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
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
Current Neurology and Neuroscience Reports
Published in: Current Neurology and Neuroscience Reports 4/2016

01-04-2016 | Stroke (HP Adams, Section Editor)

The Role of Vascular Imaging in the Initial Assessment of Patients with Acute Ischemic Stroke

Authors: Emmad Qazi, Fahad S. Al-Ajlan, Mohamed Najm, Bijoy K. Menon

Published in: Current Neurology and Neuroscience Reports | Issue 4/2016

Login to get access

Abstract

Over the last few years, improvement in radiological imaging and treatment has changed the management of acute ischemic stroke. We have made significant advances in not only the imaging modalities themselves but also in identifying imaging parameters that can help us predict patient outcomes with both intravascular thrombolysis and endovascular thrombectomy. In this review, we describe the added utility of baseline vascular imaging including computed tomography angiography and magnetic resonance angiography in the diagnosis and management of patients with acute ischemic stroke. We focus on information these imaging modalities provide on clot characteristics, tissue state, collateral status, and endovascular planning. We also highlight the benefits of newer imaging modalities like dynamic computed tomography angiography (CTA) and multi-phase CTA. Lastly, we also describe some of the disadvantages of vascular imaging in ischemic stroke.
Literature
1.
Go AS, Mozaffarian D, Roger VL, Benjamin EJ, Berry JD, Blaha MJ, et al. Heart disease and stroke statistics—2014 update: a report from the American Heart Association. Circulation. 2014;129(3):e28.CrossRefPubMed
2.••
Berkhemer OA, Fransen PS, Beumer D, van den Berg LA, Lingsma HF, Yoo AJ, et al. A randomized trial of intraarterial treatment for acute ischemic stroke. N Engl J Med. 2015;372(1):11–20. Randomized Controlled trial that showed endovascular thrombectomy is better then standard of care for proximal occlusions. CrossRefPubMed
3.••
Campbell BC, Mitchell PJ, Kleinig TJ, Dewey HM, Churilov L, Yassi N, et al. Endovascular therapy for ischemic stroke with perfusion-imaging selection. N Engl J Med. 2015;372(11):1009–18. Randomized Controlled trial that showed endovascular thrombectomy is better then standard of care for proximal occlusions. CrossRefPubMed
4.••
Goyal M, Demchuk AM, Menon BK, Eesa M, Rempel JL, Thornton J, et al. Randomized assessment of rapid endovascular treatment of ischemic stroke. N Engl J Med. 2015;372(11):1019–30. Randomized Controlled trial that showed endovascular thrombectomy is better then standard of care for proximal occlusions. CrossRefPubMed
5.••
Saver JL, Goyal M, Bonafe A, Diener H-C, Levy EI, Pereira VM et al. Stent-retriever thrombectomy after intravenous t-PA vs. t-PA alone in stroke. New England J Med. 2015. Randomized Controlled trial that showed endovascular thrombectomy is better then standard of care for proximal occlusions.
6.••
Jovin TG, Chamorro A, Cobo E, de Miquel MA, Molina CA, Rovira A et al. Thrombectomy within 8 hours after symptom onset in ischemic stroke. New England J Med. 2015. Randomized Controlled trial that showed endovascular thrombectomy is better then standard of care for proximal occlusions.
7.
Rha J-H, Saver JL. The impact of recanalization on ischemic stroke outcome a meta-analysis. Stroke. 2007;38(3):967–73.CrossRefPubMed
8.
9.
Sylaja P, Dzialowski I, Puetz V, Eliasziw M, Hill MD, Krol A, et al. Does intravenous rtPA benefit patients in the absence of CT angiographically visible intracranial occlusion? Neurol India. 2009;57(6):739.CrossRefPubMed
10.
Menon BK, Campbell BC, Levi C, Goyal M. Role of imaging in current acute ischemic stroke workflow for endovascular therapy. Stroke. 2015;46(6):1453–61.CrossRefPubMed
11.
Almekhlafi MA, Menon BK, Goyal M. Lessons learnt from recent endovascular stroke trials: finding a way to move forward. Expert Rev Cardiovasc Ther. 2014;12(4):429–36.CrossRefPubMed
12.
Demchuk AM, Goyal M, Yeatts SD, Carrozzella J, Foster LD, Qazi E, et al. Recanalization and clinical outcome of occlusion sites at baseline CT angiography in the Interventional Management of Stroke III trial. Radiology. 2014;273(1):202–10.CrossRefPubMedPubMedCentral
13.
Mishra S, Dykeman J, Sajobi T, Trivedi A, Almekhlafi M, Sohn S, et al. Early reperfusion rates with IV tPA are determined by CTA clot characteristics. Am J Neuroradiol. 2014;35(12):2265–72.CrossRefPubMed
14.
Bhatia R, Hill MD, Shobha N, Menon B, Bal S, Kochar P, et al. Low rates of acute recanalization with intravenous recombinant tissue plasminogen activator in ischemic stroke real-world experience and a call for action. Stroke. 2010;41(10):2254–8.CrossRefPubMed
15.
del Zoppo GJ, Poeck K, Pessin MS, Wolpert SM, Furlan AJ, Ferbert A, et al. Recombinant tissue plasminogen activator in acute thrombotic and embolic stroke. Ann Neurol. 1992;32(1):78–86.CrossRefPubMed
16.
Saqqur M, Uchino K, Demchuk AM, Molina CA, Garami Z, Calleja S, et al. Site of arterial occlusion identified by transcranial Doppler predicts the response to intravenous thrombolysis for stroke. Stroke. 2007;38(3):948–54.CrossRefPubMed
17.
Demchuk AM, Menon B, Goyal M. Imaging-based selection in acute ischemic stroke trials–a quest for imaging sweet spots. Ann N Y Acad Sci. 2012;1268(1):63–71.CrossRefPubMed
18.
Yarbrough CK, Ong CJ, Beyer AB, Lipsey K, Derdeyn CP. Endovascular thrombectomy for anterior circulation stroke systematic review and meta-analysis. Stroke. 2015:STROKEAHA. 115.009847.
19.
Qazi EM, Sohn SI, Mishra S, Almekhlafi MA, Eesa M, d’Esterre CD et al. Thrombus characteristics are related to collaterals and angioarchitecture in acute stroke. Can J Neurol Sci/J Canadien des Sci Neurologiques. 2015:1–8.
20.
Riedel CH, Zimmermann P, Jensen-Kondering U, Stingele R, Deuschl G, Jansen O. The importance of size successful recanalization by intravenous thrombolysis in acute anterior stroke depends on thrombus length. Stroke. 2011;42(6):1775–7.CrossRefPubMed
21.
Puetz V, Dzialowski I, Hill MD, Subramaniam S, Sylaja P, Krol A, et al. Intracranial thrombus extent predicts clinical outcome, final infarct size and hemorrhagic transformation in ischemic stroke: the clot burden score. Internat J Stroke. 2008;3(4):230–6.CrossRef
22.
Tan I, Demchuk A, Hopyan J, Zhang L, Gladstone D, Wong K, et al. CT angiography clot burden score and collateral score: correlation with clinical and radiologic outcomes in acute middle cerebral artery infarct. Am J Neuroradiol. 2009;30(3):525–31.CrossRefPubMed
23.
Saqqur M, Tsivgoulis G, Molina CA, Demchuk AM, Shuaib A, Alexandrov AV. Residual flow at the site of intracranial occlusion on transcranial Doppler predicts response to intravenous thrombolysis: a multi-center study. Cerebrovasc Dis. 2009;27(1):5–12.CrossRefPubMed
24.
Bhatia R, Bal SS, Shobha N, Menon BK, Tymchuk S, Puetz V, et al. CT angiographic source images predict outcome and final infarct volume better than noncontrast CT in proximal vascular occlusions. Stroke. 2011;42(6):1575–80.CrossRefPubMed
25.
Coutts SB, Lev MH, Eliasziw M, Roccatagliata L, Hill MD, Schwamm LH, et al. Aspects on CTA source images versus unenhanced ct added value in predicting final infarct extent and clinical outcome. Stroke. 2004;35(11):2472–6.CrossRefPubMed
26.
Barber PA, Demchuk AM, Zhang J, Buchan AM, Group AS. Validity and reliability of a quantitative computed tomography score in predicting outcome of hyperacute stroke before thrombolytic therapy. Lancet. 2000;355(9216):1670–4.CrossRefPubMed
27.
Löuvbld KO, Baird AE, Schlaug G, Benfield A, Siewert B, Voetsch B, et al. Ischemic lesion volumes in acute stroke by diffusion-weighted magnetic resonance imaging correlate with clinical outcome. Ann Neurol. 1997;42(2):164–70.CrossRef
28.
Barber P, Hill M, Eliasziw M, Demchuk A, Pexman J, Hudon M, et al. Imaging of the brain in acute ischaemic stroke: comparison of computed tomography and magnetic resonance diffusion-weighted imaging. J Neurol Neurosurg Psychiatry. 2005;76(11):1528–33.CrossRefPubMedPubMedCentral
29.
Bang OY, Saver JL, Buck BH, Alger JR, Starkman S, Ovbiagele B, et al. Impact of collateral flow on tissue fate in acute ischaemic stroke. J Neurol Neurosurg Psychiatry. 2008;79(6):625–9.CrossRefPubMedPubMedCentral
30.
Bang OY, Saver JL, Kim SJ, Kim G-M, Chung C-S, Ovbiagele B, et al. Collateral flow predicts response to endovascular therapy for acute ischemic stroke. Stroke. 2011;42(3):693–9.CrossRefPubMedPubMedCentral
31.•
Menon B, Smith E, Modi J, Patel S, Bhatia R, Watson T, et al. Regional leptomeningeal score on CT angiography predicts clinical and imaging outcomes in patients with acute anterior circulation occlusions. Am J Neuroradiol. 2011;32(9):1640–5. How to use the rLMC score on CTA and its predictive ability. CrossRefPubMed
32.•
Menon BK, d’Esterre CD, Qazi EM, Almekhlafi M, Hahn L, Demchuk AM, et al. Multiphase CT angiography: a new tool for the imaging triage of patients with acute ischemic stroke. Radiology. 2015;275(2):510–20. A description of mCTA and its clinical application. CrossRefPubMed
33.
Nambiar V, Sohn SI, Almekhlafi MA, Chang HW, Mishra S, Qazi E, et al. CTA collateral status and response to recanalization in patients with acute ischemic stroke. AJNR Am J Neuroradiol. 2014;35(5):884–90. doi:10.​3174/​ajnr.​A3817.CrossRefPubMed
34.
35.
Souza LC, Yoo AJ, Chaudhry ZA, Payabvash S, Kemmling A, Schaefer PW, et al. Malignant CTA collateral profile is highly specific for large admission DWI infarct core and poor outcome in acute stroke. AJNR Am J Neuroradiol. 2012;33(7):1331–6. doi:10.​3174/​ajnr.​A2985.CrossRefPubMedPubMedCentral
36.
Khatri R, Rodriguez GJ, Suri MFK, Vazquez G, Ezzeddine MA. Leptomeningeal collateral response and computed tomographic perfusion mismatch in acute middle cerebral artery occlusion. J Vasc Intervention Neurol. 2011;4(1):1.
37.
Miteff F, Levi CR, Bateman GA, Spratt N, McElduff P, Parsons MW. The independent predictive utility of computed tomography angiographic collateral status in acute ischaemic stroke. Brain. 2009;132(8):2231–8.CrossRefPubMed
38.
Nambiar V, Sohn S, Almekhlafi M, Chang H, Mishra S, Qazi E, et al. CTA collateral status and response to recanalization in patients with acute ischemic stroke. Am J Neuroradiol. 2014;35(5):884–90.CrossRefPubMed
39.
Menon BK, Qazi E, Nambiar V, Foster LD, Yeatts S, Liebeskind D. Differential effect of baseline cta collateral status on clinical outcomes in patients enrolled in the Ims-3 trial. Stroke. 2014;45 Suppl 1:A7-A.
40.
Demchuk A, Menon B, Eesa M, Willinsky R, Montanera W, Frei D et al., editors. Correlation between baseline imaging variables and clinical outcome: results from the ESCAPE trial. European Stroke Organization Conference; 2015; Glasgow, UK.
41.
Jansen I, Berkhemer O, Marquering H, van den Berg R, Bot J, Beenen L et al., editors. Baseline CTA cerebral collateral flow is associated with intra-arterial therapy benefit in patients with proximal anterior circulation stroke included in the MRCLEAN. European Stroke Organization Conference; 2015; Glasgow, U.K. .
42.
Hacke W, Schwab S, Horn M, Spranger M, De Georgia M, von Kummer R. ‘Malignant’ middle cerebral artery territory infarction: clinical course and prognostic signs. Arch Neurol. 1996;53(4):309–15.CrossRefPubMed
43.
Engelhorn T, Von Kummer R, Reith W, Forsting M, Doerfler A. What is effective in malignant middle cerebral artery infarction: reperfusion, craniectomy, or both? An experimental study in rats. Stroke. 2002;33(2):617–22.CrossRefPubMed
44.
Flores A, Rubiera M, Ribó M, Pagola J, Rodriguez-Luna D, Muchada M et al. Poor collateral circulation assessed by multiphase computed tomographic angiography predicts malignant middle cerebral artery evolution after reperfusion therapies. Stroke. 2015:STROKEAHA. 115.010608.
45.
46.
Menon BK, Kochar P, Ah-Seng A, Almekhlafi MA, Modi J, Wong JH, et al. Initial experience with a self-expanding retrievable stent for recanalization of large vessel occlusions in acute ischemic stroke. Neuroradiology. 2012;54(2):147–54.CrossRefPubMed
47.
Menon BK, O’Brien B, Bivard A, Spratt NJ, Demchuk AM, Miteff F, et al. Assessment of leptomeningeal collaterals using dynamic CT angiography in patients with acute ischemic stroke. J Cerebral Blood Flow Metabolism : Off J Int Soc Cerebral Blood Flow Metabol. 2013;33(3):365–71. doi:10.​1038/​jcbfm.​2012.​171.CrossRef
48.
Smit EJ, Vonken E-J, van Seeters T, Dankbaar JW, van der Schaaf IC, Kappelle LJ. Timing-invariant imaging of collateral vessels in acute ischemic stroke. Stroke. 2013;44(8):2194–9.CrossRefPubMed
49.
McDonald JS, McDonald RJ, Carter RE, Katzberg RW, Kallmes DF, Williamson EE. Risk of intravenous contrast material–mediated acute kidney injury: a propensity score–matched study stratified by baseline-estimated glomerular filtration rate. Radiology. 2014;271(1):65–73.CrossRefPubMed
50.
Hirai T, Korogi Y, Ono K, Nagano M, Maruoka K, Uemura S, et al. Prospective evaluation of suspected stenoocclusive disease of the intracranial artery: combined MR angiography and CT angiography compared with digital subtraction angiography. Am J Neuroradiol. 2002;23(1):93–101.PubMed
51.
Bash S, Villablanca JP, Jahan R, Duckwiler G, Tillis M, Kidwell C, et al. Intracranial vascular stenosis and occlusive disease: evaluation with CT angiography, MR angiography, and digital subtraction angiography. Am J Neuroradiol. 2005;26(5):1012–21.PubMed
52.
53.
Gonzalez R, Hirsch J, Koroshetz W, Lev M, Schaefer P. Acute ischemic stroke: imaging and intervention. Am J Neuroradiol. 2007;28(8):1622.CrossRef
54.
Alfke K, Jensen U, Pool C, Rohr A, Brüning R, Weber J, et al. Contrast-enhanced magnetic resonance angiography in stroke diagnostics. Clin Neuroradiol. 2011;21(1):5–10.CrossRefPubMed
55.
Alvarez-Linera J, Benito-León J, Escribano J, Campollo J, Gesto R. Prospective evaluation of carotid artery stenosis: elliptic centric contrast-enhanced MR angiography and spiral CT angiography compared with digital subtraction angiography. Am J Neuroradiol. 2003;24(5):1012–9.PubMed
56.
Jaff MR, Goldmakher GV, Lev MH, Romero JM. Imaging of the carotid arteries: the role of duplex ultrasonography, magnetic resonance arteriography, and computerized tomographic arteriography. Vasc Med. 2008;13(4):281–92.CrossRefPubMed
57.
58.
Metadata
Title
The Role of Vascular Imaging in the Initial Assessment of Patients with Acute Ischemic Stroke
Authors
Emmad Qazi
Fahad S. Al-Ajlan
Mohamed Najm
Bijoy K. Menon
Publication date
01-04-2016
Publisher
Springer US
Published in
Current Neurology and Neuroscience Reports / Issue 4/2016
Print ISSN: 1528-4042
Electronic ISSN: 1534-6293
DOI
https://doi.org/10.1007/s11910-016-0632-y

Other articles of this Issue 4/2016

Current Neurology and Neuroscience Reports 4/2016 Go to the issue

Neurology of Systemic Diseases (J Biller, Section Editor)

Neurologic Complications of Commonly Used Drugs in the Hospital Setting

Headache (R. B. Halker, Section Editor)

Allergic Rhinitis and Chronic Daily Headaches: Is There a Link?

Headache (R. B. Halker, Section Editor)

Managing Migraine During Pregnancy and Lactation

Demyelinating Disorders (DN Bourdette and M Cameron, Section Editors)

Vaccines in Multiple Sclerosis

Neurotrauma (M Kumar, Section Editor)

Cerebral Lactate Metabolism After Traumatic Brain Injury

Demyelinating Disorders (DN Bourdette and M Cameron, Section Editors)

The Use of Oral Disease-Modifying Therapies in Multiple Sclerosis