Multimodal MR examination in acute ischemic stroke

Quantification of MRI and MRS characteristics changes in a rat model at different stage of cerebral ischemia

BACKGROUND

A better understanding the mechanisms of cerebral ischemia is important both for diagnosis and treatment.

OBJECTIVE

The study aimed to quantify several characteristics of magnetic resonance imaging (MRI) and magnetic resonance spectroscopy (MRS) to indicate the brain tissue changes at different stage of cerebral ischemia in rats.

METHODS

In the present study, a rat model of cerebral ischemia was established by middle cerebral artery occlusion (MCAO) in the left hemisphere. MRI and MRS were performed on 15 Sprague Dawley rats 4 H, 24 H, and 1 W after MCAO. Apparent diffusion coefficient (ADC), relative ADC including FNR, PNR, PNF, and metabolite ratio NCC were proposed to reflect the changes of water diffusion and metabolism in brain tissue.

RESULTS

ADCs of focal zone and penumbra zone from 1 W group were significantly larger than those from 4H group, respectively (both p < 0.05). PNR and PNF of 24H and 1 W groups were significantly less than 4H group (all p < 0.01). NCCs of focal zone and penumbra zone were significantly less than the normal zone within 4H, 24H, and 1 W groups, respectively (both p < 0.01). While NCCs of penumbra zone from 24H and 1 W groups were significantly larger than 4H group (both p < 0.01).

CONCLUSION

We conclude that combination of MRI and MRS characteristics can provide significant indicators for ischemic damage at different stage of cerebral ischemia in a rat model.

Magnetic resonance diffusion-perfusion mismatch in acute ischemic stroke: An update

The concept of magnetic resonance perfusion-diffusion mismatch (PDM) provides a practical and approximate measure of the tissue at risk and has been increasingly applied for the evaluation of hyperacute and acute stroke in animals and patients. Recent studies demonstrated that PDM does not optimally define the ischemic penumbra; because early abnormality on diffusion-weighted imaging overestimates the infarct core by including part of the penumbra, and the abnormality on perfusion weighted imaging overestimates the penumbra by including regions of benign oligemia. To overcome these limitations, many efforts have been made to optimize conventional PDM. Various alternatives beyond the PDM concept are under investigation in order to better define the penumbra. The PDM theory has been applied in ischemic stroke for at least three purposes: to be used as a practical selection tool for stroke treatment; to test the hypothesis that patients with PDM pattern will benefit from treatment, while those without mismatch pattern will not; to be a surrogate measure for stroke outcome. The main patterns of PDM and its relation with clinical outcomes were also briefly reviewed. The conclusion was that patients with PDM documented more reperfusion, reduced infarct growth and better clinical outcomes compared to patients without PDM, but it was not yet clear that thrombolytic therapy is beneficial when patients were selected on PDM. Studies based on a larger cohort are currently under investigation to further validate the PDM hypothesis.

Acute stroke magnetic resonance imaging: current status and future perspective

Cerebral stroke is one of the most frequent causes of permanent disability or death in the western world and a major burden in healthcare system. The major portion is caused by acute ischemia due to cerebral artery occlusion by a clot. The minority of strokes is related to intracerebral hemorrhage or other sources. To limit the permanent disability in ischemic stroke patients resulting from irreversible infarction of ischemic brain tissue, major efforts were made in the last decade. To extend the time window for thrombolysis, which is the only approved therapy, several imaging parameters in computed tomography and magnetic resonance imaging (MRI) have been investigated. However, the current guidelines neglect the fact that the portion of potentially salvageable ischemic tissue (penumbra) is not dependent on the time window but the individual collateral blood flow. Within the last years, the differentiation of infarct core and penumbra with MRI using diffusion-weighted images (DWI) and perfusion imaging (PI) with parameter maps was established. Current trials transform these technical advances to a redefined patient selection based on physiological parameters determined by MRI. This review article presents the current status of MRI for acute stroke imaging. A special focus is the ischemic stroke. In dependence on the pathophysiology of cerebral ischemia, the basic principle and diagnostic value of different MRI sequences are illustrated. MRI techniques for imaging of the main differential diagnoses of ischemic stroke are mentioned. Moreover, perspectives of MRI for imaging-based acute stroke treatment as well as monitoring of restorative stroke therapy from recent trials are discussed.

Correlating tissue outcome with quantitative multiparametric MRI of acute cerebral ischemia in rats

Predicting tissue outcome remains a challenge for stroke magnetic resonance imaging (MRI). In this study, we have acquired multiparametric MRI data sets (including absolute T(1), T(2), diffusion, T(1rho) using continuous wave and adiabatic pulse approaches, cerebral blood flow (CBF), and amide proton transfer ratio (APTR) images) during and after 65 mins of middle cerebral artery occlusion (MCAo) in rats. The MRI scans were repeated 24 h after MCAo, when the animals were killed for quantitative histology. Magnetic resonance imaging parameters acquired at three acute time points were correlated with regionally matching cell count at 24 h. The results emphasize differences in the temporal profile of individual MRI contrasts during MCAo and especially during early reperfusion, and suggest that complementary information from CBF and tissue damage can be obtained with appropriate MRI contrasts. The data show that by using three to four MRI parameters, sensitive to both hemodynamic changes and different aspects of parenchymal changes, the fate of the tissue can be predicted with increased correlation compared with single-parameter techniques. Combined multiparametric MRI data and multiparametric analysis may provide an excellent tool for preclinical testing of new treatments and also has the potential to facilitate decision-making in the management of acute stroke patients.

Multimodal MRI segmentation of ischemic stroke lesions

The problem addressed in this paper is the automatic segmentation of stroke lesions on MR multi-sequences. Lesions enhance differently depending on the MR modality and there is an obvious gain in trying to account for various sources of information in a single procedure. To this aim, we propose a multimodal Markov random field model which includes all MR modalities simultaneously. The results of the multimodal method proposed are compared with those obtained with a mono-dimensional segmentation applied on each MRI sequence separately. We constructed an Atlas of blood supply territories to help clinicians in the determination of stroke subtypes and potential functional deficit.

Diffusion-weighted MR imaging (DWI) in the evaluation of epidural spinal lesions

INTRODUCTION

Epidural spinal cord compression is one of the most critical emergency conditions requiring medical attention and requires prompt and adequate treatment. The aim of our study was to assess the role of diffusion-weighted magnetic resonance (MR) imaging (DWI) in the diagnosis and differentiation of epidural spinal lesions.

METHODS

Three patients with epidural lymphoma, two with sarcoma and three with epidural metastatic disease were imaged on a 1.5T MRI unit. DWI was performed using navigated, interleaved, multi-shot echo planar imaging (IEPI). Three region of interest (ROI)-measurements were obtained on corresponding apparent diffusion coefficient (ADC) maps, and the mean ADC value was used for further analysis. The cellularity of tumors was determined as the N/C ratio (nucleus/cytoplasma ratio) from histological samples. The ADC values and N/C ratios of lesions were compared using a Kruskal-Wallis test.

RESULTS

The mean ADC of the lymphomas was 0.66 x 10(-3) mm2/s, that of the sarcomas was 0.85 x 10(-3) mm2/s and the ADC of the metastatic lesions was 1.05 x 10(-3) mm2/s; however, the differences were not statistically significant. Mean N/C ratios in the lymphoma, sarcomas and metastases were 4:1, 2:1, and 2.6:1, respectively, with a statistically significant difference between the groups (p < 0.025).

CONCLUSION

Although not statistically significant due to the small patient sample, our results clearly show a tendency toward decreased diffusivity in neoplastic lesions with higher cellularity. The data from our study suggest that DWI is a feasible and potentially useful technique for the evaluation of epidural lesions that cause spinal cord compression on a per-patient basis.

Established treatments for acute ischaemic stroke

This article reviews the recommended management of patients presenting to accident and emergency departments with acute ischaemic stroke, and focuses on thrombolysis. The review includes initial management, recommended clinical, laboratory, and radiographic examinations. Appropriate general medical care, consisting of monitoring of oxygenation, fever, blood pressure, and blood glucose concentrations are examined. Criteria for thrombolysis with intravenous recombinant tissue plasminogen activator (rt-PA) are discussed. Complications of rt-PA therapy, such as haemorrhagic transformation and angio-oedema, are reviewed. An approach to management of rt-PA complications is outlined. Only a small percentage of acute ischaemic stroke patients meet criteria for rt-PA; therefore, alternative acute treatment strategies are also discussed. Acute medical and neurological complications in stroke patients are analysed, along with recommendations for treatment.