The capacity for computed tomography diagnosis of cerebral infarction. An experimental study in the nonhuman primate

Prevalence and significance of hyperdense middle cerebral artery in acute stroke

BACKGROUND AND PURPOSE

Early noncontrast computed tomographic scans may visualize a hyperdense middle cerebral artery before the infarct becomes visible. This sign disappears within a few days, corresponds to the clot itself, and might be associated with a poor prognosis. The aim of the study was to determine its prevalence, diagnostic value, relationship to demographic data, ability to separate embolic from nonembolic causes, short-term prognostic value, evolution over time, and relationship to arterial occlusion on angiography.

METHODS

We performed this study using computed tomographic scans performed within 12 hours after onset in 272 consecutive unselected patients with a first acute cerebrovascular event.

RESULTS

Seventy-three subjects had the hyperdense middle cerebral artery sign, leading to a prevalence of 26.8% in the whole group and 41.2% in patients with a middle cerebral artery infarct. Specificity was 100%, but sensitivity was only 30%. This sign was not dependent on cerebrovascular risk factors, but was more likely to occur in cortical and in large, deep, middle cerebral artery infarcts (p less than 0.01). It provided only a 3.5% gain in predicting death, and one fifth of patients with the sign recovered within 2 weeks; this sign was not an independent variable of poor outcome on multiple linear regression. It spontaneously disappeared within a few days and was always related to an occlusion of the middle cerebral artery in patients who underwent early angiography.

CONCLUSIONS

The hyperdense middle cerebral artery sign is useful in the diagnosis of middle cerebral artery occlusion but does not always predict a poor prognosis.

CT in hemispheric ischaemic attacks

The authors report the three principal characteristics of hemispheric ischaemic attacks on CT scan and their development over time: hypodensity, mass effect and contrast enhancement. Their pathophysiological mechanism and prognostic importance are discussed. The topography of the territories of the large arteries vascularising the brain and their main branches is described on the basis of twelve sections cut parallel to the cantho-meatal line. Finally, selected special aspects are described (misleading aspects, haemorrhagic infarcts, border zone infarcts).

Comparison of middle cerebral artery trunk occlusion by silicone cylinder embolization and by trapping

The authors produced occlusion of the middle cerebral artery (MCA) trunk in dogs by two methods: silicone cylinder embolization and trapping. Comparative analyses of the clinicopathological features in these models, extending from the acute to chronic stage, were performed. Within 24 hours after embolization, the brain exhibited swelling without macroscopic infarction. Microangiograms revealed impaired filling in the deep areas of the brain with midline shift. At 4 to 7 days after embolization, the animals showed major neurological deficits, evident deep cerebral infarction, and poorly perfused areas in the deep cerebrum with prominent midline shift. At 3 to 4 weeks after embolization, the neurological deficits improved and the affected regions showed cavities or localized lesions. Microangiograms demonstrated hypervascular areas with abnormal vessels in the affected cerebrum. On the other hand, trapping of the MCA trunk produced mild neurological deficits, although there was no evidence of macroscopic lesions or impairment of filling. This study shows that silicone cylinder embolization in the MCA trunk produces a reliable and reproducible deep cerebral infarction in dogs.

Contrast enhancement of cerebral infarcts. Incidence and clinical value in different states of cerebral infarction

Information obtained from CT scan after contrast administration was evaluated in 59 consecutive stroke patients. CT scans before and after contrast administration were performed 3 days and 2 1/2 weeks after stroke. A plain CT scan was repeated 6 months later. Contrast enhancement was practically not seen on the first examination, but was seen in 46% on the second examination. There was a close relationship between the occurrence of contrast enhancement and the socalled "fogging effect". Contrast scanning gave additional information only when this effect was present. Plain CT scans 3 days after stroke were superior to contrast scans taken at any time for detecting and visualizing cerebral infarcts.

Transient disappearance of cerebral infarcts on CT scan, the so-called fogging effect

The fogging effect, whereby initially hypodense infarcts become isodense during the second and third week after the onset of stroke, was investigated in a prospective and consecutive series comprising 50 cases with completed stroke. CT scans were performed approximately 3 days, 10 days and 6 months after stroke. The fogging effect was found in 54% of cases. The hypodense areas reappeared on all scans at 5 months. Cerebral infarcts therefore may be overlooked or grossly underestimated if the scan is performed during the second and third week after stroke.

Tissue pertechnetate and iodinated contrast material in ischemic stroke

Isotope uptake during static radionuclide scanning and contrast enhancement during CT scanning, which may result from similar pathophysiologic mechanisms after ischemic infarction, were investigated in an animal model. Infarction was produced by transorbital occlusion of the middle cerebral artery in cats killed one, 2, 4, 8, or 16 days later. Sodium pertechnetate containing technetium-99m and 30% methylglucamine iothalamate labeled with I-125 were administered intravenously 60 and 15 min respectively prior to sacrifice. A coronal section through the infarct was parceled into 30 portions which were assayed for concentration of each isotope. Adjacent brain was prepared for histopathologic correlation. Concentrations of the 2 materials were highest in infarcted brain at 4 and 8 days. Strong positive correlation was found between tissue concentrations of the 2 materials in all brain samples. Elevated tissue levels correlated with necrosis, macrophage infiltration, and vascular hyperplasia. The results support the probability that radionuclide scan positivity and CT contrast enhancement reflect the same pathophysiologic development, probably extravasation of the respective labels, after ischemic stroke.

CT fogging effect with ischemic cerebral infarcts

Systematic CT studies on ten patients with persistent ischemic cerebral infarct revealed a constant phenomenon, the fogging effect. The hypodense infarct at the beginning will be isodense, or close to isodense, on the plain CT during the seond of third weeks and at a later stage will be hypodense again. The fogging infarcted area shows homogeneous intensive contrast enhancement. Knowledge of the fogging effect is important for correct interpretation of the CT image and the indication for contrast medium CT. CT without contrast medium may lead to misinterpretation during the second and third weeks after the onset of cerebral infarction.

Comparative cranial CT enhancement in a primate model of cerebral infarction

The value of various enhancement techniques as opposed to nonenhanced CT scanning was compared in 15 baboons with cerebral infarction secondary to embolization of the left middle cerebral artery. The most prominent CT findings in infarction included an area of low absorption in the opercula--basal ganglia--centrum semiovale region and generalized lateral ventricular enlargement. Intravenous enhancement of the low-density region occurred in 25% of the animals and often obscured the preenhancement abnormality. However, a rapid bolus injection of contrast material followed by immediate consecutive CT scans (computed angiotomography) permitted prominent visualization of early-shunting veins. Delayed scanning following intrathecal enhancement better defined small infarctions that did not exhibit the usual cerebral blush. The CT imaging of inhaled xenon provides a new technique for evaluating subtle abnormalities in cerebral perfusion, even when the routine CT scan shows no abnormality.

Xenon enhanced CT for analysis of cerebral integrity, perfusion, and blood flow

Enhancement of the brain substance for CT evaluation using inhaled Xenon is confirmed. This technique was applied to the study of the normal and the embolized adolescent baboon. Healthy cerebral tissue enhances symmetrically, while abnormal areas show significantly diminished enhancement. At maximal enhancement, an indication of gross comparative cerebral perfusion to obtained. By obtaining serial CT scans over a 10 minute time interval, the clearance rate of Xenon (cerebral blood flow) may be evaluated. Xenon-enhanced CT enables a visual and numerical analysis of both brain morphology and physiology.

Physiologic changes in regional cerebral blood flow defined by xenon-enhanced CT scanning

With adequate concentrations of commercially available nonradioactive xenon an enhancement of brain substance was readily demonstrated by computed tomography (CT). By performing successive CT scans at a fixed brain level following xenon inhalation, the partition coefficient and clearance of xenon as well as the regional cerebral blood flow (rCBF) could be calculated. The expected physiologic alterations in rCBF with acute cerebral infarction and changes in arterial CO2 were accurately defined by xenon-enhanced CT scanning affirming the potential future applications of this technique.