Stroke

IntracranialAbnormalities

Saul Sotomayor
Learning
Objectives

• In this lecture, you will learn the

role of imaging in identifying
stroke

• You will review theimaging

features
of acute stroke
What is a
Stroke?

Compromise of the blood supply toa portion of the

brain parenchyma, resulting in loss ofneurologic
function. High-yield

This may be embolic or Diagnosis is based on

thrombotic. clinical symptoms.
 Treatment

• In the setting of an acute ischemic

stroke, tissue plasminogen activator
(t-PA) can provide the most benefit High-yield
if administered within 3 hours of the
onset ofstroke.

• There is moderate benefit if

administered between 3 to 4.5
hours of the onset of stroke.
Role of Imaging in Acute
Stroke?

High-yield
Exclude hemorrhage. t – PA is contraindicated with
hemorrhage.
Exclude other causes of symptoms such as mass.
Types of
Stroke

Ischemic Hemorrhagic
 Watershed
Territory

• The area of brain parenchyma at the

junction of two vascular territories.
High-yield

• Most susceptible to ischemia.

• Common watershed areas: at the

junction of the ACA/MCA and the
MCA/PCA
 Stroke
Imaging

• Begin with CT due to quick access High-yield

and ability to excludehemorrhage.

• Ischemic stroke may not be visible

for several hours onCT.
Stroke
Imaging

MRI is most sensitive for early ischemic stroke High-yield

with the diffusion weighted images (DWI)
demonstrating
changes within20 30 minutes ofonset.
CT Findings of Ischemic
Stroke
< 24 hours 12 24 hours > 24 hours
• Negative • Vague low • Better defined
density low density
• Early signs include: High-yield
area areawith:
• Decreased
• Loss of gray-
density in the
white
basalganglia
differentiation
• Loss of
• Adjacent edema
gray/white
and mass effect
differentiation
• Changes last
• Hyperdense
for up to 4
Acute Stroke
 Acute
Stroke

• CT image on the left is negative in

patient presenting with symptoms for
2 hours.

• DWI image on the right demonstrates a

bright area in the right frontoparietal
region, indicating acute stroke.

William Herring, Learning Radiology, 3rd Edition, 2016, p. 290, Saunders (Elsevier)
 Acute
Stroke

• CT image on the left is negative in

patient presenting with symptoms for
2 hours.

• DWI image on the right demonstrates a

bright area in the right frontoparietal
region, indicating acute stroke.

William Herring, Learning Radiology, 3rd Edition, 2016, p. 290, Saunders (Elsevier)
Stroke Imaging Change Over
Time
Stroke Imaging Change Over
Time

• This image depicts the

imaging findings of a stroke
at about 24 hours.

• There is loss of gray white

differentiation with compression
of the ventricles and shift of the
midline.
Stroke Imaging Change Over
Time

• This image depicts the imaging

findings of a stroke several
weeks after the initial event.

• The low density area is more

sharplymarginatedand there is
no longer any significant mass
effect.
Hemorrhagic
Stroke

Hemorrhage into the brain parenchyma or subarachnoid

space

Risk increases with hypertension.

Case
Study
Describe
theFindings
65-year-old male presents with righ-tsided weakness which
began 2 hoursago.
Describe the
Findings
65-year-old male presents with righ-tsided weakness which
began 2 hoursago.

CT is
normal.
Describe the
Findings
65-year-old male presents with righ-tsided weakness which
began 2 hoursago.

• Patient is clinically
diagnosed with ischemic
stroke and treatedwith
t-PA and admitted to
theICU.

• He loses consciousness
the next day.

What do you do and why?

Case-study
Continued
65 year-old male presents with righ-tsided
weakness.

• CT demonstrates
intracerebral,
subarachnoid and
subdural hemorrhage
with resultantsubfalcine
herniation.

• Stroke has now become

hemorrhagic.

What do you do next?

Case-study
Continued
65 year-old male presents with righ-tsided
weakness.

Call neurosurgery for

urgent surgical
decompression to relieve
mass effect!
Learning
Outcomes

 You have reviewedthe imaging

findings and management of
acute stroke.