Role of CT and MRI in

Stroke Diagnosis

dr. Syahriar Muhammad, Sp.Rad

Instalasi Radiologi RSUD Provinsi NTB

 Stroke Imaging

Imaging Technique
Stroke VS TIA
▪ NCCT
▪ CT Angiography
▪ CT Perfusion
Core vs Penumbra
▪ MRI
▪ MR Perfusion
 Stroke Morbidity / Mortality

▪ Comprising 15·4% of all deaths (Indonesia)

▪ 99/100000 death rate (WHO 2002)
▪ disability-adjusted life years lost 685/100000 (WHO 2002)
▪ Stroke prevalence is 0,0017% in rural Indonesia, 0,022% in
urban Indonesia, 0,5% among urban Jakarta adults.
▪ Frequent risk factors include hypertension, smoking,
hypercholesterolemia, diabetes, heart disease
▪ The mean age of stroke patients is 58,8 years

Kusuima, Y., Venketasubramanian, N., Kiemas, L. S., & Misbach, J. (2009)

 Stroke Morbidity / Mortality

▪ 10% stroke and 40% haemorrhagic strokes lead to death

within 30 days
▪ For age >65, 6 months after stroke
– 50% with hemiparesis
– 30% unable to walk without assistance
– 20% aphasia
– 26% in nursing home
 Stroke Morbidity / Mortality

▪ Subarachnoid haemorrhage is found in 1,4% of patients,

intracerebral haemorrhage in 18,5%, and ischaemic stroke in
42,9%.
▪ Only city hospitals have neurology, neurosurgery and
neuroimaging services.
▪ Efforts to combat stroke include education, more stroke units
and rehabilitative services especially in the rural areas.

Indonesia

Kusuima, Y., Venketasubramanian, N., Kiemas, L. S., & Misbach, J. (2009)

Conceptual Representation of Ischemic Stroke Subtypes

Intracerebral
Hemorrhage
Subarachnoid Hemorrhage
Stroke
Ischemic Stroke

Lacunar (Majority due to small vessel disease)

Non-Lacunar
Ischemic Stroke

Cardioembolic Large
Cryptogenic Artery
Other
Non-Lacunar Stroke

ESUS

Cryptogenic Stroke NON-

ESUS

Abbreviations: ESUS indica tes embolic stroke of undetermined source; and non-ESUS, non-embolic stroke of undetermined source.
Kleindorfer, D. O., et al. (2021). 2021 AHA/ASA Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic 6
Attack. Stroke.
 Transient Ischaemic Attack

▪ Classic definition
– Focal cerebral ischaemic event with symptoms lasting <24hrs (often <1hr)

▪ Increased risk of stroke, 3-17% in first 3 months, ½ in first 48

hrs
▪ 1/3 have (+) DWI on MRI

AHA Recommendation

1. Neuroimaging within 24 hrs (preferably MRI with DWI)

2. Non-invasive cervical vessel imaging + intracranial (MRA/CTA)
Cerebral Vasculature
 Ischaemic Penumbra
▪ Metabolically challenged but reversibly injured neural tissue
surrounding core of infarction
▪ Penumbra is spatial and temporal
▪ Penumbra is dynamic
▪ Target zone of therapy

Renewed interest in
core as determinant
(70-100cc core
threshold)

Gauberti, M., De Lizarrondo, S. M., & Vivien, D. (2016)

 Stroke Imaging Tools

▪ NCCT
▪ CT Angiography
▪ CT Perfusion
▪ MRI
▪ MR Perfusion
 CT Stroke Imaging Goals
(NCCT)

▪ Exclude hemorrhagic stroke

▪ Detect alternative etiologies for neurological deficit (mass, subdural,
vasogenic edema)
▪ Asses large infarct?
CT-Performance in Stroke (subtle sign)

Hyperdense MCA Sign

CT-Performance in Stroke (subtle sign)

Insular Ribbon sign

CT-Performance in Stroke (subtle sign)

Obscuration of basal ganglia + insular ribbon sign

Hassan, Radhiana & Sharis, Syazarina & Mukari, Shahizon Azura & Hashim, Hilwati & Sobri, M. (2013)
 Questions?

▪ Isschaemic or hemorrhagic
 Non enhanced CT

▪ Large vessel occlusion

 CTA

▪ Salvageable tissue
 CT Perfusion
 MR Perfusion
 CT- Angiography

▪ Asses large cervical and ▪ Technique

intracranial arteries
 Occlusion or stenosis (50-75% to
be important
 Detect dissection
 Collateral vessel
 Atherosclerotic disease
 100 cc, 4 cc/sec
 Arch to vertex
 1 mm or less slice thickness
 Ascending aorta density trigger
 3D Surface Rendering
CTA source images (CTSI)
 MRI CT-Perfusion Protocol
▪ Diffusion-Weighted
▪ Elapsed time since symptom
Imaging (DWI)
onset
▪ Best measure of
Cost and workflow ▪ Availability of emergent imaging
infarct
considerations not for with appropriate software
▪ Becomes positive MRI reconstruction
minutes to hours after
▪ Clinician and radiologist
ischaemic onset
preference
▪ Availability of neuro-
intervention / radiologist neuro-
intervention

Prof. Dr. Anggraini Dwi Sensusiati, dr. Sp.Rad (K), 2022

Stroke Infarction DWI ADC T2 FLAIR GRE/SWI

Early hyperacute Hyperintense Hypointense Isointense Variable, usually high Hemorrhagic

(0-6 hrs) loss of ICA flow void in after 6 hrs transformation
large vessel stroke Hyperintense arterial unlikely

Late hyperacute Hyperintense Hypointense Variable, usually high hyperintense Hemorrhagic

(6-24 hrs) after 8 hours transformation
unlikely

Acute Hyperintense Hypointense Hyperintense Hyperintense Hemorrhagic

(24 hrs – 1 week) transformation most
likely within 48hrs,
risk remains for up to
5 days

Subacute Hyperintense (10-14 Hypointense Hyperintense Hyperintense Hemorrhagic

(1-3 weeks) days) After 14 days: transformation
After 14 days : T2shine hyperintense uncommon after 1
trough week

Chronic Hypointense Hyperintense Hyperintense Hypointense (gliosis,

(> 3 weeks) encephalomalacia)

Dr. dr. Sri Andreani Utomo, Sp.Rad (K)

 75-year-old woman who presented with left hemiparesis

Acute CT scans (top row) : obtained 1.5 hours

MRI (DWI) (middle row) obtained 3.5 hours after

stroke onset

follow-up DWI examination (bottom row), obtained

36.5 hours

Lansberg, M. G., Albers, G. W., Beaulieu, C., & Marks, M. P. (2000)

 CT Perfusion

▪ 70 cc 5 cc/sec
▪ 60 sec acquisition
 Brain CT-Perfusion overdose

▪ Skin burns, cataracts, sterility

▪ 3-4 Gy
▪ 8x expected dose
BMJ 2009;339:b4217

https://www.nytimes.com/2011/03/06/health/06radiation.html
CT Perfusion, why?

CT Perfusion In Acute Ischemic Stroke,

Rutgers RWJMS Neurology
 Ischaemic Penumbra
▪ Metabolically challenged but reversibly injured neural tissue
surrounding core of infarction
▪ Penumbra is spatial and temporal
▪ Penumbra is dynamic
▪ Target zone of therapy

Renewed interest in
core as determinant
(70-100cc core
threshold)
Gauberti, M., De Lizarrondo, S. M., & Vivien, D. (2016).
Fundamental Hemodynamic Properties
Perfusion parameters and perfusion maps
Fundamental Hemodynamic Properties
Perfusion parameters and perfusion maps
Fundamental Hemodynamic Properties
Perfusion parameters and perfusion maps
Fundamental Hemodynamic Properties
Perfusion parameters and perfusion maps
Fundamental Hemodynamic Properties
Perfusion parameters and perfusion maps
CT Perfusion In Acute Ischemic Stroke,
Rutgers RWJMS Neurology
CT Perfusion In Acute Ischemic Stroke,
Rutgers RWJMS Neurology
Core

▪ Infarcted brain, not salvageable

▪ CBF less than 30% of normal (CBF <30% volume in mL)
▪ Essentially equivalent to area of diffusion restriction seen on MRI
Penumbra

▪ Hypo perfused brain at risk, salvageable

▪ Represent target of reperfusion therapy
▪ Most commonly threshold in CTP is Tmax >6s
CT Perfusion In Acute Ischemic Stroke,
Rutgers RWJMS Neurology
 Hypoperfusion index
≥ 0.34 is a predictor
of poor collateral
flow and infarct
growth

CT Perfusion In Acute Ischemic Stroke,

Rutgers RWJMS Neurology
Hypoperfusion Index (Tmax> 10s/Tmax>6s): 0,1 Hypoperfusion Index (Tmax> 10s/Tmax>6s): 0,8

CT Perfusion In Acute Ischemic Stroke,

Rutgers RWJMS Neurology
 Clinical Application

Thrombectomy patient selection

▪ Within 6 hrs?  no-need for perfusion imaging

▪ DEFUSE3
 Neuroimaging Inclusion Criteria
Defuse 3
MRA / CTA reveals
Target Mismatch Profile on CT
▪ M1 segment MCA occlusion,
or
perfusion or MRI

▪ ICA occlusion (cervical or ▪ Ischaemic core volume <70 mL,

intracranial; with or without and
tandem MCA lesions)
▪ Mismatch ratio >1,8, and
▪ Mismatch volume ≥ 15 mL
 TEMPLATE
▪ Exam : (procedures)
▪ Date : (orders date)
▪ Indication : Reason for study
▪ Comparison : Field 2
▪ Technique : CT perfusion was performed utilizing a total processed (contrast volume) ml …
mg/L intravenous contrast injection rate 5mL/s. A total of 8 cm brain coverage was used for the CTP
study. The image were processed using (software) software.
▪ Findings :
– Total hypoperfusion : using threshold of Tmax greater than 6 seconds. There is an area of hypoperfusion in the (side)
MCA territory with a total volume of hypoperfusion of (Tmax > 6s volume) mL
– Core infarct using threshold of CBF less than 30%, there is area of ischaemic core in the (side) MCA territory with a
total volume of ischaemic core of (CBF < 30% volume ) mL
– Penumbra: The penumbra volume is (mismatch volume). The mismatch ratio is (mismatch ratio)

▪ Impression :
– Hypoperfusion in the (side) MCA territory with a central ischaemic core of (CBF, 30% volume) mL, total volume of
hypoperfusion of (Tmax >6s volume) mL, and penumbra of (mismatch volume) mL.
Prof. Dr. Anggraini Dwi Sensusiati, dr. Sp.Rad (K), 2022
 Pitfalls

▪ Core infarct may not show up if there is later recruitment of collateral

vessel from ACA and PCA (futile leptomeningeal perfusion)
▪ If imaging patients very early (within an hour) after stroke, the volume of
core infarct may be substantially overcalled at a CBF <30% threshold.
Within an hour of stroke, a CBF <20% threshold may be more appropriate
(not used in current practice)
▪ Understand that areas of brain with HU under a certain threshold
(approaching CSF density) will not be counted as core infarct, assumed to
represent encephalomalacia
▪ Software may only include lesions greater than 3 mL on mismatch maps so
lacunar infarcts may not show up. They may be visible on the global color
maps if provided.
Prof. Dr. Anggraini Dwi Sensusiati, dr. Sp.Rad (K), 2022
Pitfalls

CT Perfusion In Acute Ischemic Stroke,

Rutgers RWJMS Neurology
 Pitfalls

▪ AIF (arterial input function) and VOF

(venous output function)

– AIF often placed on

1. A2 segment ACA
2. MCA is often used as well.

– VOF often placed on superior

sagittal sinus
Inappropriate placement of either can give
appearance of global perfusion abnormality Vagal, A., et al. (2019).
or other abnormality
 Pitfalls

– If images or numbers don’t look right,

verify placement of AIF and VOF and
look at time curves
▪ Make sure there is good bolus and
curves have sharp upstroke
▪ If there are a lot of jagged lines in the
curves, it is suggestive of movement
– Make sure that there is no truncation
of the curves (stopped scanning too
early)

Prof. Dr. Anggraini Dwi Sensusiati, dr. Sp.Rad (K), 2022

 Summary

▪ Non-enhanced CT, may help ischemic or hemorrhagic stroke

▪ CTP protocols based on the institution’s conditions
▪ CT perfusion able to identify salvageable brain tissue
▪ Fundamental hemodynamic properties
▪ Pitfall may happen due to technical error