Neuroimaging in Acute Ischemic Stroke

  • Shashidhara Nanjundaswamy
  • Ronald A. Cohen
  • Marc Fisher


Stroke, the third leading cause of death is a medical emergency (Lloyd-Jones et al., Circulation 119:480–486, 2009). The phrase “Time is Brain” has been coined to emphasize the urgency of rapid intervention for stroke (Gomez, J Stroke Cerebrovasc Dis 3:12, 1993). For each minute, the stroke is untreated, more than two million neurons, 14 billion synapses, and 12 km (7.5 miles) of myelinated fibers may be lost (Saver, Stroke 37:263–266, 2006). Intravenous tissue plasminogen activator (tPA) is the only FDA approved treatment for a nonhemorrhagic stroke. Currently, it must be administered within 3–4.5 h of stroke onset for it to be effective in reducing infarction volume and its functional impact (Bluhmki et al., Lancet Neurol 8:1095–1102, 2009). Other non-FDA treatment approaches have been developed, including intraarterial tPA, mechanical removal of the embolus, penumbra endovascular system devices that suction the embolus through a catheter, antiplatelet and anticoagulant medications, and neuroprotective agents (Fisher et al., Stroke 40:2244–2250, 2009). All of these approaches are time sensitive and depend on the initiation of intervention soon after ischemic onset. Accordingly, there is an obvious need for a reliable and rapid means of detecting and diagnosing acute ischemic stroke to offer timely and appropriate treatment.


Apparent Diffusion Coefficient Magnetic Resonance Angiography Diffusion Weight Image Stroke Onset Compute Tomography Perfusion 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.



The authors wish to thank Dr. Satish Dundamadappa, MD Asst. Prof of Radiology, UMASS Medical School, for providing the images.


  1. 1.
    Lloyd-Jones D, Adams R, Carnethon M, et al. Heart disease and stroke statistics – 2009 update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation. 2009;119(3):480–486.CrossRefPubMedGoogle Scholar
  2. 2.
    Gomez C. Time is brain. J Stroke Cerebrovasc Dis. 1993; 3:12.Google Scholar
  3. 3.
    Saver JL. Time is brain – quantified. Stroke. 2006;37(1): 263–266.CrossRefPubMedGoogle Scholar
  4. 4.
    Bluhmki E, Chamorro A, Davalos A, et al. Stroke treatment with alteplase given 3.0–4.5 h after onset of acute ischaemic stroke (ECASS III): additional outcomes and subgroup ­analysis of a randomised controlled trial. Lancet Neurol. 2009;8(12):1095–1102.CrossRefPubMedGoogle Scholar
  5. 5.
    Fisher M, Feuerstein G, Howells DW, et al. Update of the stroke therapy academic industry roundtable preclinical recommendations. Stroke. 2009;40(6):2244–2250.CrossRefPubMedGoogle Scholar
  6. 6.
    Paciaroni M, Caso V, Agnelli G. The concept of ischemic penumbra in acute stroke and therapeutic opportunities. Eur Neurol. 2009;61(6):321–330.CrossRefPubMedGoogle Scholar
  7. 7.
    Procter AW. Can we reverse ischemic penumbra? Some mechanisms in the pathophysiology of energy-compromised brain tissue. Clin Neuropharmacol. 1990;13(Suppl 3): S34–S39.PubMedGoogle Scholar
  8. 8.
    Astrup J, Siesjo BK, Symon L. Thresholds in cerebral ischemia – the ischemic penumbra. Stroke. 1981;12(6):723–725.PubMedGoogle Scholar
  9. 9.
    Astrup J, Sorensen PM, Sorensen HR. Oxygen and glucose consumption related to Na+-K+ transport in canine brain. Stroke. 1981;12(6):726–730.PubMedGoogle Scholar
  10. 10.
    Atlas SW, ed. MRI Imaging of the Brain and Spine, vol. 1. 3rd ed. Philadelphia: Lippincott Williams & Wilkins; 2008.Google Scholar
  11. 11.
    Gray F et al. Escourolle and Poirier’s Manual of Basic Neuropathology. 4th ed. Philadelphia: Butterworth Heinemann; 2004.Google Scholar
  12. 12.
    Metting Z, Rodiger LA, De Keyser J, van der Naalt J. Structural and functional neuroimaging in mild-to-moderate head injury. Lancet Neurol. 2007;6(8):699–710.CrossRefPubMedGoogle Scholar
  13. 13.
    Lopes L, Sousa R, Ruivo J, Reimao S, Sequeira P, Campos J. The contribution of perfusion CT in stroke. Acta Med Port. 2006;19(6):484–488.PubMedGoogle Scholar
  14. 14.
    Murphy BD, Chen X, Lee TY. Serial changes in CT cerebral blood volume and flow after 4 hours of middle cerebral occlusion in an animal model of embolic cerebral ischemia. AJNR Am J Neuroradiol. 2007;28(4):743–749.PubMedGoogle Scholar
  15. 15.
    Pepper EM, Parsons MW, Bateman GA, Levi CR. CT perfusion source images improve identification of early ischaemic change in hyperacute stroke. J Clin Neurosci. 2006;13(2): 199–205.CrossRefPubMedGoogle Scholar
  16. 16.
    Meuli RA. Imaging viable brain tissue with CT scan during acute stroke. Cerebrovasc Dis. 2004;17(Suppl 3):28–34.CrossRefPubMedGoogle Scholar
  17. 17.
    Hellier KD, Hampton JL, Guadagno JV, et al. Perfusion CT helps decision making for thrombolysis when there is no clear time of onset. J Neurol Neurosurg Psychiatry. 2006;77(3):417–419.CrossRefPubMedGoogle Scholar
  18. 18.
    Detre JA, Alsop DC, Vives LR, Maccotta L, Teener JW, Raps EC. Noninvasive MRI evaluation of cerebral blood flow in cerebrovascular disease. Neurology. 1998;50(3):633–641.PubMedGoogle Scholar
  19. 19.
    Latchaw RE, Yonas H, Pentheny SL, Gur D. Adverse reactions to xenon-enhanced CT cerebral blood flow determination. Radiology. 1987;163(1):251–254.PubMedGoogle Scholar
  20. 20.
    Powers WJ, Zazulia AR. The use of positron emission tomography in cerebrovascular disease. Neuroimaging Clin N Am. 2003;13(4):741–758.CrossRefPubMedGoogle Scholar
  21. 21.
    Yamauchi H, Okazawa H, Kishibe Y, Sugimoto K, Takahashi M. Oxygen extraction fraction and acetazolamide reactivity in symptomatic carotid artery disease. J Neurol Neurosurg Psychiatry. 2004;75(1):33–37.CrossRefPubMedGoogle Scholar
  22. 22.
    Albers GW, Thijs VN, Wechsler L, et al. Magnetic resonance imaging profiles predict clinical response to early reperfusion: the diffusion and perfusion imaging evaluation for understanding stroke evolution (DEFUSE) study. Ann Neurol. 2006;60(5):508–517.CrossRefPubMedGoogle Scholar
  23. 23.
    Davis SM, Donnan GA, Parsons MW, et al. Effects of alteplase beyond 3 h after stroke in the Echoplanar Imaging Thrombolytic Evaluation Trial (EPITHET): a placebo-­controlled randomised trial. Lancet Neurol. 2008;7(4): 299–309.CrossRefPubMedGoogle Scholar
  24. 24.
    Schellinger PD, Thomalla G, Fiehler J, et al. MRI-based and CT-based thrombolytic therapy in acute stroke within and beyond established time windows: an analysis of 1210 patients. Stroke. 2007;38(10):2640–2645.CrossRefPubMedGoogle Scholar
  25. 25.
    Kane I, Carpenter T, Chappell F, et al. Comparison of 10 different magnetic resonance perfusion imaging processing methods in acute ischemic stroke: effect on lesion size, proportion of patients with diffusion/perfusion mismatch, clinical scores, and radiologic outcomes. Stroke. 2007;38(12): 3158–3164.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2011

Authors and Affiliations

  • Shashidhara Nanjundaswamy
  • Ronald A. Cohen
  • Marc Fisher
    • 1
  1. 1.UMASS-Memorial Medical CenterWorcesterUSA

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