Comparison of diffusion-weighted MRI and CT in acute stroke

The Impact of Transient Ischemic Attack (TIA) on Brain and Behavior

Transient ischemic attack (TIA) was originally defined as self-resolving focal cerebral ischemia with symptoms lasting <24 h. The newer definition also added the limitation that there should be no evidence of acute brain tissue infarction, to recognize that acute injury to the brain can result from ischemia of <24-h duration. However, several recent findings suggest that having a TIA correlates with deficits that can persist far beyond the resolution of clinical symptoms, even in the absence of imaging evidence of ischemic tissue injury. These deficits may be the result of subtle perturbations to brain structure and/or function that are not easily appreciated using the standard clinical and imaging tools that are currently employed in practice. Here, we will discuss evidence that suggests that TIA may lead to lasting changes to the structure and function of the brain.

Magnetic resonance imaging versus computed tomography for detection of acute vascular lesions in patients presenting with stroke symptoms

BACKGROUND

Magnetic resonance imaging (MRI) is increasingly used for the diagnosis of acute ischaemic stroke but its sensitivity for the early detection of intracerebral haemorrhage has been debated. Computed tomography (CT) is extensively used in the clinical management of acute stroke, especially for the rapid exclusion of intracerebral haemorrhage.

OBJECTIVES

To compare the diagnostic accuracy of diffusion-weighted MRI (DWI) and CT for acute ischaemic stroke, and to estimate the diagnostic accuracy of MRI for acute haemorrhagic stroke.

SEARCH STRATEGY

We searched MEDLINE and EMBASE (January 1995 to March 2009) and perused bibliographies of relevant studies for additional references.

SELECTION CRITERIA

We selected studies that either compared DWI and CT in the same patients for detection of ischaemic stroke or examined the utility of MRI for detection of haemorrhagic stroke, had imaging performed within 12 hours of stroke onset, and presented sufficient data to allow construction of contingency tables.

DATA COLLECTION AND ANALYSIS

Three authors independently extracted data on study characteristics and measures of accuracy. We assessed data on ischaemic stroke using random-effects and fixed-effect meta-analyses.

MAIN RESULTS

Eight studies with a total of 308 participants met our inclusion criteria. Seven studies contributed to the assessment of ischaemic stroke and two studies to the assessment of haemorrhagic stroke. The spectrum of patients was relatively narrow in all studies, sample sizes were small, there was substantial incorporation bias, and blinding procedures were often incomplete. Amongst the patients subsequently confirmed to have acute ischaemic stroke (161/226), the summary estimates for DWI were: sensitivity 0.99 (95% CI 0.23 to 1.00), specificity 0.92 (95% CI 0.83 to 0.97). The summary estimates for CT were: sensitivity 0.39 (95% CI 0.16 to 0.69), specificity 1.00 (95% CI 0.94 to 1.00). The two studies on haemorrhagic stroke reported high estimates for diffusion-weighted and gradient-echo sequences but had inconsistent reference standards. We did not calculate overall estimates for these two studies. We were not able to assess practicality or cost-effectiveness issues.

AUTHORS' CONCLUSIONS

DWI appears to be more sensitive than CT for the early detection of ischaemic stroke in highly selected patients. However, the variability in the quality of included studies and the presence of spectrum and incorporation biases render the reliability and generalisability of observed results questionable. Further well-designed studies without methodological biases, in more representative patient samples, with practicality and cost estimates are now needed to determine which patients should undergo MRI and which CT in suspected acute stroke.

Ischemic Brain Tissue Water Content: CT Monitoring during Middle Cerebral Artery Occlusion and Reperfusion in Rats1

PURPOSE

To prospectively perform computed tomography (CT) in rats to determine whether ischemic edema can be reversed by using early arterial reperfusion.

MATERIALS AND METHODS

This study was approved by the local animal protection committee. A suture model was used to occlude the right middle cerebral artery (MCA) in rats for 1, 2, 3, or 4 hours. X-ray attenuation of the brain was measured directly before reperfusion and repeatedly during reperfusion for up to 24 hours. Infarct volumes were determined with triphenyltetrazolium chloride staining. Means of attenuation and infarct volume were compared between hemispheres and groups with a paired t test and analysis of variance. Mixed linear models were applied to compare attenuation among groups over time.

RESULTS

During MCA occlusion, attenuation decreased to 69.3 HU +/- 1.9 (standard deviation) after 1 hour (n=12), 66.6 HU +/- 2.0 after 2 hours (n=10), 65.4 HU +/- 2.9 after 3 hours (n=11), and 64.1 HU +/- 1.8 after 4 hours (n=9) (P<.0001). After reperfusion, attenuation remained stable in the 1-hour occlusion group (P=.16) but further and steadily declined in the 2-, 3-, and 4-hour occlusion groups (P<.001). Attenuation during reperfusion in the 1-hour occlusion group differed significantly from that in the 2-, 3-, and 4-hour occlusion groups.

CONCLUSION

CT is able to help monitor ischemic edema after MCA occlusion and reperfusion. Ischemic brain edema was not consistently reversible with reperfusion, even after 1 hour of occlusion, and further increased with reperfusion induced at 2 hours or later.