Skip to main content
SpringerLink
Log in

Imaging in neurointerventional stroke treatment: review of the recent trials and what your neurointerventionalist wants to know from emergency radiologists

  • Review Article
  • Published:
Emergency Radiology Aims and scope Submit manuscript

Abstract

Stroke is one of the leading causes of death and disability worldwide. Standard treatment for stroke is intravenous (IV) injection of tissue plasminogen activator (t-PA) rapidly after symptom onset. However, there are limitations of IV t-PA treatment, such as a short time window for administration and risk for hemorrhage. Recent trials have demonstrated the benefit of endovascular treatment when added to standard treatment to improve outcomes for patients. Advanced imaging was utilized in some trials to identify patients with proximal intracranial occlusion to target for endovascular reperfusion therapy, and to exclude patients with large infarct cores or poor collateral circulation who would not be expected to benefit from intervention. This article summarizes the use of imaging in recent stroke trials in details, provides a stroke imaging protocol, and provides tips which radiologists should know to help their neurointerventionalists.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4

Similar content being viewed by others

References

  1. The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group (1995) Tissue plasminogen activator for acute ischemic stroke. N Engl J Med 333:1581–1587

    Article  Google Scholar 

  2. 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 (2008) Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic stroke. N Engl J Med 359:1317–1329

    Article  CAS  Google Scholar 

  3. Emberson J, Lees KR, Lyden P, Blackwell L, Albers G, Bluhmki E, Brott T, Cohen G, Davis S, Donnan G, Grotta J, Howard G, Kaste M, Koga M, von Kummer R, Lansberg M, Lindley RI, Murray G, Olivot JM, Parsons M, Tilley B, Toni D, Toyoda K, Wahlgren N, Wardlaw J, Whiteley W, del Zoppo G, Baigent C, Sandercock P, Hacke W, Stroke Thrombolysis Trialists’ Collaborative Group (2014) Effect of treatment delay, age, and stroke severity on the effects of intravenous thrombolysis with alteplase for acute ischaemic stroke: a meta-analysis of individual patient data from randomised trials. Lancet 384:1929–1935

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  4. Paciaroni M, Balucani C, Agnelli G, Caso V, Silvestrelli G, Grotta JC, Demchuk AM, Sohn SI, Orlandi G, Leys D, Pezzini A, Alexandrov AV, Silvestrini M, Fofi L, Barlinn K, Inzitari D, Ferrarese C, Tassi R, Tsivgoulis G, Consoli D, Baldi A, Bovi P, Luda E, Galletti G, Invernizzi P, DeLodovici ML, Corea F, del Sette M, Monaco S, Marcheselli S, Alberti A, Venti M, Acciarresi M, D’Amore C, Macellari F, Lanari A, Previdi P, Gonzales NR, Pandurengan RK, Vahidy FS, Sline M, Bal SS, Chiti A, Gialdini G, Dumont F, Cordonnier C, Debette S, Padovani A, Cerqua R, Bodechtel U, Kepplinger J, Nesi M, Nencini P, Beretta S, Trentini C, Martini G, Piperidou C, Heliopoulos I, D’Anna S, Cappellari M, Donati E, Bono G, Traverso E, Toni D (2012) Systemic thrombolysis in patients with acute ischemic stroke and internal carotid artery occlusion: the ICARO study. Stroke 43:125–130

    Article  PubMed  Google Scholar 

  5. Jansen O, von Kummer R, Forsting M et al (1995) Thrombolytic therapy in acute occlusion of the intracranial internal carotid artery bifurcation. Am J Neuroradiol 16:1977–1986

    CAS  PubMed  Google Scholar 

  6. Bhatia R, Hill MD, Shobha N, Menon B, Bal S, Kochar P, Watson T, Goyal M, Demchuk AM (2010) Low rates of acute recanalization with intravenous recombinant tissue plasminogen activator in ischemic stroke: real-world experience and a call for action. Stroke 41(10):2254–2258

    Article  CAS  PubMed  Google Scholar 

  7. Saver JL, Goyal M, van der Lugt A, Menon BK, Majoie CBLM, Dippel DW, Campbell BC, Nogueira RG, Demchuk AM, Tomasello A, Cardona P, Devlin TG, Frei DF, du Mesnil de Rochemont R, Berkhemer OA, Jovin TG, Siddiqui AH, van Zwam WH, Davis SM, Castaño C, Sapkota BL, Fransen PS, Molina C, van Oostenbrugge RJ, Chamorro Á, Lingsma H, Silver FL, Donnan GA, Shuaib A, Brown S, Stouch B, Mitchell PJ, Davalos A, Roos YBWEM, Hill MD, for the HERMES Collaborators (2016) Time to treatment with endovascular Thrombectomy and outcomes from ischemic stroke: a meta-analysis. JAMA 316(12):1279–1288. https://doi.org/10.1001/jama.2016.13647

    Article  PubMed  Google Scholar 

  8. Nogueira RG, Jadhav AP, Haussen DC et al (2017) Thrombectomy 6 to 24 hours after stroke with a mismatch between deficit and infarct. N Engl J Med

  9. Albers GW, Marks MP, Kemp S, Christensen S, Tsai JP, Ortega-Gutierrez S, McTaggart R, Torbey MT, Kim-Tenser M, Leslie-Mazwi T, Sarraj A, Kasner SE, Ansari SA, Yeatts SD, Hamilton S, Mlynash M, Heit JJ, Zaharchuk G, Kim S, Carrozzella J, Palesch YY, Demchuk AM, Bammer R, Lavori PW, Broderick JP, Lansberg MG, DEFUSE 3 Investigators (2018) Thrombectomy for stroke at 6 to 16 hours with selection by perfusion imaging. N Engl J Med 378:708–718

    Article  PubMed  PubMed Central  Google Scholar 

  10. Lindsberg PJ, Pekkola J, Strbian D, Sairanen T, Mattle HP, Schroth G (2015) Time window for recanalization in basilar artery occlusion: speculative synthesis. Neurology 85(20):1806–1815

    Article  PubMed  Google Scholar 

  11. Gonzalez et al (2012) Clinical MRI of acute ischemic stroke. J Magn Reson Imaging 36(2):259–271. https://doi.org/10.1002/jmri.23595

    Article  PubMed  PubMed Central  Google Scholar 

  12. Pereira VM, Yilmaz H, Pellaton A, Slater LA, Krings T, Lovblad KO (2015) Current status of mechanical thrombectomy for acute stroke treatment. J Neuroradiol 42(1):12–20

    Article  PubMed  Google Scholar 

  13. Alonso de Leciñana M, Díaz-Guzmán J, Egido JA, García Pastor A, Martínez-Sánchez P, Vivancos J, Díez-Tejedor E, Comité ad hoc del Foro de Ictus de la Asociación Madrileña de Neurología (2013) Endovascular treatment in acute ischaemic stroke. A stroke care plan for the region of Madrid. Neurologia 28:425–434

    Article  PubMed  Google Scholar 

  14. Saver JL, Goyal M, Bonafe A, Diener HC, Levy EI, Pereira VM, Albers GW, Cognard C, Cohen DJ, Hacke W, Jansen O, Jovin TG, Mattle HP, Nogueira RG, Siddiqui AH, Yavagal DR, Devlin TG, Lopes DK, Reddy V, du Mesnil de Rochemont R, Jahan R, SWIFT PRIME Investigators (2015) Solitaire™ with the intention for Thrombectomy as Primary Endovascular Treatment for Acute Ischemic Stroke (SWIFT PRIME) trial: protocol for a randomized, controlled, multicenter study comparing the Solitaire revascularization device with IV tPA with IV tPA alone in acute ischemic stroke. Int J Stroke 10(3):439–448

    Article  PubMed  PubMed Central  Google Scholar 

  15. Campbell BC, Mitchell PJ, Kleinig TJ, Dewey HM, Churilov L, Yassi N, Yan B, Dowling RJ, Parsons MW, Oxley TJ, Wu TY, Brooks M, Simpson MA, Miteff F, Levi CR, Krause M, Harrington TJ, Faulder KC, Steinfort BS, Priglinger M, Ang T, Scroop R, Barber PA, McGuinness B, Wijeratne T, Phan TG, Chong W, Chandra RV, Bladin CF, Badve M, Rice H, de Villiers L, Ma H, Desmond PM, Donnan GA, Davis SM, EXTEND-IA Investigators (2015) Endovascular therapy for ischemic stroke with perfusion-imaging selection. N Engl J Med 372(11):1009–1018

    Article  CAS  Google Scholar 

  16. Barber PA, Demchuk AM, Zhang J, Buchan AM (2000) Validity and reliability of a quantitative computed tomography score in predicting outcome of hyperacute stroke before thrombolytic therapy. ASPECTS Study Group Alberta Stroke Programme Early CT Score. Lancet 355:1670–1674. https://doi.org/10.1016/S0140-6736(00)02237-6

    Article  CAS  PubMed  Google Scholar 

  17. Goyal M, Demchuk AM, Menon BK, Eesa M, Rempel JL, Thornton J, Roy D, Jovin TG, Willinsky RA, Sapkota BL, Dowlatshahi D, Frei DF, Kamal NR, Montanera WJ, Poppe AY, Ryckborst KJ, Silver FL, Shuaib A, Tampieri D, Williams D, Bang OY, Baxter BW, Burns PA, Choe H, Heo JH, Holmstedt CA, Jankowitz B, Kelly M, Linares G, Mandzia JL, Shankar J, Sohn SI, Swartz RH, Barber PA, Coutts SB, Smith EE, Morrish WF, Weill A, Subramaniam S, Mitha AP, Wong JH, Lowerison MW, Sajobi TT, Hill MD, ESCAPE Trial Investigators (2015) Randomized assessment of rapid endovascular treatment of ischemic stroke. N Engl J Med 372(11):1019–1030

    Article  CAS  Google Scholar 

  18. Jovin TG, Chamorro A, Cobo E, de Miquel MA, Molina CA, Rovira A, San Román L, Serena J, Abilleira S, Ribó M, Millán M, Urra X, Cardona P, López-Cancio E, Tomasello A, Castaño C, Blasco J, Aja L, Dorado L, Quesada H, Rubiera M, Hernandez-Pérez M, Goyal M, Demchuk AM, von Kummer R, Gallofré M, Dávalos A, REVASCAT Trial Investigators (2015) Thrombectomy within 8 hours after symptom onset in ischemic stroke. N Engl J Med 372:2296–2306. https://doi.org/10.1056/NEJMoa1503780

    Article  CAS  Google Scholar 

  19. Berkhemer OA, Fransen PS, Beumer D, van den Berg L, Lingsma HF, Yoo AJ, Schonewille WJ, Vos JA, Nederkoorn PJ, Wermer MJ, van Walderveen M, Staals J, Hofmeijer J, van Oostayen J, Lycklama à Nijeholt GJ, Boiten J, Brouwer PA, Emmer BJ, de Bruijn SF, van Dijk L, Kappelle LJ, Lo RH, van Dijk E, de Vries J, de Kort PL, van Rooij W, van den Berg J, van Hasselt B, Aerden LA, Dallinga RJ, Visser MC, Bot JC, Vroomen PC, Eshghi O, Schreuder TH, Heijboer RJ, Keizer K, Tielbeek AV, den Hertog H, Gerrits DG, van den Berg-Vos R, Karas GB, Steyerberg EW, Flach HZ, Marquering HA, Sprengers ME, Jenniskens SF, Beenen LF, van den Berg R, Koudstaal PJ, van Zwam W, Roos YB, van der Lugt A, van Oostenbrugge R, Majoie CB, Dippel DW, MR CLEAN Investigators (2015) A randomized trial of intraarterial treatment for acute ischemic stroke. N Engl J Med 372(1):11–20

    Article  CAS  Google Scholar 

  20. Bracard S, Ducrocq X, Mas JL, Soudant M, Oppenheim C, Moulin T, Guillemin F, THRACE investigators (2016) Mechanical thrombectomy after intravenous alteplase versus alteplase alone after stroke (THRACE): a randomised controlled trial. Lancet Neurol 15:1138–1147

    Article  CAS  PubMed  Google Scholar 

  21. Lansberg MG, Christensen S, Kemp S, Mlynash M, Mishra N, Federau C, Tsai JP, Kim S, Nogueria RG, Jovin T, Devlin TG, Akhtar N, Yavagal DR, Haussen D, Dehkharghani S, Bammer R, Straka M, Zaharchuk G, Marks MP, Albers GW, for the CT Perfusion to Predict Response to Recanalization in Ischemic Stroke Project (CRISP) Investigators (2017) Computed tomographic perfusion to predict response to recanalization in ischemic stroke. Ann Neurol 81:849–856. https://doi.org/10.1002/ana.24953

    Article  PubMed  PubMed Central  Google Scholar 

  22. Gonzalez et al (2013) Current state of acute stroke imaging. Stroke 44:3260–3264

    Article  PubMed  Google Scholar 

  23. Soares BP, Dankbaar JW, Bredno J, Cheng SC, Bhogal S, Dillon WP, Wintermark M (2009) Automated versus manual post-processing of perfusion-CT data in patients with acute cerebral ischemia: influence on interobserver variability. Neuroradiology 51(7):445–451. https://doi.org/10.1007/s00234-009-0516-9

    Article  PubMed  PubMed Central  Google Scholar 

  24. Yoo AJ, Barak ER, Copen WA, Kamalian S, Gharai LR, Pervez MA, Schwamm LH, González RG, Schaefer PW (2010) Combining acute diffusion-weighted imaging and mean transmit time lesion volumes with National Institutes of Health Stroke Scale Score improves the prediction of acute stroke outcome. Stroke 41(8):1728–1735

    Article  PubMed  Google Scholar 

  25. Leslie-Mazwi TM, Hirsch JA, Falcone GJ, Schaefer PW, Lev MH, Rabinov JD, Rost NS, Schwamm L, González RG (2016) Endovascular stroke treatment outcomes after patient selection based on magnetic resonance imaging and clinical criteria. JAMA Neurol 73(1):43–49. https://doi.org/10.1001/jamaneurol.2015.3000

    Article  PubMed  Google Scholar 

  26. Fassbender K, Grotta JC, Walter S, Grunwald IQ, Ragoschke-Schumm A, Saver JL (2017) Mobile stroke units for prehospital thrombolysis, triage, and beyond: benefits and challenges. Lancet Neurol 16(3):227–237. https://doi.org/10.1016/S1474-4422(17)30008

    Article  PubMed  Google Scholar 

  27. Ebinger M, Winter B, Wendt M, Weber JE, Waldschmidt C, Rozanski M, Kunz A, Koch P, Kellner PA, Gierhake D, Villringer K, Fiebach JB, Grittner U, Hartmann A, Mackert BM, Endres M, Audebert HJ (2014) Effect of the use of ambulance-based thrombolysis on time to thrombolysis in acute ischemic stroke: a randomized clinical trial. JAMA 311(16):1622–1631. https://doi.org/10.1001/jama.2014.2850

    Article  CAS  PubMed  Google Scholar 

  28. Morhard D, Wirth CD, Reiser MF, Schulte-Altedorneburg G, Ertl-Wagner B (2013) Optimal sequence timing of CT angiography and perfusion CT in patients with stroke. Eur J Radiol 82(6):e286–e289

    Article  CAS  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Radiology and Biomedical Imaging, University of California San Francisco School of Medicine, 550 16th. Street, San Francisco, CA, 94158, USA

    Bhavya Rehani, Yi Zhang, Simon Ammanuel, Daniel L. Cooke, Steven W. Hetts & William Dillon

  2. Department of Neurology, University of California San Francisco, San Francisco, CA, USA

    Wade Smith, S. Andrew Josephson, Anthony Kim & J. Claude Hemphill III

  3. Department of Radiology, Massachusetts General Hospital, Boston, MA, USA

    Ramon G. Gonzalez

Authors
  1. Bhavya Rehani
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Yi Zhang
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Simon Ammanuel
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Wade Smith
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Ramon G. Gonzalez
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Daniel L. Cooke
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Steven W. Hetts
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. S. Andrew Josephson
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Anthony Kim
    View author publications

    You can also search for this author in PubMed Google Scholar

  10. J. Claude Hemphill III
    View author publications

    You can also search for this author in PubMed Google Scholar

  11. William Dillon
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

BR was involved in design of the work, data collection, analysis, and drafting the paper. YZ was involved in the data collection and drafting the article. SA, WS, RGG, DLC, SWH, SAJ, AK, JCH were involved in drafting the article and revision of the article. WD was involved in drafting and revision of the article, and design of the work.

Corresponding author

Correspondence to Bhavya Rehani.

Ethics declarations

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed consent

Informed consent was obtained from all individual participants included in the study.

Additional information

What your neurointerventionalist wants to know

• Patients with late or unknown stroke symptom onset and proximal vessel occlusion may also be successfully treated with endovascular therapy if the patients CT or MRI DWI perfusion mismatch profile is favorable.

• For basilar artery thrombosis, the treatment window for endovascular therapy may be up to 24 h. However, there is a lack of evidence for treatment

• NCCT is used to calculate the ASPECTS while CT angiography is used to assess for large vessel occlusion.

• Patients with infarct cores of < 70 mL on DWI on MRI or CTP have a higher likelihood of favorable outcome after thrombectomy and reperfusion.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Rehani, B., Zhang, Y., Ammanuel, S. et al. Imaging in neurointerventional stroke treatment: review of the recent trials and what your neurointerventionalist wants to know from emergency radiologists. Emerg Radiol 26, 195–203 (2019). https://doi.org/10.1007/s10140-018-01662-z

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s10140-018-01662-z

Keywords

Search

Navigation