Skip to main content
Key Specialties
Cardiology Diabetology Endocrinology Gastroenterology Geriatrics and Gerontology Gynecology and Obstetrics Hematology Infectious Disease Internal Medicine Nephrology Neurology Oncology Pediatrics Respiratory Medicine Rheumatology Surgery
Congress Coverage
2024 ACC Congress 2023 ESMO Congress 2023 EASD Congress 2023 ERS Congress 2023 ESC Congress 2023 EHA Congress 2023 ASCO Annual Meeting
Clinical Collections
Advances in Alzheimer’s

At a glance: The ONWARDS insulin icodec trials

A round-up of the ONWARDS phase 3 clinical trials evaluating the novel weekly insulin icodec in people with diabetes.
ADVANCED SEARCH
Log in
Top
Neuroradiology
Published in: Neuroradiology 3/2010

01-03-2010 | Invited Review

Computed tomography in acute ischemic stroke

Authors: Karl-Olof Lövblad, Alison E. Baird

Published in: Neuroradiology | Issue 3/2010

Login to get access

Abstract

Stroke remains the third most important cause of mortality in industrialized countries; this has prompted research for improvements in both diagnostic and therapeutic strategies for patients with signs of acute cerebral ischemia. Over the last decade, there has been a parallel in progress in techniques in both diagnostic and therapeutic options. While previously only used for excluding hemorrhage, imaging now has the possibility to detect ischemia, vascular occlusion, as well as detect tissue at risk in one setting. It should also allow to monitor treatment and predict/exclude therapeutic complications. Parallel to advances in magnetic resonance imaging of stroke, computed tomography has improved immensely over the last decade due to the development of CT scanners that are faster and that allow to acquire studies such as CT perfusion or CT angiography in a reliable way. CT can detect many signs that might help us detect impending signs of massive infarction, but we still lack the experience to use these alone to prevent a patient from benefitting from possible therapy.
Literature
1.
The NINDS rt-PA stroke study group (1995) Tissue plasminogen activator for acute ischemic stroke. N Engl J Med 333:1581–1587CrossRef
2.
Hacke W, Kaste M, Fieschi C, Toni D, Lesaffre E, von Kummer R, Boysen G, Bluhmki E, Höxter G, Mahagne MH et al (1995) Intravenous thrombolysis with recombinant tissue plasminogen activator for acute hemispheric stroke. The European Cooperative Acute Stroke Study (ECASS). JAMA 274(13):1017–1025CrossRefPubMed
3.
Hacke W, Kaste M, Fieschi C, von Kummer R, Davalos A, Meier D, Larrue V, Bluhmki E, Davis S, Donnan G, Schneider D, Diez-Tejedor E, Trouillas P (1998) Randomised double-blind placebo-controlled trial of thrombolytic therapy with intravenous alteplase in acute ischaemic stroke (ECASS II). Second European–Australasian Acute Stroke Study Investigators. Lancet 352(9136):1245–1251CrossRefPubMed
4.
Hacke W, Kaste M, Bluhmki E, Brozman M, Dávalos A, Guidetti D, Larrue V, Lees KR, Medeghri Z, Machnig T, Schneider D, von Kummer R, Wahlgren N, Toni D, ECASS Investigators (2008) Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic stroke. N Engl J Med 359(13):1317–1329CrossRefPubMed
5.
Del Zoppo GJ, Higashida RT, Furlan AJ, Pessin MS, Rowley HA, Gent M, PROACT Investigators (1998) PROACT: a phase II randomized trial of recombinant pro-urokinase by direct arterial delivery in acute middle cerebral artery stroke. Prolyse in acute cerebral thromboembolism. Stroke 29:4–11PubMed
6.
Lewandowski C, Frankel M, Tomsick T, Frey J, Clark W, Starkman S, Grotta J, Spilker J, Khoury J, Brott T, The EMS Bridging Trial Investigators (1999) Combined intravenous and intra-arterial r-tPA versus intra-arterial IV t thrombolysis therapy of acute ischemic stroke. Stroke 30:2598–2605PubMed
7.
Adams HP Jr, del Zoppo G, Alberts MJ, Bhatt DL, Brass L, Furlan A, Grubb RL, Higashida RT, Jauch EC, Kidwell C, Lyden PD, Morgenstern LB, Qureshi AI, Rosenwasser RH, Scott PA, Wijdicks EF, American Heart Association; American Stroke Association Stroke Council; Clinical Cardiology Council; Cardiovascular Radiology and Intervention Council; Atherosclerotic Peripheral Vascular Disease and Quality of Care Outcomes in Research Interdisciplinary Working Groups (2007) Guidelines for the early management of adults with ischemic stroke: a guideline from the American Heart Association/American Stroke Association Stroke Council, Clinical Cardiology Council, Cardiovascular Radiology and Intervention Council, and the Atherosclerotic Peripheral Vascular Disease and Quality of Care Outcomes in Research Interdisciplinary Working Groups: the American Academy of Neurology affirms the value of this guideline as an educational tool for neurologists. Stroke 38(5):1655–1711CrossRefPubMed
8.
Adams HP Jr, Adams RJ, Brott T, del Zoppo GJ, Furlan A, Goldstein LB, Grubb RL, Higashida R, Kidwell C, Kwiatkowski TG, Marler JR, Hademenos GJ, Stroke Council of the American Stroke Association (2003) Guidelines for the early management of patients with ischemic stroke: a scientific statement from the Stroke Council of the American Stroke Association. Stroke 34(4):1056–1083CrossRefPubMed
9.
Lövblad KO, Baird AE (2006) Actual diagnostic approach to the acute stroke patient. Eur Radiol 16(6):1253–1269CrossRefPubMed
10.
Lövblad KO, Laubach HJ, Baird AE, Curtin F, Schlaug G, Edelman RR, Warach S (1998) Clinical experience with diffusion-weighted MR in patients with acute stroke. AJNR Am J Neuroradiol 19(6):1061–1066PubMed
11.
Lövblad KO, Baird AE, Schlaug G, Benfield A, Siewert B, Voetsch B, Connor A, Burzynski C, Edelman RR, Warach S (1997) Ischemic lesion volumes in acute stroke by diffusion-weighted magnetic resonance imaging correlate with clinical outcome. Ann Neurol 42(2):164–170CrossRefPubMed
12.
Baird AE, Benfield A, Schlaug G, Siewert B, Lövblad KO, Edelman RR, Warach S (1997) Enlargement of human cerebral ischemic lesion volumes measured by diffusion-weighted magnetic resonance imaging. Ann Neurol 41(5):581–589CrossRefPubMed
13.
Schellinger PD, Jansen O, Fiebach JB, Hacke W, Sartor K (1999) A standardized MRI stroke protocol: comparison with CT in hyperacute intracerebral hemorrhage. Stroke 30(4):765–768PubMed
14.
Kidwell CS, Chalela JA, Saver JL, Starkman S, Hill MD, Demchuk AM, Butman JA, Patronas N, Alger JR, Latour LL, Luby ML, Baird AE, Leary MC, Tremwel M, Ovbiagele B, Fredieu A, Suzuki S, Villablanca JP, Davis S, Dunn B, Todd JW, Ezzeddine MA, Haymore J, Lynch JK, Davis L, Warach S (2004) Comparison of MRI and CT for detection of acute intracerebral hemorrhage. JAMA 292(15):1823–1830CrossRefPubMed
15.
Chalela JA, Kidwell CS, Nentwich LM, Luby M, Butman JA, Demchuk AM, Hill MD, Patronas N, Latour L, Warach S (2007) Magnetic resonance imaging and computed tomography in emergency assessment of patients with suspected acute stroke: a prospective comparison. Lancet 369(9558):293–298CrossRefPubMed
16.
Tomura N, Uemura K, Inugami A, Fujita H, Higano S, Shishido F (1988) Early CT finding in cerebral infarction: obscuration of the lentiform nucleus. Radiology 168(2):463–467PubMed
17.
von Kummer R, Meyding-Lamadé U, Forsting M, Rosin L, Rieke K, Hacke W, Sartor K (1994) Sensitivity and prognostic value of early CT in occlusion of the middle cerebral artery trunk. AJNR Am J Neuroradiol 15(1):9–1
18.
von Kummer R, Holle R, Gizyska U, Hofmann E, Jansen O, Petersen D, Schumacher M, Sartor K (1996) Interobserver agreement in assessing early CT signs of middle cerebral artery infarction. AJNR Am J Neuroradiol 17(9):1743–1748
19.
Schuknecht B, Ratzka M, Hofmann E (1990) The “dense artery sign”—major cerebral artery thromboembolism demonstrated by computed tomography. Neuroradiology 32(2):98–103 (Erratum in: Neuroradiology 1991;33(1):94)CrossRefPubMed
20.
Ricci S, Caputo N, Aisa G, Celani MG, Chiurulla C, Mercuri M, Guercini G, Scaroni R, Senin U, Signorini E (1991) Prognostic value of the dense middle cerebral artery sign in patients with acute ischemic stroke. Ital J Neurol Sci 12(1):45–47CrossRefPubMed
21.
Launes J, Ketonen L (1987) Dense middle cerebral artery sign: an indicator of poor outcome in middle cerebral artery area infarction. J Neurol Neurosurg Psychiatry 50(11):1550–1552CrossRefPubMed
22.
Grotta JC, Welch KM, Fagan SC, Lu M, Frankel MR, Brott T, Levine SR, Lyden PD (2001) Clinical deterioration following improvement in the NINDS rt-PA Stroke Trial. Stroke 32(3):661–668PubMed
23.
Manno EM, Nichols DA, Fulgham JR, Wijdicks EF (2003) Computed tomographic determinants of neurologic deterioration in patients with large middle cerebral artery infarctions. Mayo Clin Proc 78(2):156–160CrossRefPubMed
24.
Leary MC, Kidwell CS, Villablanca JP, Starkman S, Jahan R, Duckwiler GR, Gobin YP, Sykes S, Gough KJ, Ferguson K, Llanes JN, Masamed R, Tremwel M, Ovbiagele B, Vespa PM, Vinuela F, Saver JL (2003) Validation of computed tomographic middle cerebral artery “dot” sign: an angiographic correlation study. Stroke 34(11):2636–2640CrossRefPubMed
25.
Barber PA, Demchuk AM, Hudon ME, Pexman JH, Hill MD, Buchan AM (2001) Hyperdense sylvian fissure MCA “dot” sign: a CT marker of acute ischemia. Stroke 32(1):84–88PubMed
26.
Na DG, Kim EY, Ryoo JW, Lee KH, Roh HG, Kim SS, Song IC, Chang KH (2005) CT sign of brain swelling without concomitant parenchymal hypoattenuation: comparison with diffusion- and perfusion-weighted MR imaging. Radiology 235(3):992–948CrossRefPubMed
27.
Dzialowski I, Weber J, Doerfler A, Forsting M, von Kummer R (2004) Brain tissue water uptake after middle cerebral artery occlusion assessed with CT. J Neuroimaging 14(1):42–48PubMed
28.
von Kummer R, Allen KL, Holle R, Bozzao L, Bastianello S, Manelfe C, Bluhmki E, Ringleb P, Meier DH, Hacke W (1997) Acute stroke: usefulness of early CT findings before thrombolytic therapy. Radiology 205(2):327–333
29.
Lev MH, Farkas J, Gemmete JJ, Hossain ST, Hunter GJ, Koroshetz WJ, Gonzalez RG (1999) Acute stroke: improved nonenhanced CT detection-benefits of soft-copy interpretation by using variable window width and center level settings. Radiology 213(1):150–155PubMed
30.
Eastwood JD, Lev MH, Wintermark M, Fitzek C, Barboriak DP, Delong DM, Lee TY, Azhari T, Herzau M, Chilukuri VR, Provenzale JM (2003) Correlation of early dynamic CT perfusion imaging with whole-brain MR diffusion and perfusion imaging in acute hemispheric stroke. AJNR Am J Neuroradiol 24(9):1869–1875PubMed
31.
Wintermark M, Thiran JP, Maeder P, Schnyder P, Meuli R (2001) Simultaneous measurement of regional cerebral blood flow by perfusion CT and stable xenon CT: a validation study. AJNR Am J Neuroradiol 22(5):905–914PubMed
32.
Wintermark M, Reichhart M, Thiran JP, Maeder P, Chalaron M, Schnyder P, Bogousslavsky J, Meuli R (2002) Prognostic accuracy of cerebral blood flow measurement by perfusion computed tomography, at the time of emergency room admission, in acute stroke patients. Ann Neurol 51(4):417–432CrossRefPubMed
33.
Wintermark M, Fischbein NJ, Smith WS, Ko NU, Quist M, Dillon WP (2005) Accuracy of dynamic perfusion CT with deconvolution in detecting acute hemispheric stroke. AJNR Am J Neuroradiol 26(1):104–112PubMed
34.
Wintermark M, Meuli R, Browaeys P, Reichhart M, Bogousslavsky J, Schnyder P, Michel P (2007) Comparison of CT perfusion and angiography and MRI in selecting stroke patients for acute treatment. Neurology 68(9):694–697CrossRefPubMed
35.
Wintermark M, Flanders AE, Velthuis B, Meuli R, van Leeuwen M, Goldsher D, Pineda C, Serena J, van der Schaaf I, Waaijer A, Anderson J, Nesbit G, Gabriely I, Medina V, Quiles A, Pohlman S, Quist M, Schnyder P, Bogousslavsky J, Dillon WP, Pedraza S (2006) Perfusion-CT assessment of infarct core and penumbra: receiver operating characteristic curve analysis in 130 patients suspected of acute hemispheric stroke. Stroke 37(4):979–985CrossRefPubMed
36.
Schaefer PW, Roccatagliata L, Ledezma C, Hoh B, Schwamm LH, Koroshetz W, Gonzalez RG, Lev MH (2006) First-pass quantitative CT perfusion identifies thresholds for salvageable penumbra in acute stroke patients treated with intra-arterial therapy. AJNR Am J Neuroradiol 27(1):20–25PubMed
37.
Schaefer PW, Barak ER, Kamalian S, Gharai LR, Schwamm L, Gonzalez RG, Lev MH (2008) Quantitative assessment of core/penumbra mismatch in acute stroke: CT and MR perfusion imaging are strongly correlated when sufficient brain volume is imaged. Stroke 39(11):2986–2992CrossRefPubMed
38.
Knoepfli AS, Sekoranja L, Bonvin C, Delavelle J, Kulcsar Z, Rüfenacht D, Yilmaz H, Sztajzel R, Altrichter S, Lövblad KO (2009) Evaluation of perfusion CT and TIBI grade in acute stroke for predicting thrombolysis benefit and clinical outcome. J Neuroradiol 36:131–137CrossRefPubMed
39.
Hacke W, Furlan AJ, Al-Rawi Y, Davalos A, Fiebach JB, Gruber F, Kaste M, Lipka LJ, Pedraza S, Ringleb PA, Rowley HA, Schneider D, Schwamm LH, Leal JS, Söhngen M, Teal PA, Wilhelm-Ogunbiyi K, Wintermark M, Warach S (2009) Intravenous desmoteplase in patients with acute ischaemic stroke selected by MRI perfusion–diffusion weighted imaging or perfusion CT (DIAS-2): a prospective, randomised, double-blind, placebo-controlled study. Lancet Neurol 8:151–150CrossRef
40.
Sims JR, Rordorf G, Smith EE, Koroshetz WJ, Lev MH, Buonanno F, Schwamm LH (2005) Arterial occlusion revealed by CT angiography predicts NIH stroke score and acute outcomes after IV tPA treatment. AJNR Am J Neuroradiol 26(2):246–251PubMed
41.
Schaefer PW, Yoo AJ, Bell D, Barak ER, Romero JM, Nogueira RG, Lev MH, Schwamm LH, Gonzalez RG, Hirsch JA (2008) CT angiography-source image hypoattenuation predicts clinical outcome in posterior circulation strokes treated with intra-arterial therapy. Stroke 39(11):3107–3109CrossRefPubMed
42.
Rosenthal ES, Schwamm LH, Roccatagliata L, Coutts SB, Demchuk AM, Schaefer PW, Gonzalez RG, Hill MD, Halpern EF, Lev MH (2008) Role of recanalization in acute stroke outcome: rationale for a CT angiogram-based “benefit of recanalization” model. AJNR Am J Neuroradiol 29(8):1471–1475CrossRefPubMed
43.
Camargo EC, Furie KL, Singhal AB, Roccatagliata L, Cunnane ME, Halpern EF, Harris GJ, Smith WS, Gonzalez RG, Koroshetz WJ, Lev MH (2007) Acute brain infarct: detection and delineation with CT angiographic source images versus nonenhanced CT scans. Radiology 244(2):541–548CrossRefPubMed
44.
Coutts SB, Lev MH, Eliasziw M, Roccatagliata L, Hill MD, Schwamm LH, Pexman JH, Koroshetz WJ, Hudon ME, Buchan AM, Gonzalez RG, Demchuk AM (2004) ASPECTS on CTA source images versus unenhanced CT: added value in predicting final infarct extent and clinical outcome. Stroke 35(11):2472–2476CrossRefPubMed
45.
Parsons MW, Pepper EM, Chan V, Siddique S, Rajaratnam S, Bateman GA, Levi CR (2005) Perfusion computed tomography: prediction of final infarct extent and stroke outcome. Ann Neurol 58(5):672–679CrossRefPubMed
46.
Schwamm LH, Rosenthal ES, Swap CJ, Rosand J, Rordorf G, Buonanno FS, Vangel MG, Koroshetz WJ, Lev MH (2005) Hypoattenuation on CT angiographic source images predicts risk of intracerebral hemorrhage and outcome after intra-arterial reperfusion therapy. AJNR Am J Neuroradiol 26(7):1798–1803PubMed
47.
Gobin YP, Starkman S, Duckwiler GR, Grobelny T, Kidwell CS, Jahan R, Pile-Spellman J, Segal A, Vinuela F, Saver JL (2004) MERCI 1: a phase 1 study of mechanical embolus removal in cerebral ischemia. Stroke 35(12):2848–2854CrossRefPubMed
48.
Vora NA, Gupta R, Thomas AJ, Horowitz MB, Tayal AH, Hammer MD, Uchino K, Wechsler LR, Jovin TG (2007) Factors predicting hemorrhagic complications after multimodal reperfusion therapy for acute ischemic stroke. AJNR Am J Neuroradiol 28(7):1391–1394CrossRefPubMed
49.
Mullins ME, Lev MH, Schellingerhout D, Gonzalez RG, Schaefer PW (2005) Intracranial hemorrhage complicating acute stroke: how common is hemorrhagic stroke on initial head CT scan and how often is initial clinical diagnosis of acute stroke eventually confirmed? AJNR Am J Neuroradiol 26(9):2207–2212PubMed
50.
Yoon W, Seo JJ, Kim JK, Cho KH, Park JG, Kang HK (2004) Contrast enhancement and contrast extravasation on computed tomography after intra-arterial thrombolysis in patients with acute ischemic stroke. Stroke 35(4):876–881CrossRefPubMed
51.
Masdeu JC, Irimia P, Asenbaum S, Bogousslavsky J, Brainin M, Chabriat H, Herholz K, Markus HS, Martínez-Vila E, Niederkorn K, Schellinger PD, Seitz RJ (2006) EFNS.EFNS guideline on neuroimaging in acute stroke. Report of an EFNS Task Force. Eur J Neurol 13(12):1271–1283CrossRefPubMed
52.
Köhrmann M, Jüttler E, Huttner HB, Nowe T, Schellinger PD (2007) Acute stroke imaging for thrombolytic therapy—an update. Cerebrovasc Dis 24(2–3):161–169PubMed
53.
Lansberg M, Albers G, Beaulieu C, Marks M (2000) Comparison of diffusion-weighted MRI and CT in acute stroke. Neurology 54:1557–1561PubMed
54.
Barber P, Darby D, Desmond P, Gerraty R, Yang Q, Li T, Jolley D, Donnan G, Tress B, Davis S (1999) Identification of major ischaemic change: diffusion-weighted imaging versus computed tomography. Stroke 30:2059–2065PubMed
55.
Mullins ME, Schafer PW, Sorensen AG, Halpern EF, Ay H, He J, Koroshetz WJ, Gonzalez RG (2002) CT and conventional and diffusion-weighted MR imaging in acute stroke: study in 691 patients at presentation to the emergency department. Radiology 224:353–360CrossRefPubMed
56.
Fiebach JB, Schellinger PD, Jansen O, Meyer M, Wilde P, Bender J, Schramm P, Jüttler E, Oehler J, Hartmann M, Hähnel S, Knauth M, Hache W, Sartor K (2002) CT and diffusion-weighted MR imaging inrandomized order. Diffusion-weighted Imaging results in higher accuracy and lower interrater variability in the diagnosis of hyperacute ischemic stroke. Stroke 33:2206–2210CrossRefPubMed
57.
Fiebach J, Jansen O, Schellinger P, Knauth M, Hartmann M, Heiland S, Ryssel H, Pohlers O, Hacke W, Sartor K (2001) Comparison of CT with diffusion-weighted MRI in patients with hyperacute stroke. Neuroradiology 43(8):628–632CrossRefPubMed
58.
Wintermark M, Albers GW, Alexandrov AV, Alger JR, Bammer R, Baron JC, Davis S, Demaerschalk BM, Derdeyn CP, Donnan GA, Eastwood JD, Fiebach JB, Fisher M, Furie KL, Goldmakher GV, Hacke W, Kidwell CS, Kloska SP, Köhrmann M, Koroshetz W, Lee TY, Lees KR, Lev MH, Liebeskind DS, Ostergaard L, Powers WJ, Provenzale J, Schellinger P, Silbergleit R, Sorensen AG, Wardlaw J, Wu O, Warach S (2008) Acute stroke imaging research roadmap. AJNR Am J Neuroradiol 29(5):e23–e30PubMedCrossRef
59.
Koroshetz WJ, Gonzalez G (1997) Diffusion-weighted MRI: an ECG for “brain attack”? Ann Neurol 41(5):565–566CrossRefPubMed
60.
San Millán Ruíz D, Murphy K, Gailloud P (2009) 320-Multidetector row whole-head dynamic subtracted CT angiography and whole-brain CT perfusion before and after carotid artery stenting: technical note. Eur J Radiol. 2009 Apr 30 (in press)
61.
Söderman M, Babic D, Holmin S, Andersson T (2008) Brain imaging with a flat detector C-arm: technique and clinical interest of XperCT. Neuroradiology 50(10):863–868CrossRefPubMed
Metadata
Title
Computed tomography in acute ischemic stroke
Authors
Karl-Olof Lövblad
Alison E. Baird
Publication date
01-03-2010
Publisher
Springer-Verlag
Published in
Neuroradiology / Issue 3/2010
Print ISSN: 0028-3940
Electronic ISSN: 1432-1920
DOI
https://doi.org/10.1007/s00234-009-0633-5

Other articles of this Issue 3/2010

Neuroradiology 3/2010 Go to the issue

Interventional Neuroradiology

Treatment of a wide-necked aneurysm of the anterior cerebral artery using two Enterprise stents in “Y”-configuration stenting technique and coil embolization: a technical note

Society News

European Society of Neuroradiology (ESNR)

Head and Neck Radiology

Diffusion tensor imaging (DTI) and tractography of the brachial plexus: feasibility and initial experience in neoplastic conditions

Diagnostic Neuroradiology

An enhanced voxel-based morphometry method to investigate structural changes: application to Alzheimer’s disease

Stroke Imaging

Acute stroke imaging

Editorial

Imaging techniques for acute ischemic stroke: nice gadgets or essential tools for effective treatment?