Acute cerebral ischemic infarction: a pathophysiologic review and radiologic perspective

Effects of Solitaire AB stent thrombectomy with tirofiban and butylphthalide on neurological function and inflammatory factors in acute cerebral infarction patients

BACKGROUND

Acute cerebral infarction profoundly affects patients' neurological function and quality of life. This study explores the impact of Solitaire AB stent thrombectomy, combined with tirofiban and butylphthalide, on neurological function and inflammatory factors in patients with acute cerebral infarction.

METHODS

Seventy-three eligible patients treated between 2021 and 2023 were divided into a control group (Solitaire AB stent thrombectomy) and a treatment group (Solitaire AB stent thrombectomy with tirofiban and butylphthalide). Postoperative neurological function scores and inflammatory factor levels were analyzed.

RESULTS

The treatment group demonstrated a higher clinical effective rate, lower National Institutes of Health Stroke Scale scores at one day and seven days and higher Mini-Mental State Examination and Montreal Cognitive Assessment scores post-treatment. Inflammatory factor levels (Neuron Specific Enolase (NSE), S100-β, TNF-α and IL-6) were lower in the treatment group. No significant differences in adverse outcomes were observed.

CONCLUSION

Solitaire AB stent thrombectomy with tirofiban and butylphthalide shows superior efficacy, improving neurological function and inflammatory factors without increasing adverse outcomes. This offers valuable insights for clinical treatment of acute cerebral infarction.

Use of Magnetic Resonance Imaging in Neuroprognostication After Pediatric Cardiac Arrest: Survey of Current Practices

BACKGROUND

Use of magnetic resonance imaging (MRI) as a tool to aid in neuroprognostication after cardiac arrest (CA) has been described, yet details of specific indications, timing, and sequences are unknown. We aim to define the current practices in use of brain MRI in prognostication after pediatric CA.

METHODS

A survey was distributed to pediatric institutions participating in three international studies. Survey questions related to center demographics, clinical practice patterns of MRI after CA, neuroimaging resources, and details regarding MRI decision support.

RESULTS

Response rate was 31% (44 of 143). Thirty-four percent (15 of 44) of centers have a clinical pathway informing the use of MRI after CA. Fifty percent (22 of 44) of respondents reported that an MRI is obtained in nearly all patients with CA, and 32% (14 of 44) obtain an MRI in those who do not return to baseline neurological status. Poor neurological examination was reported as the most common factor (91% [40 of 44]) determining the timing of the MRI. Conventional sequences (T1, T2, fluid-attenuated inversion recovery, and diffusion-weighted imaging/apparent diffusion coefficient) are routinely used at greater than 97% of centers. Use of advanced imaging techniques (magnetic resonance spectroscopy, diffusion tensor imaging, and functional MRI) were reported by less than half of centers.

CONCLUSIONS

Conventional brain MRI is a common practice for prognostication after CA. Advanced imaging techniques are used infrequently. The lack of standardized clinical pathways and variability in reported practices support a need for higher-quality evidence regarding the indications, timing, and acquisition protocols of clinical MRI studies.

Magnetic Resonance Imaging Adds Prognostic Value to EEG After Pediatric Cardiac Arrest

AIM

To investigate how combined electrographic and radiologic data inform outcomes in children after cardiac arrest.

METHODS

Retrospective observational study of children admitted to the pediatric intensive care unit (PICU) of a tertiary children's hospital with diagnosis of cardiac arrest from 2009 to 2016. The first 20 min of electroencephalogram (EEG) background was blindly scored. Presence and location of magnetic resonance imaging (MRI) diffusion-weighted image (DWI) abnormalities were correlated with T2-weighted signal. Outcomes were categorized using Pediatric Cerebral Performance Category (PCPC) scores at hospital discharge, with "poor outcome" reflecting a PCPC score of 4-6. Logistic regression models examined the association of EEG and MRI variables with outcome.

RESULTS

41 children met inclusion criteria and had both post-arrest EEG monitoring within 72 hours after ROSC and brain MRI performed within 8 days. Among the 19 children with poor outcome, 10 children did not survive to discharge. Severely abnormal EEG background (p < 0.0001) and any diffusion restriction (p < 0.0001) were associated with poor outcome. The area under the ROC curve (AUC) for identifying outcome based on EEG background alone was 0.86, which improved to 0.94 with combined EEG and MRI data (p = 0.02).

CONCLUSION

Diffusion abnormalities on MRI within 8 days after ROSC add to the prognostic value of EEG background in children surviving cardiac arrest.

Electric Acupuncture Treatment Promotes Angiogenesis in Rats with Middle Cerebral Artery Occlusion Through EphB4/EphrinB2 Mediated Src/PI3K Signal Pathway

BACKGROUND

Cerebral infarction is one of the most common causes of disability and death worldwide. It is reported that electric acupuncture was able to improve the prognosis of cerebral infarction by promoting angiogenesis. However, the corresponding signal pathways of angiogenesis promotes by electric acupuncture treatment needs to be further explored.

METHODS

MCAO rat was employed as the animal model, and clopidogrel hydrogen sulfate treatment was set as the positive control. Behaviors of rats, H&E staining, and TTC-staining was used to evaluate the recovery of infarcted brain tissue and nervous function. After that, immunocytochemical and immunofluorescence staining was used to quantify the angiogenesis and compensatory circulation, which including the analysis of microvessel density, field/ microvessel area ratio, and microvessel diameter. Western blot and RT-PCR for the detection of the related signal molecule, PI3K, Src, and EphB4/ephrinB2.

RESULTS

The neurologic impairment scores were decreased, and the brain tissue damage that showed with H&E and TTC-staining was relieved by the treatment of electric acupuncture in MCAO rat. The quantification of microvessel density and field/ microvessel area ratio was improved obviously, and the microvessel diameter was decreased which represent the angiogenesis of capillary in day 3 and 7 by the electric acupuncture treatment. We also found that the level of Src and PI3K was increased markedly followed by the up-regulation of EphB4 and EphrinB2 mRNA during the electric acupuncture treatment, and the pre-treatment of Src and/or PI3K inhibitor was able to disturb the angiogenesis of capillary.

CONCLUSIONS

We proved that electric acupuncture was able to accelerate the recovery of infarcted brain tissue and nervous function in MCAO rat by the promotion of angiogenesis, which was regulated by EphB4/EphrinB2 mediated Src/PI3K signal pathway. Our study provides a potential therapy and theoretical basis for the clinical treatment of cerebral infarction by the use of electric acupuncture.

The value of resting-state functional MRI in subacute ischemic stroke: comparison with dynamic susceptibility contrast-enhanced perfusion MRI

To evaluate the potential clinical value of the time-shift analysis (TSA) approach for resting-state fMRI (rs-fMRI) blood oxygenation level-dependent (BOLD) data in detecting hypoperfusion of subacute stroke patients through comparison with dynamic susceptibility contrast perfusion weighted imaging (DSC-PWI). Forty patients with subacute stroke (3–14 days after neurological symptom onset) underwent MRI examination. Cohort A: 31 patients had MRA, DSC-PWI and BOLD data. Cohort B: 9 patients had BOLD and MRA data. The time delay between the BOLD time course in each voxel and the mean signal of global and contralateral hemisphere was calculated using TSA. Time to peak (TTP) was employed to detect hypoperfusion. Among cohort A, 14 patients who had intracranial large-vessel occlusion/stenosis with sparse collaterals showed hypoperfusion by both of the two approaches, one with abundant collaterals showed neither TTP nor TSA time delay. The remaining 16 patients without obvious MRA lesions showed neither TTP nor TSA time delay. Among cohort B, eight patients showed time delay areas. The TSA approach was a promising alternative to DSC-PWI for detecting hypoperfusion in subacute stroke patients who had obvious MRA lesions with sparse collaterals, those with abundant collaterals would keep intact local perfusion.

Diffusion-weighted imaging with dual-echo echo-planar imaging for better sensitivity to acute stroke

BACKGROUND AND PURPOSE

Parallel imaging facilitates the acquisition of echo-planar images with a reduced TE, enabling the incorporation of an additional image at a later TE. Here we investigated the use of a parallel imaging-enhanced dual-echo EPI sequence to improve lesion conspicuity in diffusion-weighted imaging.

MATERIALS AND METHODS

Parallel imaging-enhanced dual-echo DWI data were acquired in 50 consecutive patients suspected of stroke at 1.5T. The dual-echo acquisition included 2 EPI for 1 diffusion-preparation period (echo 1 [TE = 48 ms] and echo 2 [TE = 105 ms]). Three neuroradiologists independently reviewed the 2 echoes by using the routine DWI of our institution as a reference. Images were graded on lesion conspicuity, diagnostic confidence, and image quality. The apparent diffusion coefficient map from echo 1 was used to validate the presence of acute infarction. Relaxivity maps calculated from the 2 echoes were evaluated for potential complementary information.

RESULTS

Echo 1 and 2 DWIs were rated as better than the reference DWI. While echo 1 had better image quality overall, echo 2 was unanimously favored over both echo 1 and the reference DWI for its high sensitivity in detecting acute infarcts.

CONCLUSIONS

Parallel imaging-enhanced dual-echo diffusion-weighted EPI is a useful method for evaluating lesions with reduced diffusivity. The long TE of echo 2 produced DWIs that exhibited superior lesion conspicuity compared with images acquired at a shorter TE. Echo 1 provided higher SNR ADC maps for specificity to acute infarction. The relaxivity maps may serve to complement information regarding blood products and mineralization.

Quantitative evaluation for secondary injury to perihematoma of hypertensive cerebral hemorrhage by functional MR and correlation analysis with ischemic factors

OBJECTIVES

To analyse quantitatively for the secondary injury to the perihematoma region of intracerebral hemorrhage (ICH) patients by functional MR imaging technique.

METHODS

35 ICH patients were recruited and performed T1, T2, perfusion weight imaging (PWI), diffusion weight imaging (DWI) and FLAIR sequence scanning. Hematoma volume and edema volume of perihematomal area as well as parameters of blood volume [regional cerebral blood volume (rCBV), mean transit time (MTT)] alteration were calculated.

RESULTS

Varied blood flow decline was detected in the patients on the perihematoma sides, compared with the corresponding area of the opposite sides. There was significant difference of rCBV and MTT (p=0.00) and mild negative correlation between rCBV and hematoma volume (p=0.00) among groups; edema volume of perihematoma region and hematoma volume showed a linear correlation (p=0.00). Moreover, positive correlation between edema intensity and rCBV was detected, (p=0.00); the most significant perihematoma edema was in the group of day 10 to day 14; the lowest rCBV occurred in the early stage. (days 2-5 from symptom onset).

CONCLUSION

We have concluded that rCBV and MTT of perihematoma region decreased remarkably compared with the contralateral side, and the decline would last over 3 weeks. Quantitative research suggested edema intensity is closely related with rCBV. We believe that the reduced regional blood flow of perihematoma contributes to the secondary ischemic injury of perihematoma tissue. However, the peak of edema would appear later than the onset of the peak of ischemia, it suggests that edema surrounding the hematoma is not only the result from the single ischemic factor, but also results from multiple disadvantage mechanisms.

Serial MRI changes in comatose cardiac arrest patients

BACKGROUND

Neuroimaging may prove useful in identifying cardiac arrest patients destined for a poor recovery, as certain patterns have been associated with a poor outcome. However, MRI changes evolve temporally and spatially, which may lead to misinterpretation and misclassification of patients.

METHODS

Eight comatose patients following cardiac arrest underwent diffusion-weighted imaging (DWI) at two time points, and one patient underwent DWI at three time points. Each of the prespecified areas of each study were read as either "normal" or "abnormal" by two stroke neurologists. Neurological examinations, including GCS scores, were recorded on days 0, 1, 3, and 7. Outcomes were determined by the modified Rankin Scale (mRS), with poor outcome defined as mRS score ≥4 at 6 months.

RESULTS

In the acute (<24 h) period, two patients exhibited changes on DWI and FLAIR in the cerebellum and basal ganglia. In the early subacute period (days 1-5), cortical abnormalities predominated, with a shift to more white matter changes in the late subacute period (days 6-12). We observed more widespread imaging abnormalities in patients with poor outcomes, and partial or full resolution of DWI abnormalities in the two patients with good outcomes.

CONCLUSIONS

MRI patterns after global hypoxic-ischemic injury follow a characteristic pattern with variable acute changes in the cortex, basal ganglia, and cerebellum, followed by predominantly cortical and white matter changes in the early and late subacute periods. Diffuse, persistent widespread changes on MRI may help to predict poor outcome.

Endothelin-1 induced MCAO: dose dependency of cerebral blood flow

The purpose of this study was to characterize the magnitude and duration of cerebral blood flow (CBF) reduction in the somatosensory cortical region in a rat model of middle cerebral artery occlusion (MCAO) induced by endothelin-1 (ET1) microinjection under isoflurane anesthesia. MCAO was induced by microinjection of ET1 proximal to the MCA in 41 isoflurane-anesthetized male Sprague-Dawley rats. Three doses of ET1 were studied, 60 pmol (Group 1), 150 pmol (Group 2), and 300 pmol (Group 3). CBF was monitored for 4h following injection using a laser Doppler probe stereotaxically inserted into the left somatosensory cortical region. Computed tomography perfusion imaging was used to verify the extent and duration of blood flow reduction in a subset of 12 animals. The magnitude and duration of blood flow reduction was variable (60-92% of baseline). The 300 pmol dose provided the greatest sustained decrease in blood flow. Evidence of tissue damage was obtained in cases where CBF decreased to <40% of baseline. At the doses studied, ET1-induced ischemia in the presence of isoflurane anesthesia can be used as a minimally invasive but variable model of MCAO. The model is well suited for acute imaging studies of ischemia.

Comparison of T2 and LASER T2dagger image contrast in a rat model of acute cerebral ischemia

Previous studies have shown that T2(dagger)-weighted magnetic resonance images acquired using localization by adiabatic selective refocusing (LASER) can provide early tissue contrast following ischemia, possibly due to alterations in microscopic susceptibility within the tissue. The purpose of this study was to make a direct in vivo comparison of T2-, T2(dagger)- and diffusion-weighted image contrast during acute ischemia. Acute middle cerebral artery (MCA) occlusion was attempted in 14 rats using a modified Tamura approach incorporating electrocoagulation of the left MCA. T2(dagger)-weighted LASER images (Echo Time [TE]=108 ms), T2-weighted Carr-Purcell-Meiboom-Gill (CPMG) images (TE=110 ms) and diffusion-weighted images (b value=105 s/mm(2)) were acquired at 4 T within 1.5 h of ischemia onset. Tissue contrast in the MCA territory was quantified for histologically verified ischemic tissue (n=6) and in sham controls (n=4). T2(dagger)-weighted LASER images demonstrated greater contrast compared to the T2-weighted CPMG images, and more focal contrast compared to the diffusion-weighted images, suggesting different contrast mechanisms were involved.

The Management of Blood Pressure After Stroke

BACKGROUND

Control of hypertension is a well-established goal of primary prevention of stroke, but management of blood pressure in patients with a previous stroke or in the setting of acute stroke is complicated by the effect blood pressure changes may have on cerebral perfusion.

REVIEW SUMMARY

For patients with previous transient ischemic attack or chronic stroke, blood pressure reduction appears to be a safe and important facet of the secondary prevention of recurrent stroke. Less information is available concerning blood pressure management in acute stroke. Current protocols require strict blood pressure control in patients who are treated with thrombolytic therapy, to reduce the risk of hemorrhagic complications. In patients presenting with acute intracerebral hemorrhage, blood pressure reduction does not appear to cause significant reduction of cerebral blood flow, but at this time there are no studies to determine if there is a clinical benefit of acute blood pressure reduction in these patients. Finally, blood pressure reduction is not routinely recommended in patients with acute ischemic stroke, as it may precipitate further cerebral ischemia. Preliminary studies suggest, in fact, that there may be a role in the future for blood pressure elevation in the treatment of patients with acute ischemic stroke.

CONCLUSIONS

Current data support the use of blood pressure reduction in the secondary prevention of stroke in patients with cerebrovascular disease. In the setting of acute stroke, however, data are limited and blood pressure management must be tailored to the specific clinical situation.

Technology insight: brain MRI and cardiac surgery--detection of postoperative brain ischemia

Annually, an estimated 1 million patients undergo heart surgery worldwide. Unfortunately, stroke continues to be a frequent complication of cardiac surgery, with the specific cerebrovascular risk depending upon the particular surgical procedure performed. Neuroimaging has an integral role in the initial evaluation and management of patients who present with acute stroke symptoms following cardiac surgery. The aim of this paper is to review the role brain MRI has in detecting postoperative brain ischemia in these patients. Multimodal MRI--using diffusion-weighted MRI (DWI), perfusion-weighted MRI, and gradient-recalled echo imaging--has an excellent capacity to identify and delineate the size and location of acute ischemic strokes as well as intracerebral hemorrhages. This differentiation is critical in making appropriate treatment decisions in the acute setting, such as determining patient eligibility for thrombolytic or hemodynamic therapies. At present, DWI offers prognostic value in patients with strokes following cardiac surgery. Additionally, DWI could be a valuable tool for evaluating stroke preventive measures as well as therapeutic interventions in patients undergoing CABG surgery.

Complementary aspects of diffusion imaging and fMRI; I: structure and function

Studying the intersection of brain structure and function is an important aspect of modern neuroscience. The development of magnetic resonance imaging (MRI) over the last 25 years has provided new and powerful tools for the study of brain structure and function. Two tools in particular, diffusion imaging and functional MRI (fMRI), are playing increasingly important roles in elucidating the complementary aspects of brain structure and function. In this work, we review basic technical features of diffusion imaging and fMRI for studying the integrity of white matter structural components and for determining the location and extent of cortical activation in gray matter, respectively. We then review a growing body of literature in which the complementary aspects of diffusion imaging and fMRI, applied as separate examinations but analyzed in tandem, have been exploited to enhance our knowledge of brain structure and function.

Modern Emergent Stroke Imaging: Pearls, Protocols, and Pitfalls

Stroke remains one of the most important clinical diagnoses for which patients are referred to the radiologist for emergent imaging. Timely and accurate imaging guides admission from the emergency department or transfer to a hospital with a dedicated stroke service, triage to the intensive care unit, anticoagulation, thrombolysis, and many other forms of treatment and management. It is important to approach each patient's imaging needs logically and tailor each work-up, and constantly to review the entire process for potential improvements. Time saved in getting an accurate diagnosis of stroke may indeed decrease morbidity and mortality. This article discusses the current management of stroke imaging and reviews the relevant literature.

T(2) + measurement during acute cerebral ischemia by Carr-Purcell MRI at 4T

Metabolic and structural changes occur in brain tissue within minutes of ischemia. The adiabatic multi-echo (Carr-Purcell) localization pulse sequence LASER has shown promise in detecting tissue contrast changes within the first hour of ischemia. The purpose of this initial study was to combine the LASER localization sequence with fast 3D echo-planar imaging (EPI) to quantify the regional apparent transverse relaxation (T(2) (dagger)) in a rabbit model of acute embolic ischemia at 4 Tesla. Carr-Purcell T(2) (dagger)-weighted images were acquired at 7 different echo-times and used to estimate T(2) (dagger) in both cortex and striatum. In ischemic tissue identified by 2,3,5-triphenyltetrazolium chloride (TTC) staining, the T(2) (dagger) increased by approximately 31% after 1 hour of ischemia and remained elevated until study completion at 4 h of ischemia. Lesion volume, defined as the number of pixels with T(2) (dagger) greater than 90 ms, increased by 40% between 1 and 4 h after induction of ischemia. Carr-Purcell LASER-EPI T(2) (dagger)-weighted images show promise in detecting early tissue changes in focal cerebral ischemia.

Diffusion-perfusion MR evaluation and spectroscopy before and after surgical therapy for intracerebral hemorrhage

INTRODUCTION

Advanced magnetic resonance imaging (MRI) techniques provide metabolic/hemodynamic information that is useful in the diagnosis of ischemic stroke. To date, however, their application in intracerebral hemorrhage (ICH) has been limited. We postulate that these MRI techniques may help define mechanisms of secondary damage and assess effects of therapeutic interventions in perihematoma tissue after ICH.

METHODS

A 44-year-old woman presented with severe headache resulting from a right temporal ICH. After developing neurological deterioration 5 days after the bleed, the patient underwent evacuation of the hematoma. Specimen pathology suggested the presence of a small vascular malformation. Diffusion- and perfusion-weighted imaging as well as proton magnetic resonance spectroscopic imaging (1H-MRSI) investigations to assess perihematoma brain tissue metabolic and circulatory profiles were performed before and after hematoma evacuation.

RESULTS

Pre-operative results showed mild oligemia posterior to the hematoma, increased average diffusion coefficient (DAV), and normal perihematoma N-acetyl-aspartate (NAA) concentration on 1H-MRSI. This profile was interpreted as inconsistent with ischemia (as defined by reduced DAV and NAA) but compatible with perihematoma inflammation (as defined by elevated DAV and lactate signal). Postsurgical MRI investigations showed near normalization of the perfusion deficit.

CONCLUSION

We postulate that mass effect produced by the hematoma, and perhaps inflammation, can induce perilesional reduced cerebral perfusion in a reversible manner.

Sodium T2*-weighted MR imaging of acute focal cerebral ischemia in rabbits

Changes in T2*-weighted tissue sodium (23Na) signal following acute ischemia may help to identify necrotic tissue and estimate the duration of ischemia. Sodium signal was monitored in a rabbit model of acute (0-4 h) focal cerebral ischemia, using gradient echo 23Na MR images (echo time = 3.2 ms) acquired continuously in 20-min intervals on a 4-Tesla MRI. 2,3,5-Triphenyl-tetrazolium chloride staining was used to identify regions of necrosis. In necrotic tissue, average 23Na image signal intensity decreased by 11% +/- 8% during the first 40 min of ischemia followed by a linear increase (0.19%/min) to 25% +/- 14% greater than baseline after 4 h of ischemia. The time course of 23Na signal change observed in necrotic tissue following focal ischemia in this rabbit model is consistent with an initial decrease in 23Na T2* relaxation time followed by an increase in tissue sodium concentration and provides further evidence that tissue 23Na signal may offer unique information regarding tissue viability that is complementary to other MR imaging techniques.

Brain injury after adult cardiac surgery

Despite remarkable progress in surgical, cardiopulmonary bypass and anaesthetic techniques during the last three decades, brain damage remains an important complication of adult cardiac surgery. Effective brain protection strategies are already implemented today, but ongoing research is needed to meet the challenges faced in operating on increasingly old and disabled patients. The incidence of brain injury may be reduced by modifying the surgical procedure according to carotid duplex scanning and epiaortic echocardiography, by using techniques to reduce microembolization during cardiopulmonary bypass and by optimizing patient temperature during and after surgery. Increased knowledge will aid in choosing the best procedure or combination of procedures in each case to ensure that risks do not outweigh benefits.

Perfusion-weighted MRI as a marker of response to treatment in acute and subacute stroke

We carried out baseline and short-term follow-up MRI, including perfusion-weighted imaging (PWI) and tests of neurologic and cognitive function on 15 consecutive patients with large-vessel ischemic stroke who showed a persistent large perfusion-diffusion mismatch at enrollment up to seven days after the onset of symptoms. Of these, ten underwent induced blood pressure elevation with phenylephrine and oral medications (in eight) or intravenous fluids (in two) with the goal of improving perfusion; five had no such treatment. Significant functional improvement was defined by a reduction of 3 or more points on the NIH stroke scale (NIHSS). Significant improvement in perfusion was defined by a reduction in the volume of hypoperfused brain by 30 cc on PWI using time-to-peak (TTP) maps, without enlargement of the infarct. There was a strong, statistically significant association between improved function and improved perfusion: six (75%) of eight patients who improved in function, but none of the seven who did not, showed a reduction in volume of hypoperfused brain. All six patients who met the perfusion goal, and only two (22%) of nine who did not showed significant functional improvement (Fisher's exact: P < 0.01). There were no differences between patients who improved functionally and those who did not with respect to age, initial volume of abnormality on DWI or PWI, initial NIHSS, or changes on DWI. These findings indicate that reduction in volume of hypoperfused brain on PWI is a marker of response to treatment to improve perfusion even in subacute stroke and that partial reperfusion of regions of salvageable but dysfunctional tissue is a mechanism of improved function associated with induced blood pressure elevation.

Which MR-derived perfusion parameters are the best predictors of infarct growth in hyperacute stroke? Comparative study between relative and quantitative measurements

PURPOSE

To compare predictors of infarct growth in hyperacute stroke from a retrospective review of various relative and quantitative parameters calculated at perfusion-weighted magnetic resonance (MR) imaging performed within 6 hours after ictus.

MATERIALS AND METHODS

Fluid-attenuated inversion recovery and diffusion- and perfusion-weighted images were obtained in 66 patients. The initial infarct was delineated on diffusion-weighted images; the hemodynamic disturbance, on apparent mean transit time (MTT) maps; and the final infarct, on follow-up fluid-attenuated inversion recovery images. Relative (without and with deconvolution) and quantitative values of the bolus arrival time, time to peak (TTP), apparent MTT or MTT, cerebral blood volume (CBV), peak height, and cerebral blood flow (CBF) index or CBF were calculated for initial infarct, infarct growth (final minus initial infarct contour), viable hemodynamic disturbance (apparent MTT minus final infarct contour), and contralateral mirror regions. Univariate and multivariate analyses (receiver operating characteristic curves and discriminant analysis) were performed to compare the diagnostic performance of these parameters for predicting infarct growth.

RESULTS

At univariate analysis, relative peak height and quantitative CBF were the best predictors of infarct growth; at multivariate analysis, a function of peak height and TTP for relative measurements and CBF alone for quantitative measurements. Quantitative and relative measurements (without or with deconvolution) worked equally well. A combined relative peak height or TTP threshold (<54% or >5.2 seconds, respectively) had a sensitivity of 71% and a specificity of 98%. A quantitative CBF threshold (<35 mL/min/100 g) had a sensitivity of 69% and a specificity of 85%.

CONCLUSION

A combination of relative peak height and TTP measurements allowed the best prediction of infarct growth, which obviates more complex quantitative calculation.

High b-value diffusion-weighted MRI of normal brain

PURPOSE

As MR scanner hardware has improved, allowing for increased gradient strengths, we are able to generate higher b values for diffusion-weighted (DW) imaging. Our purpose was to evaluate the appearance of the normal brain on DW MR images as the diffusion gradient strength ("b value") is increased from 1,000 to 3,000 s/mm2.

METHOD

Three sets of echo planar images were acquired at 1.5 T in 25 normal subjects (mean age 61 years) using progressively increasing strengths of a diffusion-sensitizing gradient (corresponding to b values of 0, 1,000, and 3,000 s/mm2). All other imaging parameters remained constant. Qualitative assessments of trace images were performed by two neuroradiologists, supplemented by quantitative measures of MR signal and noise in eight different anatomic regions.

RESULTS

As gradient strength increased from b = 1,000 to 3,000, both gray and white matter structures diminished in signal as expected based on their relative diffusion coefficients [calculated average apparent diffusion coefficient (ADC) values: gray matter = 8.5 x 10(-4) mm2/s, white matter = 7.5 x 10(-4) mm2/s]. The signal-to-noise ratios for the b = 1,000 images were approximately 2.2 times higher than for the b = 3,000 images (p < 0.0001). As the strength of the diffusion-sensitizing gradient increased, white matter became progressively hyperintense to gray matter. Relative to the thalamus, for example, the average MR signal intensity of white matter structures increased by an average of 27.5%, with the densely packed white matter tracts (e.g., middle cerebellar peduncle, tegmentum, and internal capsule) increasing the most.

CONCLUSION

Brain DW images obtained at b = 3,000 appear significantly different from those obtained at b = 1,000, reflecting expected loss of signal from all areas of brain in proportion to their ADC values. Consequently, when all other imaging parameters are held constant, b = 3,000 DW images appear significantly noisier than b = 1,000 images, and white matter tracts are significantly more hyperintense than gray matter structures.

Correlation of the apparent diffusion coefficient and the creatine level in early ischemic stroke: a comparison of different patterns by magnetic resonance

It has been reported that reduction of the apparent diffusion coefficient (ADC) after stroke can persist for several days, after which the ADC increases gradually to an abnormally high level. We evaluated ADC values of stroke lesions and compared the results to the cellular density of the lesion by means of the creatine (Cre) level. This two-parameter estimation is of particular relevance in ascertaining the underlying cellular status. Lesion-to-contralateral ADC ratios (ADCn) were obtained based on diffusion-weighted echo-planar and fast spin-echo imaging. Single-voxel localized spectroscopy was used for quantification of cerebral metabolites in infarcted regions. Their levels were also compared to that in homotopic contralateral regions. Fifteen patients with ischemic stroke were examined at times ranging from 18-88 hours following the onset of symptoms. In the stroke lesion, there was a significant correlation between the ADC and the Cre level showing that the higher the cell density the lower the ADC value. For ADCn vs. the lesion Cre concentration and the lesion-to-contralateral Cre ratio (Cre(n)), the strengths of relationship were R2 = 0.70 and 0.58, respectively. It is concluded that ADC is a good reflection of cell density. Greatly lowered ADC values occur within the context of a stable cellularity. ADC and the Cre level have complementary roles in the characterization of stroke lesion with regard to the sequential stage.

Combined perfusion- and diffusion-weighted MR imaging in acute ischemic stroke during the 1st week: a longitudinal study

PURPOSE

To compare findings with different magnetic resonance (MR) perfusion maps in acute ischemic stroke.

MATERIALS AND METHODS

Combined diffusion-weighted (DW) and perfusion-weighted (PW) MR imaging was performed in 49 patients with acute (<24 hours) stroke, on the 1st and 2nd days and 1 week after stroke. Volumes of hypoperfused tissue on maps of relative cerebral blood volume (rCBV), relative cerebral blood flow (rCBF), and mean transit time (MTT) were compared with the volume of infarcted tissue at DW imaging.

RESULTS

The mean infarct volume increased from 41 to 65 cm(3) between the 1st and 2nd days (P: <.001; n = 49). On the 1st day, all perfusion maps on average showed hypoperfusion lesions larger than the infarct at DW imaging (P: <.001; n = 49). MTT maps showed significantly (P: <.001) larger hypoperfusion lesions than did rCBF maps, which showed significantly (P: <.001) larger hypoperfusion lesions than did rCBV maps. The sizes of the initial perfusion-diffusion mismatches correlated significantly with the extent of infarct growth (0.479 < r < 0.657; P: </=.001). The hypoperfusion volume on the initial rCBV maps correlated best with the final infarct size at 1 week (r = 0.891; P: <.001).

CONCLUSION

Combined DW and PW imaging is a powerful tool in evaluating the hemodynamics of acute ischemic stroke.

Multi-component apparent diffusion coefficients in human brain: relationship to spin-lattice relaxation

In vivo measurements of the human brain tissue water signal decay with b-factor over an extended b-factor range up to 6,000 s/mm(2) reveal a nonmonoexponential decay behavior for both gray and white matter. Biexponential parametrization of the decay curves from cortical gray (CG) and white matter voxels from the internal capsule (IC) of healthy adult volunteers describes the decay process and serves to differentiate between these two tissues. Inversion recovery experiments performed in conjunction with the extended b-factor signal decay measurements are used to make separate measurements of the spin-lattice relaxation times of the fast and slow apparent diffusion coefficient (ADC) components. Differences between the spin-lattice relaxation times of the fast and slow ADC components were not statistically significant in either the CG or IC voxels. It is possible that the two ADC components observed from the extended b-factor measurements arise from two distinct water compartments with different intrinsic diffusion coefficients. If so, then the relaxation results are consistent with two possibilities. Either the spin-lattice relaxation times within the compartments are similar or the rate of water exchange between compartments is "fast" enough to ensure volume averaged T(1) relaxation yet "slow" enough to allow for the observation of biexponential ADC decay curves over an extended b-factor range. Magn Reson Med 44:292-300, 2000.

Cerebral hemodynamics in human acute ischemic stroke: a study with diffusion- and perfusion-weighted magnetic resonance imaging and SPECT

Nineteen patients with acute ischemic stroke (<24 hours) underwent diffusion-weighted and perfusion-weighted (PWI) magnetic resonance imaging at the acute stage and 1 week later. Eleven patients also underwent technetium-99m ethyl cysteinate dimer single-photon emission computed tomography (SPECT) at the acute stage. Relative (ischemic vs. contralateral control) cerebral blood flow (relCBF), relative cerebral blood volume, and relative mean transit time were measured in the ischemic core, in the area of infarct growth, and in the eventually viable ischemic tissue on PWI maps. The relCBF was also measured from SPECT. There was a curvilinear relationship between the relCBF measured from PWI and SPECT (r = 0.854; P < 0.001). The tissue proceeding to infarction during the follow-up had significantly lower initial CBF and cerebral blood volume values on PWI maps (P < 0.001) than the eventually viable ischemic tissue had. The best value for discriminating the area of infarct growth from the eventually viable ischemic tissue was 48% for PWI relCBF and 87% for PWI relative cerebral blood volume. Combined diffusion and perfusion-weighted imaging enables one to detect hemodynamically different subregions inside the initial perfusion abnormality. Tissue survival may be different in these subregions and may be predicted.

Diagnostic evaluation of stroke

Diagnostic testing in patients with ischemic stroke serves many purposes, including confirmation of the diagnosis and providing clues as to possible causes. Evaluation of the cerebral vasculature, the heart, the blood coagulation system, and selected other diagnostic tests may point to a mechanism of stroke which helps determine treatment and prognosis. With the recent advent of acute interventions for ischemic stroke, diagnostic testing is now an important component in the emergency management of stroke. In this article, the authors will review the standard approach to diagnostic testing for patients with ischemic stroke or transient ischemic attack, and new developments in neuro-imaging and their use in acute stroke assessment.

Diffusion-weighted MRI and proton MR spectroscopic imaging in the study of secondary neuronal injury after intracerebral hemorrhage

BACKGROUND AND PURPOSE

Cerebral ischemia has been proposed as contributing mechanism to secondary neuronal injury after intracerebral hemorrhage (ICH). Possible tools for investigating this hypothesis are diffusion-weighted (DWI) and proton magnetic resonance spectroscopic imaging ((1)H-MRSI). However, magnetic field inhomogeneity induced by paramagnetic blood products may prohibit the application of such techniques on perihematoma tissue. We report on the feasibility of DWI and (1)H-MRSI in the study of human ICH and present preliminary data on their contribution to understanding perihematoma tissue functional and metabolic profiles.

METHODS

Patients with acute supratentorial ICH were prospectively evaluated using DWI and (1)H-MRSI. Obscuration of perihematoma tissue with both sequences was assessed. Obtainable apparent diffusion coefficient (Dav) and lactate spectra in perihematoma brain tissue were recorded and analyzed.

RESULTS

Nine patients with mean age of 63.4 (36 to 87) years were enrolled. Mean time from symptom onset to initial MRI was 3.4 (1 to 9) days; mean hematoma volume was 35.4 (5 to 80) cm(3). Perihematoma diffusion values were attainable in 9 of 9 patients, and (1)H-MRSI measures were obtainable in 5 of 9 cases. Dav in perihematoma regions was 172.5 (120.0 to 302.5)x10(-5) mm(2)/s and 87.6 (76.5 to 102.1)x10(-5) mm(2)/s in contralateral corresponding regions of interest (P=0.002). One patient showed an additional area of reduced Dav with normal T(2) intensity, which suggests ischemia. (1)H-MRSI revealed lactate surrounding the hematoma in 2 patients.

CONCLUSIONS

DWI and (1)H-MRSI can be used in the study of ICH patients. Our preliminary data are inconsistent with ischemia as the primary mechanism for perihematoma tissue injury. Further investigation with advanced MRI techniques will give a clearer understanding of the role that ischemia plays in tissue injury after ICH.

Centennial dissertation. Honoring Arthur W. Goodspeed, MD and James B. Bullitt, MD. CT and MR imaging and nontraumatic neurologic emergencies

This review has highlighted some of the disease processes that produce diagnostic difficulty in the emergency neuroradiology setting. Because radiologists are often the first individuals to consider these entities, they must be familiar with the clinical features that suggest the diagnosis. Furthermore, acquaintance with the various imaging findings of these diseases will allow early diagnosis and will help limit the severe complications that follow these neurologic emergency conditions if left untreated.

Cerebral hemorrhagic complications of thrombolytic therapy

Thrombolytic therapy is well established in the management of a select group of atherothrombotic and thromboembolic diseases at the expense of definite but increased risk of intracranial hemorrhage. The incidence of intracranial hemorrhage is higher (6.4% to 20%) in the thrombolytic treatment of acute ischemic stroke, whereas the cerebral hemorrhagic complications of thrombolytic treatment in acute myocardial infarction, acute pulmonary embolism, deep venous thrombosis, and arterial and graft occlusion is less than 2%. Although systemic fibrinolysis after thrombolysis is responsible for hemorrhagic complications, many factors are implicated in predisposition to cerebral hemorrhagic complications such as old age, untreated or chronic hypertension, history of cardiac disease, hyperglycemia, patients with small body mass, previous stroke, longer therapeutic treatment window, increasing neurological deficit or severity of neurological deficit, higher thrombolytic dose and computed tomography findings of mass effect, edema, or extended infarct sign involving more than one third of the territory of the middle cerebral artery. Although the knowledge of different factors associated with intracranial hemorrhage is important, it is the judicious use and strict adherence of appropriate clinical protocols in different clinical settings of thrombolytic treatment and avoidance of the contra-indications that will minimize the rate of hemorrhagic complication to achieve good clinical outcome and desired benefit.

Acute cerebral infarction: quantification of spin-density and T2 shine-through phenomena on diffusion-weighted MR images

PURPOSE

To quantify the relative contributions of spin density and T2 effects ("shine through") on diffusion-weighted (DW) magnetic resonance (MR) images of acute and subacute cerebral infarction.

MATERIALS AND METHODS

In 30 patients, 1.5-T imaging was performed within the first 7 days after onset of cerebral infarction. Estimates of T2, spin density, and apparent diffusion coefficient (ADC) in the region of stroke and contralateral normal brain were computed by means of standard regression techniques after quadruple-echo conventional MR imaging and single-shot echo-planar DW imaging with a maximum b value of 1,000 sec/mm2. Expected signal intensity (S) enhancement ratios resulting from independent changes in T2, spin density, and ADC were then calculated for the DW sequence.

RESULTS

The overall SI of cerebral infarction on DW images was significantly higher than that of normal brain throughout the 1st week after stroke (mean relative SI enhancement ratio, 2.29; P < .001). During the first 2 days after stroke, decreased ADC within the stroke region made the dominant contribution to increased SI on DW images. By day 3, increased T2 values in the stroke region became equally important, and, from days 3-7, the contribution to SI from T2 effects became dominant. A slight increase of spin density in the stroke region made a relatively small and constant contribution to DW SI over the 1st week.

CONCLUSION

The increased SI of subacute cerebral infarction on DW images reflects not only a shortening of ADC but a prolongation of T2 and spin-density values.

Combined diffusion and perfusion MRI with correlation to single-photon emission CT in acute ischemic stroke. Ischemic penumbra predicts infarct growth

BACKGROUND AND PURPOSE

More effective imaging methods are needed to overcome the limitations of CT in the investigation of treatments for acute ischemic stroke. Diffusion-weighted MRI (DWI) is sensitive in detecting infarcted brain tissue, whereas perfusion-weighted MRI (PWI) can detect brain perfusion in the same imaging session. Combining these methods may help in identifying the ischemic penumbra, which is an important concept in the hemodynamics of acute stroke. The purpose of this study was to determine whether combined DWI and PWI in acute (<24 hours) ischemic stroke can predict infarct growth and final size.

METHODS

Forty-six patients with acute ischemic stroke underwent DWI and PWI on days 1, 2, and 8. No patient received thrombolysis. Twenty-three patients underwent single-photon emission CT in the acute phase. Lesion volumes were measured from DWI, SPECT, and maps of relative cerebral blood flow calculated from PWI.

RESULTS

The mean volume of infarcted tissue detected by DWI increased from 46.1 to 75.6 cm(3) between days 1 and 2 (P<0.001; n=46) and to 78.5 cm(3) after 1 week (P<0.001; n=42). The perfusion-diffusion mismatch correlated with infarct growth (r=0. 699, P<0.001). The volume of hypoperfusion on the initial PWI correlated with final infarct size (r=0.827, P<0.001). The hypoperfusion volumes detected by PWI and SPECT correlated significantly (r=0.824, P<0.001).

CONCLUSIONS

Combined DWI and PWI can predict infarct enlargement in acute stroke. PWI can detect hypoperfused brain tissue in good agreement with SPECT in acute stroke.

Imaging of acute cerebral ischemia

Until recently, there was no efficacious treatment for acute cerebral ischemia. As a result, the role of neuroimaging and the radiologist was peripheral in the diagnosis and management of this disease. The demonstration of efficacy using thrombolysis has redefined this role, with the success of intervention becoming increasingly dependent on timely imaging and accurate interpretation. The potential benefits of intervention have only begun to be realized. In this State-of-the-Art review of imaging of acute stroke, the role of imaging in the current and future management of stroke is presented. The role of computed tomography is emphasized in that it is currently the most utilized technique, and its value has been demonstrated in prospective clinical trials. Magnetic resonance techniques are equally emphasized in that they have the potential to provide a single modality evaluation of tissue viability and vessel patency in an increasingly rapid evaluation.

Recent advances in imaging of cerebrovascular disease

The recent advances made in CT and MR imaging have led to increased accuracy in making a number of diagnoses in the emergency room setting. Increasingly, radiologists are asked to perform these studies and accurately interpret the findings, which often have a dramatic impact on triaging and treatment of the patient. Future trials need to address further the relative merits of each of the techniques outlined previously in specific settings. In addition, given the increasing number of means of obtaining diagnostic information, cost effectiveness studies are needed to better formulate an appropriate algorithm for each diagnosis.

Neurovascular applications of CT angiography

CT angiography, which has important advantages over both MR and ultrasound, is rapidly becoming an important modality for noninvasive evaluation of the neurovasculature. This article discusses CT angiography techniques for imaging the neurovasculature, including spiral acquisition protocols and image processing techniques, with a focus on the use of volume rendering for three-dimensional visualization. The clinical results for CT angiography of the cervical carotid arteries, intracranial aneurysms, arteriovenous malformations, and emerging work in the evaluation of acute stroke are reviewed. Important areas of ongoing research also are described.