Hyperacute ischaemic changes on non-contrast CT brain

Poster No.:

R-0011

Congress:

2014 CSM

Type:

Scientific Exhibit

Authors:

B. McAllister, L. Lam; ELIZABETH BAY/AU

Keywords:

Ischemia / Infarction, Diagnostic procedure, Audit and standards,

CT, Neuroradiology brain

DOI:

10.1594/ranzcr2014/R-0011

Any information contained in this pdf file is automatically generated from digital material
submitted to EPOS by third parties in the form of scientific presentations. References
to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not
in any way constitute or imply RANZCR/AIR/ACPSEM's endorsement, sponsorship
or recommendation of the third party, information, product or service. RANZCR/AIR/
ACPSEM is not responsible for the content of these pages and does not make any
representations regarding the content or accuracy of material in this file.
As per copyright regulations, any unauthorised use of the material or parts thereof as
well as commercial reproduction or multiple distribution by any traditional or electronically
based reproduction/publication method ist strictly prohibited.
You agree to defend, indemnify, and hold RANZCR/AIR/ACPSEM harmless from and
against any and all claims, damages, costs, and expenses, including attorneys' fees,
arising from or related to your use of these pages.
Please note: Links to movies, .ppt slideshows, .doc documents and any other multimedia
files are not available in the pdf version of presentations.

Page 1 of 13

Aim
Stroke is Australia's second biggest killer after coronary heart disease and a leading
1

cause of disability .The NHMRC recommends CT brain as the imaging modality of choice
*, 2

for initial imaging in stroke patients and that it should be performed urgently , however
patients who are candidates for thrombolysis are recommended to undergo imaging
3

immediately . The role of CT imaging is to confirm cerebral ischemia or haemorrhage

and exclude stroke mimics (such as SDH, tumor); it has high specificity (1.00, 95% CI
5

0.94-1.00) but low sensitivity (0.39, 95% CI 0.16-0.69) . To date there is no evidence
4

of differences in outcomes between plain CT and advanced imaging such as MRI DWI,
however the latter has both high sensitivity (0.99, 95% CI 0.23 -1.00) and specificity (0.92,
5

95% CI 0.83-0.97) for acute stroke .

Well described findings on non contrast CT brain in acute stroke include (i)
hypoattenuating brain tissue (loss of grey-white matter differentiation); (ii) obscuration
of the lentiform nucleus; (iii) dense MCA sign; (iv) "insular ribbon sign"; (v) sulcal
6,7

effacement . It is often the case that patients presenting with hyperacute stroke (defined
as within 3 - 6 hours of symptoms onset) have a negative CT brain due to lack of these
characteristic changes.
The purpose of this educational exhibit is to review parenchymal changes on non contrast
CT brain in patients presenting with acute stroke. We propose that an additional finding
of cortical surface blur may be seen in cases of hyperacute ischaemia and that this
may be used as a reliable sign in evaluation of these patients. This will be illustrated in
our review series by using pictorial examples.

Methods and materials

Non-contrast CT brains performed on patients presenting to Liverpool Hospital with
acute stroke symptoms were evaluated retrospectively. Dates of inclusion were from
01/01/2013 - 31/12/2013.
Inclusion criteria:
1. Symptoms of less then 6 hours onset ("hyperacute" stage).
2. Patients had to be eligible for thrombolysis therapy (use of NIHSS score).
Page 2 of 13

3. Established ischaemia had to be demonstrated on progress imaging, either CT brain

or MRI, to confirm initial findings.
Exclusion criteria:
1. Intracranial haemorrhage or other stroke mimic.

Data of patients was collected using the hospital Stroke journal.

The CT's of eligible patients were reviewed by a registrar and staff specialist radiologist
at Liverpool Hospital.

Results

55 patients met the inclusion criteria above.

19 of these 55 patients had the sign of cortical surface blur on review (34.5%).
Each of these 19 cases had progress imaging performed (either repeat non contrast CT
brain or MRI brain) which demonstrated evolution of the infarction.
4 cases have been chosen for use as pictoral examples of cortical surface blur.
Each cases demonstrates the sign; progress imaging is also provided which
demonstrates evolution of infarction and more characteristic changes including sulcal
effacement and loss of grey-white matter differentiation.
Images for this section:

Page 3 of 13

Fig. 1: Cortical surface blur is seen in the right parietal lobe of this patient presenting
with acute stroke symptoms.

Page 4 of 13

Fig. 2: Progress imaging performed from the patient in Figure 1 72 hours after the initial
CT. There is evolution of the infarct with loss of grey-white matter differentiation and
sulcal effacement.

Page 5 of 13

Fig. 3: Cortical surface blur in left parietal lobe.

Page 6 of 13

Fig. 4: Progress imaging performed one day later (following figure 3) showing evolution
of infarction.

Page 7 of 13

Fig. 5: Cortical surface blur in the right frontoparietal region in a patient presenting with
acute stroke symptoms.

Page 8 of 13

Fig. 6: CT brain performed 4 days later (patient in figure 5) demonstrating infarction.

Page 9 of 13

Fig. 7: Cortical surface blur at the left frontoparietal lobe in this patient presenting with
acute stroke symptoms.

Page 10 of 13

Fig. 8: Progress CT brain performed 72 hours after the initial CT (figure 7) showing
evolution of infarction with sulcal effacement and loss of grey-white matter differentiation.

Page 11 of 13

Conclusion
Patients presenting with symptoms of stroke routinely undergo investigation with non
contrast CT brain in the acute setting.
Review of imaging performed in these patients presenting to Liverpool Hospital in 2013
revealed an additional sign of cortical surface blur in 34 % of patients with hyperactue
cerebral ischaemia.
This finding may indeed be present on imaging before other well described findings of
acute infarction and should necessitate careful review of these studies.

Personal information
Dr Brylie McAllister
Radiology Registrar
Liverpool Hospital
Sydney, NSW

Dr Leon Lam
Staff Specialist
Liverpool Hospital
Sydney, NSW

References
Annotations:
* urgent: as soon as possible, preferably within 24 hours.
References:
1. Australian Institute of Health and Welfare 2012. Australia's Health 2012).
Page 12 of 13

2.
http://www.nhmrc.gov.au/_files_nhmrc/file/publications/
cp116_summary_clinicians.pdf
3.
http://strokefoundation.com.au/site/media/
clinical_guidelines_stroke_managment_2010_interactive.pdf
4. Wardlaw JM, Steveson MD, Chappell F, Rothwell PM, Gillard J, Young G, et al. Carotid
artery imaging for secondary stroke prevention; Both imaging modality and rapid access
to imaging are important. Stroke, 2009b, November; 40(11):3511-7
5. Brazzelli M, Sandercock PA, Chappell FM, Celani MG, Righetti E, Arestis N, et
al. Magnetic resonance imaging versus computed tomography for detection of acute
vascular lesions in patients presenting with stroke symptoms. Cochrane Database Syst
Rev. 2009, Issue 4. CD007424.
6. R von Kummer et al. Acute stroke: usefulness of early CT findings before thrombolytic
therapy. Radiology 1997, Vol 205, 327-333
7. N Tomura et al. Early CT findings in cerebral infarction: obscuration of the lentiform
nucleus. Radiology 1988, Vol 168, 463 - 467

Page 13 of 13