy+
-;9, ;./
$egree o% con%idence
Angiogra'hy remain$ the !riterion $tandard for the imaging of #a$!ular
di$ea$e$ of the "rain and great #e$$el$ of the ne!k and $er#e$ a #ital role
29
for a!ute $troke inter#ention+ =o*e#er, angiogra'hy may "e normal in
'atient$ *ith $maller and le$$ $e#ere $troke$ or *ith di$tal arterial
o!!lu$ion$+
Diffu$ion4*eighted imaging i$ the !riterion $tandard for imaging
infar!tion+ @erfu$ion imaging *ith 5I or C1 remain the "e$t method$ for
e$timating the i$!hemi! 'enum"ra+
False positives/negatives
Negati#e angiogram$ are "elie#ed to "e $e!ondary to early re!anali:ation or from
di$ea$e in $mall, 'enetrating arterie$ "eyond the re$olution of angiogra'hy+
-;)/
Negati#e angiogra'hy "e!ome$ more fre6uent a$ angiogram$ are 'erformed later
after $troke on$et+
&ntervention
Current treatment$ for a!ute i$!hemi! $troke in!lude intra#enou$ throm"olyti!
thera'y *ith t@A and endo#a$!ular thera'ie$, in!luding intraarterial throm"olyti!
thera'y and !lot retrie#al de#i!e$+ Surgi!al management *ith hemi$'heri!
de!om're$$ion in 'atient$ *ith middle !ere"ral artery territory infar!tion and
a$$o!iated life4threatening 'aren!hymal edema ha$ al$o "een $u''orted+
->, ;>/
Ne*er $troke trial$ ha#e $ho*n the "enefit of u$ing neuroimaging to $ele!t the
'atient$ *ho are mo$t likely to "enefit from throm"olyti! thera'y and the
'otential "enefit$ of e0tending the *indo* for throm"olyti! thera'y "eyond the
guideline of 9 hour$ *ith t@A and ne*er agent$+
1he Diffu$ion and @erfu$ion Imaging E#aluation for ,nder$tanding Stroke
E#olution %DE7,SE& trial demon$trated the "enefit of admini$tering IV
t@A *ithin 94? hour$ of $troke on$et in 'atient$ *ith $mall i$!hemi! !ore$
on DBI and larger 'erfu$ion a"normalitie$ %large i$!hemi! 'enum"ra$&+
1he De$mote'la$e In A!ute I$!hemi! Stroke %DIAS& trial $imilarly
demon$trated the "enefit of admini$tering de$mote'la$e in 'atient$ *ithin
94A hour$ of on$et of a!ute $troke in 'atient$ *ith a $ignifi!ant mi$mat!h
%Q(3<& "et*een 'erfu$ion a"normalitie$ and i$!hemi! !ore on DBI+
Ad#an!ed neuroimaging *ith diffu$ion and 'erfu$ion imaging may then $er#e an
im'ortant role in identifying 'otentially $al#agea"le ti$$ue at ri$k and guiding
!lini!al de!i$ion making regarding thera'y+
-.9, ;?, ;2, ;;, ;A/
&ntravenous tissue plasinogen activator
1i$$ue 'la$minogen a!ti#ator i$ !urrently the only drug authori:ed "y the ,S 7DA
for treatment of a!ute i$!hemi! $troke+

7DA a''ro#al *a$ "a$ed on data from the National In$titute of

Neurologi!al Di$order$ and Stroke %NINDS& trial, *hi!h demon$trated an
30
e0!ellent out!ome in >3< of 'atient$ treated *ith IV t@A !om'ared *ith
9;< of !ontrol$+
-A/

1reatment *ith IV t@A mu$t "e initiated *ithin 9 hour$ of on$et of !learly
defined neurologi! defi!it+
-(>/

E#iden!e4"a$ed guideline$ ha#e al$o re!ommended again$t admini$tering

IV t@A in 'atient$ *ith greater than one4third in#ol#ement of the middle
!ere"ral artery di$tri"ution or *ith *ell4defined area$ of hy'oattenuation
on C1, due to an in!rea$ed ri$k of intra!ranial hemorrhage+
-.9, (>, A3/

Effi!a!y a''ear$ to "e highe$t in moderate to le$$4$e#ere $troke$ in *hi!h

the ICA or a ma8or !ere"ral artery i$ not o!!luded+
-.9, A./

@atient$ mu$t "e !arefully $ele!ted due to the $mall "ut $ignifi!ant
in!rea$ed ri$k of hemorrhage a$$o!iated *ith IV t@A %$ee the image
"elo*&+
1hrom"olyti! thera'y !arrie$ a $mall "ut $ignifi!ant ri$k of life4threatening
hemorrhage+ 7or thi$ rea$on, !arefully $!reening for e0!lu$ionary !riteria
'rior to admini$tering t@A i$ im'ortant; thi$ !riteria in!lude$ hemorrhage,
large area$ of infar!tion, and 'atient 're$entation "eyond the 94hour
*indo* for IV t@A or 'o$$i"ly "eyond ? hour$ for IA t@A+ 1hi$ !a$e
illu$trate$ thi$ 'oint in a 'atient *ith normal NCC1 *ho *a$ treated *ith
IV t@A for a!ute $troke and, o#er the ne0t ( day$, de#elo'ed $ignifi!ant
hemorrhage+ =emorrhage i$ noted to 'rogre$$i#ely in!rea$e in $i:e along
the medial margin of the right thalamu$ and the third #entri!le+ O"$tru!ti#e
hydro!e'halu$ *ith hemorrhage layering i$ $een in the de'endent 'ortion$
of the o!!i'ital horn$+
&ntra)arterial throbolysis
1hrom"olyti! agent$ !an "e infu$ed dire!tly into an o!!luded #e$$el to di$$ol#e
the !lot and re!anali:e the #e$$el+ 1he Ameri!an =eart A$$o!iation
%A=A&JAmeri!an Stroke A$$o!iation %ASA& Stroke Coun!il ha$ re!ommended
that IA1 may "e of "enefit if admini$tered *ithin ? hour$ of a!ute i$!hemi! $troke
in !arefully $ele!ted 'atient$ *ith o!!lu$ion of the CA and *ho are not eligi"le
to re!ei#e intra#enou$ throm"oly$i$+
-.9, A(, A9/
Mechanical recanali*ation
Currently, ( 7DA4a''ro#ed de#i!e$ for the endo#a$!ular treatment of a!ute
i$!hemi! $troke e0i$t: the Con!entri! 5etrie#er, mainly a gra$'ing de#i!e, and the
@enum"ra de#i!e, *hi!h u$e$ an a$'iration fun!tion to remo#e !lot+

1he ulti e!hani!al Em"olu$ 5etrie#al in Cere"ral I$!hemia %E5CI&

trial u$ed the ne*er generation Con!entri! retrie#al de#i!e %L>&+
5e!anali:ation *a$ demon$trated in a''ro0imately >>< of 'atient$ *ho
did not re!ei#e t@A and in ?;< of tho$e for *hom t@A *a$ gi#en in a
grou' of 'atient$ *ith a!ute i$!hemi! $troke 're$enting *ithin ; hour$ of
31
on$et of $ym'tom$+ Se#enty4three 'er!ent of 'atient$ *ho failed IV t@A
thera'y had re!anali:ation follo*ing me!hani!al em"ole!tomy+
-A)/

1he @enum"ra trial demon$trated ;(< re!anali:ation in 'atient$ *hen

u$ing the a$'iration fun!tion of the @enum"ra de#i!e+
-A>/
+ndovascular therapy o% aneuryss
Endo#a$!ular thera'y u$ing !oil em"oli:ation ha$ "een in!rea$ingly u$ed in re!ent
year$ *ith great $u!!e$$ a$ an alternati#e to $urgi!al !li''ing, although
!ontro#er$y $till e0i$t$ o#er *hi!h treatment i$ ultimately $u'erior+
1he International Su"ara!hnoid Aneury$m 1rial %ISA1& of neuro$urgi!al !li''ing
#er$u$ endo#a$!ular !oiling attem'ted to 'ro#ide !larifi!ation "y !om'aring
out!ome$ in 'atient$ *ho *ere $uita"le for "oth treatment$+ In thi$ randomi:ed
multi!enter trial !ondu!ted mainly in the ,F and Euro'e, the large$t of it$ ty'e,
(.)9 'atient$ *ere randomi:ed to either neuro$urgi!al !li''ing or endo#a$!ular
!oiling+ 1he ISA1 re'orted that inde'endent $ur#i#al *a$ higher at . year *ith
endo#a$!ular !oiling and that the $ur#i#al "enefit !ontinue$ for at lea$t 2 year$+
=o*e#er, the $mall ri$k of late re"leeding found in "oth grou'$ *a$ higher in the
endo#a$!ular !oiling grou', re!onfirming the higher long4term anatomi! !ure rate
of $urgery+
-A?, A2/
Endo#a$!ular treatment of aneury$m$ may "e fa#ored o#er $urgi!al !li''ing in the
follo*ing $ituation$:

Aneury$m lo!ation that i$ diffi!ult to a!!e$$ $urgi!ally, eg, !a#ernou$ ICA,

"a$ilar terminu$

Small4ne!ked 'o$terior fo$$a aneury$m$

Elderly 'atient$

@atient$ *ith 'oor !lini!al grade

-A2/
7a!tor$ mitigating again$t endo#a$!ular treatment in!lude the follo*ing:
Bide4"a$ed aneury$m$ or tho$e *ithout an identifia"le ne!k
Aneury$m$ *ith a #e$$el e0tending off the aneury$m dome
@atient$ *ith $e#erely athero$!leroti! or tortuou$ #e$$el$ that limit the
endo#a$!ular a''roa!h
Va$o$'a$m may "e treated *ith intra4arterial 'harma!euti!al agent$, $u!h a$
#era'amil or ni!ardi'ine or *ith "alloon angio'la$ty for o'ening larger #e$$el$+
1he !om"ination of the ( treatment$ a''ear$ to 'ro#ide $afe and long4la$ting
thera'y of $e#ere !lini!al $ignifi!ant #a$o$'a$m %$ee the image$ "elo*&+
-A;/

7rontal #ie* from a !ere"ral angiogram in a ).4year4old male *ho 're$ented 2
day$ 'rior *ith $u"ara!hnoid hemorrhage from a ru'tured anterior !ommuni!ating
32
artery aneury$m treated *ith $urgi!al !li''ing+ Signifi!ant narro*ing of the
'ro0imal left anterior !ere"ral artery %ACA&, left . $egment, and left
$u'ra!linoid internal !arotid artery %ICA& indi!ate$ #a$o$'a$m+

Angiogra'hi! #ie* in the $ame 'atient %image on left& *ith $u'erim'o$ed road
ma' image demon$trate 'la!ement of a *ire a!ro$$ the left . $egment and
"alloon angio'la$ty+ 1he left 'ro0imal anterior !ere"ral artery %ACA& and
$u'ra!linoid internal !arotid artery %ICA& *ere al$o angio'la$tied and intra4arterial
#era'amil *a$ admini$tered+ 7ollo*4u' image on the right after treatment
demon$trate$ re$olution of the left . $egment and di$tal ICA, *hi!h are no*
*idely 'atent+ 5e$idual narro*ing i$ $een in the left 'ro0imal ACA+

Cere"ral angiogram *a$ 'erformed in a >24year4old male *ith family hi$tory of
$u"ara!hnoid hemorrhage and found on 're#iou$ imaging to ha#e a left di$tal
internal !arotid artery %ICA& aneury$m+ 1he lateral 'ro8e!tion from the angiogram
demon$trate$ a narro*4ne!ked aneury$m ari$ing off the 'o$terior a$'e!t of the
di$tal $u'ra!linoid left ICA *ith an additional ni''le4like 'ro8e!ting off the
inferior a$'e!t of the dome of the aneury$m+ ild lo"ulated dilatation of the
!a#ernou$ left ICA i$ al$o 're$ent+

7ollo*4u' !ere"ral angiogram in the $ame 'atient a$ 're#iou$ image after !oil
em"oli:ation+ ulti'le !oil$ *ere 'la!ed *ith $e6uential o!!lu$ion of the
aneury$m, in!luding the ni''le at it$ inferior a$'e!t+ A $mall amount of re$idual
filling i$ noted at the 'ro0imal ne!k of the aneury$m, *hi!h may throm"o$e o#er
time+
Medical legal pit%alls

1he "enefit$ and ri$k$ $hould "e fully de$!ri"ed and informed !on$ent
o"tained 'rior to any diagno$ti! or inter#entional 'ro!edure or other
treatment+ 1hi$ in!lude$ ri$k of radiation e0'o$ure for 'atient$ undergoing
C1 $!anning or angiogra'hy+

@ro'er $!reening for im'lanted metalli! de#i!e$ %eg, 'a!emaker$ and

defi"rillator$, !o!hlear im'lant$& mu$t "e o"tained 'rior to 5I+

@rior to admini$tering intra#enou$ !ontra$t for C1, 5I and angiogra'hy

or any medi!ation, hi$tory of allergie$ $hould "e eli!ited+ Alternati#e
method$ for diagno$i$, in!luding non!ontra$t e0amination$, $hould "e
'ur$ued in all 'atient$ *ith hi$tory of !ontra$t allergy+ If a"$olutely
ne!e$$ary, a $tandard 'remedi!ation regimen $hould "e admini$tered for
tho$e *ho are at ri$k 'rior to the !ontra$t e0amination+

Iodinated !ontra$t agent$ run the ri$k of !ontra$t4indu!ed ne'hro'athy+ 1he

u$e of iodinated !ontra$t, e$'e!ially in a 'atient 'o'ulation at ri$k for
!ontra$t ne'hro'athy %eg, dia"eti!$ and tho$e *ith !om'romi$ed renal
fun!tion& $hould "e #ie*ed *ith !aution and only 'erformed if a"$olutely
ne!e$$ary+ Standard 'ro'hyla0i$ for !ontra$t4indu!ed ne'hro'athy $hould
therefore "e $trongly !on$idered in 'atient$ *ho are at ri$k "efore !ontra$t
admini$tration+
33

Gadolinium4"a$ed intra#enou$ !ontra$t agent$ ha#e al$o "een linked to the

de#elo'ment of ne'hrogeni! $y$temi! fi"ro$i$ or ne'hrogeni! fi"ro$ing
dermo'athy %NS7JN7D& in 'atient$ *ith moderate to end$tage renal
in$uffi!ien!y+ 7or thi$ rea$on, the AC5 re!ommend$ $!reening at4ri$k
'atient$R glomerular filtration rate$ 'rior to !ontra$t4enhan!ed 5I+ If the
5I e0amination i$ a"$olutely ne!e$$ary, half %or lo*er& do$e
admini$tration of $ome gadolinium4"a$ed agent$ may "e !on$idered in
'atient$ *ith G75 "et*een 93D>A mLJmin 'er .+29 m
(
+ 5enal !on$ultation
i$ re!ommend for tho$e *ith G75 "elo* 93 mLJmin 'er .+29 m
(,
*ith the
AC5 re!ommending ( dialy$i$ $e$$ion$ *ithin () hour$ for hemodialy$i$
'atient$ re!ei#ing gadolinium4"a$ed 5 !ontra$t agent$, "eginning a$
$oon a$ the 5 e0amination i$ !om'leted+
-AA/

@atient$ mu$t "e !arefully $ele!ted a!!ording to e$ta"li$hed guideline$

'rior to admini$tering throm"olyti!$ or me!hani!al throm"e!tomy due to
the inherent ri$k of hemorrhagi! !on#er$ion of a "land i$!hemi! infar!t
follo*ing re'erfu$ion+

Other 'ro!edure $'e!ifi! ri$k$ for !ere"ral angiogra'hy and neuro#a$!ular

inter#entional 'ro!edure$ in!lude em"oli:ation of throm"u$ in i$!hemi!
$troke, aneury$m 'erforation *ith hemorrhage during !oil em"oli:ation,
and arterial di$$e!tion+

Com'li!ation$ from femoral artery 'un!ture in!lude lo!ali:ed hematoma

at the groin 'un!ture $ite, retro'eritoneal hematoma, di$$e!tion,
'$eudoaneury$m, and arterio#enou$ fi$tula formation+
Further reading
Clinical guidelines
Adam$ =@ Er, del So''o G, Al"ert$ E et al+ Guideline$ for the early
management of adult$ *ith i$!hemi! $troke: a guideline from the
Ameri!an =eart A$$o!iationJAmeri!an Stroke A$$o!iation Stroke Coun!il,
Clini!al Cardiology Coun!il, Cardio#a$!ular 5adiology and Inter#ention
Coun!il, and the Athero$!leroti! @eri'heral Va$!ular Di$ea$e and Kuality
of Care Out!ome$ in 5e$ear!h Interdi$!i'linary Borking Grou'$: the
Ameri!an A!ademy of Neurology affirm$ the #alue of thi$ guideline a$ an
edu!ational tool for neurologi$t$+ Stroke + (332; 9;%>&: .?>>4.2..
Croderi!k E, Connolly S, 7eldmann E, =anley D, Fa$e C, Frieger D,
ay"erg , orgen$tern L, Ogil#y CS, Ve$'a @, Su!!arello , Ameri!an
=eart A$$o!iation, Ameri!an Stroke A$$o!iation Stroke Coun!il, =igh
Clood @re$$ure 5e$ear!h Coun!il, Kuality of Care and Out!ome$ in
5e$ear!h Interdi$!i'linary Borking Grou'+ Guideline$ for the
management of $'ontaneou$ intra!ere"ral hemorrhage in adult$: (332
u'date+ Stroke+ (332 Eun;9;%?&:(33.4(9+
Ceder$on EC, Connolly ES Er, Cat8er ==, et al+ Guideline$ for the
management of aneury$mal $u"ara!hnoid hemorrhage+ A $tatement for
34
health!are 'rofe$$ional$ from a $'e!ial *riting grou' of the Stroke
Coun!il, Ameri!an =eart A$$o!iation+ Stroke+ (33A;)3:AA)4.3(>+
Clinical trials
NINDS Grou'+ 1i$$ue 'la$minogen a!ti#ator for a!ute i$!hemi! $troke+ N+
Engl+ E+ ed+ .AA>; 999:.>;.4.>;2
Al"er$ GB, 1hi8$ VN, Be!h$ler L et al+ agneti! re$onan!e imaging
'rofile$ 'redi!t !lini!al re$'on$e to early re'erfu$ion: the diffu$ion and
'erfu$ion imaging e#aluation for under$tanding $troke e#olution
%DE7,SE& $tudy+ Ann+ Neurol+ (33?; ?3%>&:>3;4>.2
=a!ke B, Al"er$ G, Al45a*i T et al+ 1he De$mote'la$e in A!ute I$!hemi!
Stroke 1rial %DIAS&: a @ha$e II 5I4"a$ed A4hour *indo* a!ute $troke
throm"oly$i$ trial *ith intra#enou$ de$mote'la$e+ Stroke+ ,--./ 9?%.&,??4
29 %(33>&+
7urlan A, =iga$hida 5, Be!h$ler L, et al+ Intra4arterial 'rourokina$e for
a!ute i$!hemi! $troke+ 1he @5OAC1 II $tudy: a randomi:ed !ontrolled
trial+ @roly$e in A!ute Cere"ral 1hrom"oem"oli$m+ EAA .AA; / (;(%(.&:
(3394(3..
del So''o GE, =iga$hida 51, 7urlan AE, @e$$in S, 5o*ley =A, Gent +
@5OAC1: a @ha$e II randomi:ed trial of re!om"inant 'ro4urokina$e "y
dire!t arterial deli#ery in a!ute middle !ere"ral artery $troke+ @5OAC1
In#e$tigator$+ @roly$e in A!ute Cere"ral 1hrom"oem"oli$m+ Stroke+ .AA;;
(A:)4..
Smith BS, Sung G, Sa#er E, et al+ e!hani!al throm"e!tomy for a!ute
i$!hemi! $troke: final re$ult$ of the ulti E5CI trial+ Stroke+ (33;:
9A%)&,.(3>4.(.(
Co$e A, =enke$ =, Alfke F, et al+ 1he @enum"ra Sy$tem: a me!hani!al
de#i!e for the treatment of a!ute $troke due to throm"oem"oli$m+ AEN5
Am+ E+ Neuroradiol+ (33;: (A%2&,.)3A4.).9
olyneu0 AE; Ferr 5S; Tu L; Clarke , et al+ International
$u"ara!hnoid aneury$m trial %ISA1& of neuro$urgi!al !li''ing #er$u$
endo#a$!ular !oiling in (.)9 'atient$ *ith ru'tured intra!ranial
aneury$m$: a randomi$ed !om'ari$on of effe!t$ on $ur#i#al, de'enden!y,
$ei:ure$, re"leeding, $u"grou'$, and aneury$m o!!lu$ion+ Lancet+ (33>;
9??:;3A4.2
35