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. 2013 Jun;44(6 Suppl 1):S53-4.
doi: 10.1161/STROKEAHA.113.001939.

The alphabet of imaging in acute stroke: does it spell improved selection and outcome?

Howard A Rowley  1
Affiliations

The alphabet of imaging in acute stroke: does it spell improved selection and outcome?

Howard A Rowley. Stroke. 2013 Jun.
No abstract available

Keywords: CT; MRI; brain perfusion; stroke; thrombolysis.

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Figures

Figure.
Figure.
71-year-old woman presented with fluctuating aphasia and right facial weakness, with a National Institutes of Health Stroke Scale=7, last seen normal 4.5 hours earlier. Computerized tomography was negative except for old lacunes, and tissue-type plasminogen activator was not given because of late time and rapidly resolving deficits. MRI done at 7 hours shows old bilateral lacunes in the basal ganglia on fluid-attenuated inversion recovery (FLAIR), but also subtle new left centrum semiovale ischemic changes on diffusion-weighted images (DWIs) and apparent diffusion coefficient maps (ADCs, arrows). A critical stenosis of the left middle cerebral artery (MCA) is seen on magnetic resonance angiography (MRA, arrow). Perfusion maps show relatively preserved cerebral blood flow and volumes (CBF, CBV), but marked prolongation of transit times (MTT and Tmax). This pattern indicates severe but partially compensated perfusion deficits extending well beyond the ischemic region on diffusion. The observed perfusion changes suggest a large ischemic penumbra, despite initial clinical improvement. The patient was observed overnight, but the next morning she was found globally aphasic and hemiplegic. An MR protocol was repeated, with only slight interval increase in the DWI lesion. There was a large persistent penumbra corresponding to her severe clinical deficits. B, She was referred for endovascular intervention, based on failure of medical therapy and favorable penumbral pattern. Angiography done at 23 hours after admission confirms a critical stenosis of the left M1 MCA segment (arrows). A Wingspan stent was placed (arrows depict end markers), with follow-up angiography showing excellent recanalization and reperfusion. The patient also recovered rapidly; now 2 years after intervention, she has normal language, only mild residual hemiparesis, lives at home, and walks a mile a day without assistance. (Case courtesy of Dr. David Niemann, University of Wisconsin, Madison WI.)
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