19/8/2015

Neuroimagingofacuteischemicstroke

OfficialreprintfromUpToDate
www.uptodate.com2015UpToDate

Neuroimagingofacuteischemicstroke
Author
JamaryOliveiraFilho,MD,
MS,PhD

SectionEditors
ScottEKasner,MD
EricDSchwartz,MD

DeputyEditor
JohnFDashe,MD,PhD

Alltopicsareupdatedasnewevidencebecomesavailableandourpeerreviewprocessiscomplete.
Literaturereviewcurrentthrough:Jul2015.|Thistopiclastupdated:Jul29,2015.
INTRODUCTIONImagingstudiesareusedtoexcludehemorrhageintheacutestrokepatient,toassessthe
degreeofbraininjury,andtoidentifythevascularlesionresponsiblefortheischemicdeficit.SomeadvancedCT
andMRItechnologiesareabletodistinguishbetweenbraintissuethatisirreversiblyinfarctedandthatwhichis
potentiallysalvageable,therebyallowingbetterselectionofpatientslikelytobenefitfromtherapy.Theuseofthis
technologyisdependentuponavailability,anditsroleinguidingtreatmentdecisionsisstillunderstudy.
Neuroimagingduringtheacutephase(firstfewhours)ofanischemicstrokewillbereviewedhere.Otheraspects
oftheacuteevaluationofstroke,theclinicaldiagnosisofvarioustypesofstroke,andthesubacuteandlongterm
assessmentofpatientswhohavehadastrokearediscussedseparately.(See"Initialassessmentand
managementofacutestroke"and"Clinicaldiagnosisofstrokesubtypes"and"Overviewoftheevaluationof
stroke".)
COMPUTEDTOMOGRAPHYThemainadvantagesofCTarewidespreadaccessandspeedofacquisition.In
thehyperacutephase,anoncontrastCT(NCCT)scanisusuallyorderedtoexcludeorconfirmhemorrhageitis
highlysensitiveforthisindication.ANCCTscanshouldbeobtainedassoonasthepatientismedicallystable.
Thepresenceofhemorrhageleadstoverydifferentmanagementandconcernsthananormalscanoronethat
showsinfarction.ImmediateCTscanningofallpatientswithsuspectedstrokeisalsothemostcosteffective
strategywhencomparedwithalternatestrategiessuchasscanningselectedpatientsordelayedratherthan
immediateimaging[1].
TheutilityofCTforacutestrokehasbeenenhancedbytheadventofadditionalCTtechniquesincludingCT
perfusionimaging(CTP)andCTangiography(CTA).MultimodalCTevaluationthatemploysthethreetechniques
(NCCT,CTA,andCTP)combinedshowsimproveddetectionofacuteinfarctionwhencomparedwithNCCT
evaluationalone[25].Inaddition,multimodalevaluationthatincludesCTAandCTPmaypermitassessmentof
thesiteofvascularocclusion,infarctcore,salvageablebraintissueanddegreeofcollateralcirculation[6,7].
EarlysignsofinfarctiononnoncontrastCTThesensitivityofstandardnoncontrastCTforbrainischemia
increasesafter24hours.However,inasystematicreviewinvolving15studieswhereCTscanswereperformed
withinsixhoursofstrokeonset,theprevalenceofearlyCTsignsofbraininfarctionwas61percent(standard
deviation+/21percent)[8].
Earlysignsofinfarctionincludethefollowing[812]:

Hypoattenuationinvolvingonethirdormoreofthemiddlecerebralartery(MCA)territory
Obscurationofthelentiformnucleus
Corticalsulcaleffacement
Focalparenchymalhypoattenuation
LossoftheinsularribbonorobscurationoftheSylvianfissure
Hyperattenuationoflargevessel(eg,"hyperdenseMCAsign")
Lossofgraywhitematterdifferentiationinthebasalganglia

ThepresenceofearlyCTsignsofinfarctionimpliesaworseprognosis.Inthesystematicreview,thepresenceof
thesesignswasassociatedwithanincreasedriskofpoorfunctionaloutcome(oddsratio3.11,95%CI2.773.49)
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[8].
HyperdensityoftheMCA,indicatingthepresenceofthrombusinsidethearterylumen(brightarterysign),canbe
visualizedonnoncontrastCTin30to40percentofpatientswithanMCAdistributionstroke[11,13].Thisfinding
ishighlyspecificforMCAocclusion,althoughitmaybelessusefulforpredictingoutcomethantheotherearlyCT
signs.
WhileearlyCTsignsofinfarctionareassociatedwithaworseoutcome,itremainsunclearwhetherearlyinfarction
signsshouldbeconsideredwhendecidingwhethertouseintravenous(IV)thrombolytictreatmentforacute
ischemicstroke[8].AnanalysisfromtheNINDStrialfoundthatearlyCTsignsofinfarctionwerenot
independentlyassociatedwithincreasedriskofadverseoutcomeafterIValteplase(tPA)treatment,andpatients
treatedwithalteplasedidbetterwhetherornottheyhadearlyCTsigns[14].(See"Reperfusiontherapyforacute
ischemicstroke",sectionon'Intravenousthrombolysis'.)
Carefulattentiontothepresenceofthesesignsbyexperiencedpersonnelisnecessarymistakeshaveoccurred
inupto20percentofcasesinacontrolledsetting[15].Studiesthathaveexaminedtheabilityofneurologists,
neuroradiologists,andgeneralpractitionershavefoundthatearlyinfarctioncanbeverydifficulttorecognizeonCT
[16].However,theimportanceofatrulynormalheadCTinacutestrokeshouldnotbeunderestimateditexcludes
majorischemicdamagewithhighspecificity[17].
StandardizedmethodssuchasASPECTShavebeendevelopedtoaidrecognitionofearlyischemiabecauseof
theknowndifficultyindetectingsuchchanges.Inaddition,accentuatingthecontrastbetweennormaland
edematous(ischemic)braintissuebyvariablewindowwidthandcenterlevelsettingsmayimprovedetectionof
earlyischemicchangeonnoncontrastCT[18].
ASPECTSmethodofassessingischemicchangesTheAlbertastrokeprogramearlyCTscore(ASPECTS)
wasdevelopedtoprovideasimpleandreliablemethodofassessingischemicchangesonheadCTscaninorder
toidentifyacutestrokepatientsunlikelytomakeanindependentrecoverydespitethrombolytictreatment[19].
TheASPECTSvalueiscalculatedfromtwostandardaxialCTcutsoneatthelevelofthethalamusandbasal
ganglia,andonejustrostraltothebasalganglia(figure1andfigure2)[19,20].
ThescoredividestheMCAterritoryinto10regionsofinterest.
Subcorticalstructuresareallottedthreepoints(oneeachforcaudate,lentiformnucleus,andinternal
capsule).
MCAcortexisallottedsevenpoints.FourofthesepointscomefromtheaxialCTcutatthelevelofthe
basalganglia,withonepointforinsularcortexandonepointeachforM1,M2,andM3regions(anterior,
lateral,andposteriorMCAcortex).
ThreepointscomefromtheCTcutjustrostraltothebasalganglia,withonepointeachforM4,M5,andM6
regions(anterior,lateral,andposteriorMCAcortex).
Onepointissubtractedforanareaofearlyischemicchange,suchasfocalswellingorparenchymal
hypoattenuation,foreachofthedefinedregions.
Therefore,anormalCTscanhasanASPECTSvalueof10points,whilediffuseischemicchangethroughoutthe
MCAterritorygivesavalueof0.
UtilityofASPECTSIntheinitialASPECTSstudy,pretreatmentnoncontrastheadCTscansfrom156
patientswithanteriorcirculationischemiatreatedwithintravenousalteplase(IVtPA)wereprospectivelyscored
withASPECTS[19].Thefollowingobservationsweremadeforbaselinevalues.
ASPECTSwasinverselycorrelatedwithstrokeseverity.
ThemedianASPECTSvaluewas8avalueof7orlesswasassociatedwithasharpincreasein
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dependenceanddeathatthreemonths.
ASPECTSpredictedfunctionaloutcomeandsymptomaticintracerebralhemorrhage,withgoodsensitivity
andspecificityforfunctionaloutcome(0.78and0.96)andforintracerebralhemorrhage(ICH)(0.90and0.61).
Theinterandintraobserverreliabilitywasgoodtoexcellentscorereliabilityappearstobegoodwhen
performedinrealtimebytreatingphysiciansascomparedwithexpertreaders[21].
Inaprospectivestudyof100patientswithacuteischemicstroke,theabilitytodetectearlyischemicchangesby
ASPECTSwassimilaronnoncontrastCTanddiffusionweightedimaging(DWI)[22].
ASPECTShasbeenretrospectivelyappliedtobaselineand24hourCTscansforpatientswithmiddlecerebral
arteryocclusionwhowererandomizedtointraarterialthrombolysisorplacebointhePROACTIIstudy[23].
TreatedpatientswithabaselineASPECTS>7hadariskratio(RR)of3.2(95%CI1.29.1)foranindependent
functionaloutcome,whilepatientswithASPECTS7hadaRRof1.0(95%CI0.61.9).
Despiteitspromise,theavailabledatasuggestthatASPECTSanalysisofnoncontrastCTdoesnotidentify
patientswhomaybenefitfromthrombolysis.TheprospectiveCASESobservationalcohortstudyof1135patients
treatedwithIVtPAfoundthateachonepointdecrementinthebaselineASPECTSscoreswasassociatedwitha
lowerprobabilityofindependentfunctionaloutcome(oddsratio0.81,95%CI0.750.87)[24].However,the
ASPECTSscorewasnotapredictorofsymptomaticintracranialhemorrhageinpatientstreatedwithinthe
standardthreehourtimewindow.
SubsequentreportsshowedthattheASPECTSscoreofbaselinenoncontrastCTscansfromtheNINDSand
ECASSIItPAstrokestudieswasnotassociatedwithastatisticallysignificantmodificationoftPAtreatment
effect[25,26].ThisfindingisinagreementwithareportcitedabovefromtheNINDScohort,whichfoundthat
signsofearlyischemicchangeonCTwerenotindependentlyassociatedwithincreasedriskofadverseoutcome
afterIVtPAtreatment[14].(See'EarlysignsofinfarctiononnoncontrastCT'above.)
OneproblemwithASPECTSmaybethatthevarioustypesofparenchymalchangesonnoncontrastCT
consideredtorepresentearlyischemicchangemayactuallyhavedifferentpathophysiologicmechanisms.In
particular,thereisevidencesuggestingthathypoattenuationrepresentsirreversibleinfarction,whereasfocal
swellingmayrepresentpenumbraltissue[27,28].ASPECTSmayhavegreateraccuracyfordetectionofischemic
changeandforidentifyingfinalinfarctvolumewhenusedtoanalyzeCTAsourceimagesandthecontrastCT
imagesobtainedfromCTPthanwhenusedtoanalyzenoncontrastCTimages[29,30].(See'UtilityofCTcontrast
dye'belowand'CTperfusionimaging'below.)
ItisimportanttonotethatASPECTSisnotapplicabletolacunarstroke,brainstemstroke,oranystrokeoutsideof
themiddlecerebralarteryterritory.
UtilityofCTcontrastdyeSpiral(helical)CTandnewgenerationmultidetectorCTscannersincreasescan
speedandallowCTAofbothextracranialandintracranialcerebralarteries.ThespeedoftheseCTunitsalso
offersCTPcapabilities.ThesescanscanbeperformedimmediatelyafterconventionalCTscanning,requiringonly
5to10minutesofadditionaltime.Inpractice,onecanperformbothCTAandCTPduringthesameexamination,
withseparatecontrastboluses[30].
AdvantagesofthesefastCTscansincludetheabilitytorapidlyidentifypatientswithocclusionofthemajor
vesselswithinthecircleofWillisorextracranialcerebralarteries,aswellastheabilitytoevaluatetheperfusion
statusofthebrainparenchyma.Additionalinformationaboutbrainperfusioncanbeobtainedbypostimaging
analysisoftherawdata(orsourceimages)ofCTAandCTPstudies.(See'CTangiography'belowand'CT
perfusionimaging'below.)
CTangiographyCTAisperformedbyadministeringarapidbolusofstandardintravenousCTcontrastthrough
alargeboreintravenouslineintheantecubitalfossa.ThehelicalCTscanistimedtocapturethearrivalofdyeinto
thebrain.DyecanbeseeninthegreatvesselsontherawCTimagestheseserveasdataforthreedimensional
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computerreconstructionsofthecircleofWillisandextracranialcerebralarteries.Clotcausesafillingdefectinthe
vesselonCTA,whichoftencanbeseenontherawimages(alsocalledsourceimages).(See"Principlesof
computedtomographyofthechest".)
Forthedetectionofintracraniallargevesselstenosisandocclusion,CTAinvariousstudieshadsensitivitiesof92
to100percentandspecificitiesof82to100percentwhencomparedwithconventionalangiography[31].The
accuracyofCTAforthediagnosisofextracranialcarotidstenosisisdiscussedseparately.(See"Evaluationof
carotidarterystenosis",sectionon'CTangiography'.)
Recanalizationratesforintravenousorintraarterialthrombolysisdifferdependinguponthesiteofarterialocclusion.
CTAhasbecomethestandardofpracticeinourcentertotriagepatientsbetweenintravenousthrombolysis,
mechanicalthrombectomy,andintraarterialthrombolysis.Itisalsohelpfulindiagnosingstrokemimics.Asan
example,thepatientwithseverebrainstemsignsthoughtduetobasilarthrombosiswhohasanormalbasilar
arteryonCTAdemandsanalternativediagnosis.(See"Differentialdiagnosisoftransientischemicattackand
stroke".)
ThepialarterycollateralvesselsofthebraincanbeassessedusingmultiphaseCTA,whichacquiresbloodflow
informationinthreephasesaftercontrastinjectionthefirstphaseconsistsofconventionalCTAwithimage
acquisitionfromtheaorticarchtoskullvertexduringthepeakarterialphasethesecondandthirdphasesconsist
ofimageacquisitionfromtheskullbasetovertexduringthemidvenousandlatevenousphases[32].Compared
withperfusionCT,advantagesofthismethodincludewholebraincoverage,reducedvulnerabilitytopatient
motion,noneedforadditionalcontrastorpostprocessing,andmorerapiddeterminationofcollateralstatus.Inthe
ESCAPEtrial,thepresenceofmoderatetogoodpialcollateralcirculation,determinedbymultiphaseCTAina
majorityofsubjects,wasoneofthecriteriausedtoselectpatientsformechanicalthrombectomyinthesettingof
acuteischemicstrokecausedbyaproximalintracranialarteryocclusionintheanteriorcirculation[33].(See
"Reperfusiontherapyforacuteischemicstroke",sectionon'Mechanicalthrombectomy'.)
CTAsourceimagesCTAsourceimagescanprovideanestimateofperfusionbytakingadvantageofthe
contrastenhancementinthebrainvasculaturethatoccursduringaCTA[34],potentiallyobviatingtheneedfora
separateCTperfusionstudyandasecondcontrastbolus.CTAsourceimagestypicallycovertheentirebrain,in
contrasttoCTperfusionsourceimagesthatarelimitedtoafewbrainslices.
DuringaCTA,contrastdyefillsthebrainmicrovasculatureinthenormalperfusedtissuethatisaccessibletothe
bloodpoolandappearsasincreasedsignalintensityontheCTAsourceimages.Indistinction,contrastdyedoes
notfillthemicrovasculatureinischemicbrainregionsthatarelessaccessibletothebloodpoolandhavepoor
collateralflow.Theseischemicareasareeasilyseenasregionsofhypoattenuation(lowdensityordark)onCTA
sourceimages(image1)[35,36].
CTAsourceimagesaremoresensitivethannoncontrastCTscansforthedetectionofearlybraininfarction
[31,37].HypoattenuationonCTAsourceimagescorrelateswithischemicedema[36],andwiththeabnormalityon
diffusionweightedMRI[38].Inthissense,CTAsourceimages(orrawimagesofCTperfusionstudies)canbe
consideredasasurrogateforDWI.(See'Diffusionweightedimaging'below.)
CTperfusionimagingUsinganintravenousbolusofCTdye,awholebrain"perfusedbloodvolumemap"can
beobtainedbytimingthescantothepassageofthecontrastdyethroughthebrain[39].Thiscanbeobtainedby
continuingtoscanthebrainduringaCTangiogramorbyusinganewbolusofcontrastfollowingtheCTA.
However,CTPrequiresrepeatedlyscanningthesameportionofthebrainparenchymaoverthetimerequiredfor
thebolustopassthroughthevasculature.
SimilartoCTASI,thesourceimagesoftheCTP(CTPSI)areavailableforanalysis.AswithCTASI,areasof
hypoattenuationonCTPSIshouldcorrelatewithischemicbrainregions.Inaddition,quantitativeanalysisofthe
kineticsofabolusofCTdyepassingthroughthebrainenableestimationofcerebralbloodflow(CBF),cerebral
bloodvolume(CBV),andthemeantransittime(MTT)thatittakesbloodtoflowthroughthetissue.Thresholdsof
CBFandCBVcanbeusedtopredictwhethertissuewilldieorsurvive,butstandardized,reliable,andvalidated
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thresholdshavenotbeendefinitivelyestablished[40,41].
OnestudyfoundthattheASPECTSmethodappliedtoCTPSIorCBVmapswasmoreaccurateforidentifying
irreversibleischemiaandclinicaloutcomethanASPECTSappliedtononcontrastCTorCTASI[30].Inaddition,
ASPECTSappliedtoCBFmapsorMTTappearedtoidentifythemaximalextentofinfarctionintheabsenceof
majorreperfusion,andthedifferencebetweenCTPSI(orCBV)andCBF(orMTT)onASPECTSappearedto
identifyischemictissueatriskforinfarction.Thus,ASPECTSappliedtoCTPanditsmultipleparametricmaps
(CBV,CBV,MTT)holdspromiseforimprovingpatientselectionforintravenousthrombolysisofacuteischemic
stroke,andforextendingthetimewindowbeyondthreehours[30,42].However,thishypothesisshouldbe
confirmedinrandomizedclinicaltrials.
MAGNETICRESONANCEIMAGINGAdvancedMRIimagingtechniqueshavethepotentialforfurtherdefining
strokesubgrouppopulationsthatmaybenefitfromintravenousthrombolysisorinterventionalvasculartreatments
[43].Inaddition,MRIsequencesusinghighsusceptibilitymethods,suchasgradientecho(GRE)pulse
sequences,areequivalenttoCTforthedetectionofacuteintracerebralhemorrhage(ICH)andbetterthanCTfor
thedetectionofchronichemorrhage[4446].ICHcanbediagnosedbyMRIwithupto100percentsensitivityand
accuracybyexperiencedreaders[45].(See"Spontaneousintracerebralhemorrhage:Pathogenesis,clinical
features,anddiagnosis",sectionon'Hemorrhageappearance'.)
BrainMRIprotocolsthatcombineconventionalT1andT2sequenceswithdiffusionweightedimaging(DWI),
perfusionweightedimaging(PWI),andGREcanreliablydiagnosebothacuteischemicstrokeandacute
hemorrhagicstrokeinemergencysettings.TheseMRItechniquesmayobviatetheneedforemergentCTin
centerswherebrainMRIisreadilyavailable.Asanexample,onespecializedstrokecenterfoundthatroutineuse
oftheseMRIsequencestoscreenpatientspriortointravenousthrombolysisforsuspectedischemicstrokewas
practicalandsafe[47].Furthermore,MRIscreeningdidnotcauseexcessivetreatmentdelaysorleadtoworse
outcomes.Ontheotherhand,MRIspecificselectioncriteriaforacutethrombolysisofischemicstrokehavenot
beenvalidated,andnorandomizedstudieshavecomparedCTandMRIscreeninginthissetting.
NewerultrafastMRIimagingprotocolscanreduceacquisitiontimesfromthe15to20minutesrequiredby
conventionalMRItofiveminutesorless,buttheutilityofthesenewermethodsisnotyetestablished[48,49].
DiffusionweightedimagingDWIisbaseduponthecapacityoffastMRItodetectasignalrelatedtothe
movementofwatermoleculesbetweentwocloselyspacedradiofrequencypulses.Thistechniquecandetect
abnormalitiesduetoischemiawithin3to30minutesofonset,[5052],whenconventionalMRIandCTimages
wouldstillappearnormal.
Inacutestroke,swellingoftheischemicbrainparenchymalcellsfollowsfailureoftheenergydependentNaK
ATPasepumpsandisbelievedtoincreasetheratioofintracellulartoextracellularvolumefractions[53].
DWIcontainsanadditionalcomponentofT2effect,andincreasedT2signalduetovasogenicedemacan"shine
through"onDWIimages,makingitdifficulttodistinguishvasogenicfromcytotoxicedemaontheseimages.This
problemcanbeovercomebyuseoftheapparentdiffusioncoefficient(ADC).TheADCprovidesaquantitative
measureofthewaterdiffusion.Inacuteischemicstrokewithcytotoxicedema,decreasedwaterdiffusionin
infarctedtissuecausesincreased(hyperintense)DWIsignalandadecreasedADC,visualizedashypointense
signalonADCmapsofthebrain.Incontrast,vasogenicedemamaycauseincreasedDWIsignalmayoccurdue
toT2shinethrough,butwaterdiffusionisincreased,andincreasedADCisseenashyperintensesignalonADC
maps.
ThedecreaseinADCintheregionoftheinfarctisanecessarytransitiononthewaytoinfarction.Thedecreasein
diffusionintheinfarctistransient,lastingonetotwoweeks.Itthenactuallyreverses,passingthroughaphaseof
pseudonormalizationandlaterbecomingelevatedandbrightonADCmaps[54].DWIabnormalitieslastsomewhat
longerduetotheprominentT2effect,butchronicinfarctionisnotbrightonDWI.
InastudycomparingCT,DWI,andstandardMRI,wefoundthatabnormalDWIwasasensitiveandspecific
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indicatorofischemicstrokeinpatientspresentingwithinsixhoursofsymptomonset[55].Othershaveconfirmed
theseresults[5660].However,occasionalpatientswithacuteischemicdeficitshaveanormalDWI,butfollowup
MRIorCTconfirmsaninfarct[61,62].Insomeofthesepatients,thestrokewasasmallbrainstemlacunein
others,ischemiawasseenonperfusionMRIinregionsthathadnotyetbecomeabnormalonDWI[61].
MRandDWIutilizinghighermagneticfieldstrengthsof3Tesla(T)unitsareincreasinglyavailableinclinical
settings.However,thereisonlylimitedandconflictingevidenceregardingwhetherDWIobtainedusing3TMRI
scannersisbetterforthedetectionofearly(6hours)andsmallinfarctscomparedwithstandard1.5TMRI
[63,64].Althoughseeminglyadvantageousbecauseofimprovedsignaltonoiseratios,highermagneticfield
strengthsalsointroduceincreasedimagingartifactsandgeometricdistortions[65],andtheseartifactsmay
obscureearlyischemicchanges,particularlyinregionsofbrainneartheskullbase[64].Thus,furtherrefinement
ofhigherfieldstrengthDWIimagingisneededtodetermineifsuchimagingisusefulinacuteischemicstroke.
ClinicalutilityofDWIAsystematicreviewpublishedin2010fromtheAmericanAcademyofNeurology
(AAN)concludedthatDWIissuperiortononcontrastCTforthediagnosisofacuteischemicstrokeinpatients
presentingwithin12hoursofsymptomonset[66].Althoughbasedonweakerevidence,theAANconcludedthat
DWImaybeusefulforpredictinglateclinicaloutcomeasmeasuredbytheNationalInstitutesofHealthStroke
ScaleandtheBarthelIndex.
Eveninpatientswithsubacuteischemicstrokewhodelayseekingmedicalattention,DWImayaddclinically
usefulinformationtostandardMRI.Inaprospectiveobservationalstudyof300patientswithsuspectedstrokeor
transientischemicattack(TIA)andamediandelayof17daysfromsymptomonset,DWIcomparedwithT2
providedadditionalclinicalinformationimagingfor108patients(36percent)suchasclarificationofdiagnosisor
vascularterritorythiswasconsideredlikelytochangemanagementin42patients(14percent)[67].
IntheevaluationofacuteischemicstrokeorTIA,thepresenceofmultipleDWIlesionsonthebaselineMRIscan
isassociatedwithanincreasedriskofearlylesionrecurrence[6870].Furthermore,thepresenceofmultipleDWI
lesionsofvaryingages,asdeterminedbytheADCvalue,isanindependentpredictoroffutureischemicevents
[71].
PerfusionweightedimagingDiffusionweightedimagingrevealsevidenceofischemicinjury,notischemia
itself.Incontrast,perfusionweightedimaging(PWI)usesfastMRItechniquestoquantifytheamountofMR
contrastagentreachingthebraintissueafterafastintravenousbolus.Integrationoftheamountofgadolinium
enteringthebrainonfirstpassallowsconstructionofmapsofcerebralbloodvolume.Analysisthatalsoincludes
thetimecourseofarrivalandwashoutpermitstheconstructionofmapsofrelativecerebralbloodflowandmean
transittime.Thelattersensitivelyidentifiestheischemiczone.
PWIcanbeperformedwithstandardMRIandMRangiography,requiringatotalimagingtimeoflessthan15
minutes.AccesstoMRIisusuallythelimitingfactor.
AnothermethodofMRIperfusionimagingiscontinuousarterialspinlabeling(CASL).Insteadofusingan
intravascularcontrastagent,CASLmagneticallylabelsthebloodenteringthebrain.CASLimagingwithin24hours
ofstrokesymptomonsetcandepictperfusiondefectsanddiffusionperfusionmismatches[72].Inaddition,
cerebralbloodflowasymmetryonCASLappearstocorrelatewithstrokeseverityandoutcome.
GuidelinesfromtheAANpublishedin2010concludedthatthebaselinelesionvolumeonPWImaypredict
baselinestrokeseverity,butfoundthatevidencewasinsufficienttosupportorrefutetheutilityofPWIforusein
diagnosingacuteischemicstroke[66].
IdentifyingreversibleischemiaAccurateidentificationofpatientswithreversibleischemicinjuryinthebrain
isimportantforselectingthosepatientsmostlikelytobenefitandleastlikelytobeharmedbyreperfusionand
neuroprotectivetherapy.Inpatientswithacutestroke,thereareoftenareasthatareischemicbutdonotyet
appearabnormalbyDWIorADCmapsonearlyscans.Regionswithdecreasedcerebralbloodvolumeareusually
involvedinthefinalinfarct,whileregionswithnormalcerebralbloodvolumebutlowcerebralbloodflowand
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increasedmeantransittimemayormaynotsurvivetheischemicinsult.
TheexpectationthatPWIandDWIcouldreliablydefinetheischemicpenumbraandinfarctcoreinacutestrokeis
stillunrealized[73].AlthoughPWIcanrevealtheischemiczone,thethresholdsofPWIderivedcerebralbloodflow
andvolumethatmightdiscriminatetheischemicpenumbrafrominfarctcorehavenotbeendefinitivelyestablished
[74].AndwhileDWIcanoftenrevealirreversiblyinfarctedtissue,itisnowclearthatsomeDWIlesionsrepresent
injuredbutstillviabletissue[75,76].Inaddition,whilesomecasesmanifestwitha"classic"mismatchpattern
wheretheischemiccoreonDWIisembeddedwithinahypoperfusedpenumbralbrainregiononPWI(image2),
othersshowa"nonclassic"fragmentedmismatchpatterninwhichpartoralloftheischemicregiononDWIis
dissociatedfromthehypoperfusedregiononPWI(image3)[7779].
ConsensusguidelinesfromtheAmericanHeartAssociationpublishedin2003concludedthatnorecommendation
couldbegiventoemployPWIeithertoguidetheuseofthrombolysisorpredictresultingcomplicationssuchas
postthrombolytichemorrhage[80].AsubsequentreviewevaluatedMRImethodsforselectingpatientsfor
thrombolysisandconcludedthatalthoughDWIandPWIthresholdscandelineateareasofbrainwithhigher
probabilityofinfarctionorsalvage,theirpreciseroleinacutestrokemanagementisnotyetsettled[81].
Despitetheselimitations,DWIandPWIhaveclearutility.
Severeperfusiondefectsinareaswithadiffusionperfusion(DWI/PWI)mismatchmaybeariskfactorfor
lesionenlargement[82,83].
Patientswithanoccludedarteryareatahigherriskforlesionenlargementbygrowthofinfarctionintoareas
ofperfusiondeficit,implyingthatearlyrecanalization(eitherspontaneouslyorwiththrombolyticagents)may
preventlesiongrowth[84].
AbnormalvolumesonDWIandPWIduringanacutestrokecorrelatewellwithinitialNIHstrokescale
scores,chronicscores,andfinallesionvolume,andalsomaypredictearlyneurologicdeterioration[85,86].
SignificantcorrectionoffocalbrainhypoperfusiononPWIaftertPAcanpredictexcellentoutcomeatthree
monthsinischemicstroke[87].
PatientswithacuteischemicstrokemayintheorybeselectedforthrombolytictherapybasedonDWI/PWI
mismatch,therebyallowingextensionoftheconventional3hourwindowofopportunityforacutestroke
thrombolysis[88,89].(See"Reperfusiontherapyforacuteischemicstroke",sectionon'Intravenous
thrombolysis'.)
Thetechniqueofcerebrospinalfluidsuppressedapparentdiffusioncoefficient(ADC)measurementscanreduce
thefalseelevationofADCthatresultsfromcerebrospinalfluid(CSF)artifactandallowforamoreaccurate
identificationofischemictissueatriskforinfarction[90].Thisinformationmayultimatelybemostusefulin
identifyingriskgroupsofpatientswhowouldbenefitfromvarioustherapiessuchasthrombolysisintheacute
setting.
MRangiographyMRangiography(MRA)todetectvascularstenosisorocclusionisdoneatmanycentersas
partofafastMRIprotocolforacuteischemicstroke.Resultsfromacaseseriesshowedthatthecombineduseof
DWIwithMRAwithin24hoursofhospitalizationsubstantiallyimprovedtheearlydiagnosticaccuracyofischemic
strokesubtypes[91].
ContrastenhancedMRAshowspromiseforimprovedimagingofintracraniallargevesselscomparedwiththe
moreestablishedtimeofflighttechnique[92].Forthedetectionofintracraniallargevesselstenosisandocclusion,
contrastenhancedMRAinvariousstudieshadsensitivitiesof86to97percentandspecificitiesof62to91
percentwhencomparedwithconventionalangiography[31].TheaccuracyofMRAforthediagnosisofextracranial
carotidstenosisisdiscussedseparately.(See"Evaluationofcarotidarterystenosis",sectionon'MR
angiography'.)
HighsusceptibilitysequencesIncreasingevidencesupportstheutilityofhighsusceptibilityMRIsequences
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(ie,GREorT2*weightedimages)fortheearlydetectionofacutethrombosisandocclusioninvolvingthemiddle
cerebralartery(MCA)orinternalcarotidartery(ICA)[93,94].Acutethromboticocclusionmayappearonhigh
susceptibilityMRIasahypointense(dark)signalwithintheMCAorICA,ofteninacurvilinearshapethediameter
ofthehypointensesignalislargerthanthatofthecontralateralunaffectedvessel.Thisfindingiscalledthe
susceptibilitysign,anditisanalogoustothehyperdenseMCAsigndescribedforCTimaging.(See'Computed
tomography'above.)
Inaretrospectivereportof42patientswithstrokeintheMCAterritorywhohadMRimaging95to360minutes
fromstrokeonset,apositivesusceptibilitysigncorrespondingtoMCAorICAocclusionwasfoundin30(71
percent)[94].Thespecificityofthesignwas100percent.Theoverallsensitivitywas83percentcomparedwith
MRangiographybutvariedwidelydependingonlocation,from38percentforocclusionsdistaltotheMCA
bifurcationto97percentforocclusionsproximaltotheMCAtrunk.Patientswhohadpositivesusceptibilitysigns
hadsignificantlyhigherNIHSSscores(table1)comparedwithpatientswhodidnothavethesign,butno
significantdifferenceswerefoundforinfarctvolume.
HighsusceptibilityMRIsequencesarealsousefulforthedetectionofacuteintraparenchymalhemorrhage,
especiallyifthisisaconcernafterintraarterialtherapy,asituationwhereretainedcontrastisnoteasily
distinguishedfrombloodonCT[95].(See"Spontaneousintracerebralhemorrhage:Pathogenesis,clinicalfeatures,
anddiagnosis",sectionon'Hemorrhageappearance'.)
CTVERSUSMRITECHNIQUESINHYPERACUTESTROKEThegoalsofveryearlyneuroimagingareto
excludehemorrhageorstrokemimics,detectsignsofearlyinfarction,depicttheinfarctcoreandextentof
perfusiondeficit,revealthestatusoflargecervicalandintracranialarteries,andguidetreatmentdecisions[96].As
alreadynoted,diffusionweightedMRI(DWI)ismoresensitivethanCTfortheearlydetectionofacuteischemia,
andhighsusceptibilityMRIsequencessuchasgradientecho(GRE)arenowknowntobeasgoodasCTforthe
detectionofacutehemorrhage.(See'Magneticresonanceimaging'above.)
Thesepointsareillustratedbyaprospectivesinglecenterstudythatevaluated356patientsreferredbecauseof
suspicionforacutestrokeirrespectiveoftimefromsymptomonset[57].Ofthese,217hadafinalclinical
diagnosisofacutestroke.All356patientshadbothbrainMRI(employingDWIandGRE)andheadCT,with
mediantimesfromsymptomonsettoscanningof6.1and6.5hours,respectively.Assessmentofallbrainimages
wasblindedtoclinicalinformation.
Thefollowingobservationswerereported[57]:
AcuteischemicstrokewasdetectedinmorepatientsbyMRIthanbyCT(46versus10percent),a
differencethatwasstatisticallysignificant
AcuteintracranialhemorrhagedetectionwassimilarwithMRIandCT(6versus7percent)
ThesensitivityforthedetectionofanyacutestrokewasmuchgreaterforMRIthanforCT(83versus26
percent),whilespecificitywassimilar(98versus97percent)
ContraindicationstoMRI(eg,electronicimplants,patientintolerance,ormedicalinstability)ledtothe
exclusionofabout11percentofthe450patientsscreenedforthisstudy
TheseresultssuggestthatMRIcanbeusedastheonlyimagingmethodforpatientswithsuspectedacute
ischemicorhemorrhagicstrokewhohavenoMRIcontraindications.Inaddition,afewreportshavedemonstrated
thatitispossibletouseMRIroutinelyasthesoleneuroimagingscreeningmethodpriortointravenous
thrombolytictherapy[97,98].Inonesuchstudyof135patientsscreenedwithMRIandtreatedwithintravenous
tPA,qualityimprovementprocessesledtoreduceddoortoneedletimesof60minutes[97].
LimitedevidencesuggeststhattheutilityofheadCT,whenperformedwithCTperfusionimaging(CTP),maybe
equaltothatofMRIinhyperacutestrokeevaluation,asfoundinastudyof22patientswhowereevaluatedusing
bothCTandMRItechniqueswithinsixhoursofstrokeonset(averagetimeintervalof2.33hoursforCTand3.0
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hoursforMRI)[99].Thefollowingresultswerenoted:
PerfusionlesionvolumesderivedbyCTPdidnotdifferfromthosederivedbyperfusionweightedimaging
(PWI)forbothtimetopeakmapsandcerebralbloodvolumemaps.
CTASIischemiclesionvolumesdidnotdifferfromDWIischemiclesionvolumes.
LesionvolumesonCTPcerebralbloodflowmapssignificantlycorrelatedwithlesionvolumesonfollowup
noncontrastCT.
OtherstudieshaveshownthattheCTPderivedmapofcerebralbloodvolume(CBV)correlateswiththeMRIDWI
lesionsize[38]andispredictiveofinfarctedbraintissuethatisnotsalvageabledespitereperfusion[35].
ManymorepatientsconsideredforthestudywereeligibleforcontrastenhancedCTthanforMRI(93versus58
percent)[99].ThisreflectsthewellknownproblemthatMRIinpracticeismorelimitedbypatientcontraindications
orintolerancethanCT.Inaddition,MRIislesswidelyavailablethanCToutsideofmajorstrokecenters.
ULTRASOUNDMETHODSCarotidDuplexultrasound(CDUS)andtranscranialDoppler(TCD)ultrasoundare
noninvasivemethodsforneurovascularevaluationoftheextracranialandintracraniallargevessels.Carotidand
vertebralDuplexandTCDhavetraditionallybeenusedindependentlyinanelectivefashiontoevaluatepatients
withtransientischemicattack(TIA)andischemicstrokeofpossiblelargearteryorigin.
Althoughbothmethodsmayhelptoestablishthesourceofanembolicstroke,theyhaverarelybeenusedacutely
forthispurpose.However,accumulatingevidencesuggeststhatbothDuplexandTCDcanbeusedurgentlyat
thebedsidetoselectpatientsforinterventionalthrombolyticorendovasculartreatment[100103].(See'Combined
duplexandTCD'below.)
CarotidandvertebralduplexColorflowguidedduplexultrasoundiswellestablishedasanoninvasive
examinationtoevaluateextracranialatheroscleroticdisease.Thistopicisdiscussedseparately.(See"Evaluation
ofcarotidarterystenosis".)
TranscranialDopplerTCDultrasounduseslowfrequency(2MHz)pulsedsoundtopenetratebonywindows
andvisualizeintracranialvesselsofthecircleofWillis.Itsusehasgainedwideacceptanceinstrokeand
neurologicintensivecareunitsasanoninvasivemeansofassessingthepatencyofintracranialvessels.
Inpatientswithacutestroke,TCDisabletodetectintracranialstenosis,identifycollateralpathways,detect
embolionarealtimebasis,andmonitorreperfusionafterthrombolysis[104106].Majordrawbacksinclude
examinerdependence,poorpatientwindows(unabletoinsonateaflowsignalin15percentofcases),andlow
sensitivityinthevertebrobasilarsystem.
CombinedduplexandTCDThecombinationofurgentduplexandTCDappearstohavehighutilitywhen
performedbyskilledultrasonographers,althoughtheavailabledatacomemainlyfromsmallstudies.Asan
example,astudyof150patientsfoundthatthedetectionofarteriallesionsamenabletointerventionaltreatment
(LAITs)bycombinedduplexandTCD(n=150)atmeantimeof128minutesafterstrokeorTIAonsetwas100
percentsensitiveandspecificcomparedwithdigitalsubtractionangiography(DSA,n=30)[107].Thecombination
ofduplexandTCDdetectedLAITsin96percentofpatientseligibleforthrombolysis.Accuracyoftheindividual
componentswaslowerbutstillgoodduplexultrasoundhadasensitivityandspecificityof96and90percent
comparedwithDSA,whilethatofTCDwas96and75percent.About10percentofpatientshadincompleteTCD
studiesbecauseofinadequatetemporalwindows.
Amajorlimitationofthisapproachisthatmostcentersareunabletoperformexaminationsacutelybecausethey
lacksufficientnumbersofexperiencedultrasonographers.
CONVENTIONALANGIOGRAPHYDigitalsubtractionangiography,themostwidelyusedmethodof
conventionalcatheterbasedangiography,remainsthegoldstandardforevaluatingthecerebralvesselswithregard
todeterminingthedegreeofarterialstenosisandthepresenceofdissection,vasculopathy,vasculitis,oroccult
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lesionssuchasvascularmalformations[31].Inaddition,itprovidesinformationaboutcollateralflowandperfusion
status.
Nevertheless,diagnosticconventionalangiographyisrarelyperformedintheacutesettingfortwomainreasons.
Oneistheavailabilityofthenoninvasivetechniques,suchasCTangiography,MRangiography,duplex
ultrasonography,andtranscranialDopplerultrasound,torapidlyvisualizeintracranialandextracranialarterial
disease.Theotheristheriskofstroke,albeitlow,associatedwithconventionalangiography.
Themajorexceptionissuspectedlargevesselocclusionangiographyismoresensitivethannoninvasivemethods
inthesecasesandoffersthepotentialfor"insitu"treatment.Inaddition,angiographyshowspromisewhen
combinedwithneurointerventionaltechniquesforacuteintraarterialthrombolysisandangioplasty.
Themaindrawbacktoconventionalcerebralangiographyistheriskofstroke(0.14to1percent)andtransient
ischemia(0.4to3percent)[108113].Theriskofneurologiccomplicationsappearstobehigherinpatients55
yearsofage,inpatientswithatheroscleroticcerebrovasculardiseaseorcardiovasculardisease,andwith
fluoroscopictime10minutes[112,113].Clinicallysilentembolismasdetectedbydiffusionweightedmagnetic
resonanceimaging(DWI)mayoccurinupto25percentofcerebralangiographicprocedures[114,115].Therateof
clinicallysilentembolismmaybereducedbyuseofairfiltersandheparin[116],butitisunclearifsuchmethods
reducethemoreimportantclinicalparameterofischemicstroke.
INFORMATIONFORPATIENTSUpToDateofferstwotypesofpatienteducationmaterials,"TheBasics"and
"BeyondtheBasics."TheBasicspatienteducationpiecesarewritteninplainlanguage,atthe5thto6thgrade
readinglevel,andtheyanswerthefourorfivekeyquestionsapatientmighthaveaboutagivencondition.These
articlesarebestforpatientswhowantageneraloverviewandwhoprefershort,easytoreadmaterials.Beyond
theBasicspatienteducationpiecesarelonger,moresophisticated,andmoredetailed.Thesearticlesarewritten
atthe10thto12thgradereadinglevelandarebestforpatientswhowantindepthinformationandarecomfortable
withsomemedicaljargon.
Herearethepatienteducationarticlesthatarerelevanttothistopic.Weencourageyoutoprintoremailthese
topicstoyourpatients.(Youcanalsolocatepatienteducationarticlesonavarietyofsubjectsbysearchingon
"patientinfo"andthekeyword(s)ofinterest.)
Basicstopics(see"Patientinformation:Stroke(TheBasics)")
SUMMARYANDRECOMMENDATIONSOurrecommendationsarebasedupontheavailableliterature,
consensusguidelines[31,117],andclinicalexperience.
Brainimagingplaysavitalroleinacutestrokeby:
Delineatingischemiafromhemorrhage
Estimatingtissueatriskforinfarction
Excludingsomestrokemimics,suchastumor
HeadCTisthepreferredimagingstudyatmostcentersbecauseofwidespreadavailability,rapidscantimes,and
easeofdetectingintracranialhemorrhage.MRIhasanadvantageintheveryearlydetectionofischemiawithDWI
imaging,anditreliablydetectshyperacutehemorrhagewithpropersequencesincludinghighsusceptibilityimages.
AdvancesintheuseofCTangiography(CTA)sourceimagesandCTperfusionimaging(CTP)suggestthatCT
techniquesareincreasinglyabletoprovidecrucialinformationregardingearlyischemiaandperfusionlesionsin
hyperacutestrokeassessment.CTremainsindispensableinthefrequentcircumstancewherethereare
contraindicationstoMRIsuchaspacemakersandpatientintoleranceduetoanxietyormotion.
Brainimagingandacomprehensiveneurovascularevaluationshouldbeobtainedformostpatientssuspected
ofhavingacuteischemicstrokeortransientischemicattack.Neurovascularimagingisimportantinacute
stroketodeterminethepotentialsourcesofembolismorlowflowinischemicstrokeandtodetectpossible
aneurysmsorvesselmalformationsinhemorrhagicstroke.
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Brainimagingisrequiredtoguidetheselectionofacuteinterventionstotreatpatientswithstroke.(See
"Initialassessmentandmanagementofacutestroke"and"Reperfusiontherapyforacuteischemicstroke"
and"Antithrombotictreatmentofacuteischemicstrokeandtransientischemicattack".)
BrainimaginginacuteischemicstrokecanbeobtainedwitheithernoncontrastheadCTorconventional
MRI.Bothimagingtechniquescanbeusedtoexcludeacuteintracerebralhemorrhage.BrainMRIwith
diffusionimagingissuperiortononcontrastCTforthedetectionofacuteischemiaandtheexclusionofsome
strokemimics.However,atpresenttherearenodatatoshowthatMRIissuperiortoCTforselecting
patientswhocouldbetreatedwithintravenousrecombinanttissueplasminogenactivator(alteplase[tPA]).
Thus,MRIshouldbeusedratherthanCTonlyifitdoesnotundulydelaytreatmentwithintravenous
alteplaseinaneligiblepatient.
Whereavailable,assessmentofischemicbraininjuryandbrainperfusionstatuswitheitherdiffusionand
perfusionMRIorwithcontrastCTsourceimagesandperfusionCTshouldbeperformedifthefindingsare
likelytoinfluencetreatmentdecisions,suchasacutethrombolysisorendovascularinterventions.
Neurovascularimagingshouldassesstheextracranial(internalcarotidandvertebral)andintracranial(internal
carotid,vertebral,basilar,andCircleofWillis)largevessels.Noninvasivemethodsarepreferredunless
urgentendovasculartherapyisplanned.MRangiography(MRA),CTA,orthecombinationofultrasound
methods(DuplexandtranscranialDoppler[TCD])canbeused.Conventionalangiographyisusuallyreserved
forsituationswhereacuteintraarterialthrombolysisisbeingconsideredandforfollowupwhennoninvasive
studiesareinconclusive.Availabilityandexpertiseatindividualcentersisamajorfactorinthechoiceofthe
initialnoninvasiveneurovascularstudies.Adetailedcomparisonoftheadvantagesanddisadvantagesof
thesestudiesforthediagnosisofcarotidarterydiseaseisfoundseparately.(See"Evaluationofcarotid
arterystenosis".)
VascularimagingshouldnotdelaytreatmentwithintravenoustPA(alteplase)foreligiblepatientswithacute
ischemicstroke.(See"Reperfusiontherapyforacuteischemicstroke".)
Inselectpatients,neurovascularimagingoftheaorticarch,vertebralarteryorigins,andcommoncarotid
arteriesshouldbeconsideredifclinicalsuspicionforaproximallargearterysourceofstrokeortransient
ischemicattack(TIA)ishigh.UsefulmethodsincludeCTA,timeofflightMRA,andcontrastenhanced
MRA.Inaddition,transesophagealechocardiographyisusefulforassessingtheaorticarch.
Thebrainimagingandneurovascularstudiesshouldnotbeconsideredinisolation,butratherasonepartof
theacutestrokeevaluation.(See"Initialassessmentandmanagementofacutestroke".)
ACKNOWLEDGMENTTheeditorialstaffatUpToDatewouldliketoacknowledgeWalterKoroshetz,MD,who
contributedtoanearlierversionofthistopicreview.
UseofUpToDateissubjecttotheSubscriptionandLicenseAgreement.
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intraarterialcerebralangiography:aprospective,randomizedtrial.Circulation2004110:2210.
117. JauchEC,SaverJL,AdamsHPJr,etal.Guidelinesfortheearlymanagementofpatientswithacute
ischemicstroke:aguidelineforhealthcareprofessionalsfromtheAmericanHeartAssociation/American
StrokeAssociation.Stroke201344:870.
Topic1085Version19.0

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GRAPHICS
ASPECTSstudyform

TheASPECTSvalueiscalculatedfromtwostandardaxialCTcuts:oneatthe
levelofthethalamusandbasalganglia(left),andonejustrostraltothe
basalganglia(right).A:anteriorcirculationP:posteriorcirculationC:
caudateL:lentiformIC:internalcapsuleI:insularribbonMCA:middle
cerebralarteryM1:anteriorMCAcortexM2:MCAcortexlateraltoinsular
ribbonM3:posteriorMCAcortexM4,M5,andM6areanterior,lateral,and
posteriorMCAterritoriesimmediatelysuperiortoM1,M2,andM3,rostralto
basalganglia
Reproducedwithpermissionfrom:Barber,PA,Demchuk,AM,Zhang,J,Buchan,AM.
Validityandreliabilityofaquantitativecomputedtomographyscoreinpredicting
outcomeofhyperacutestrokebeforethrombolytictherapy.ASPECTSStudyGroup.
AlbertaStrokeProgrammeEarlyCTScore.Lancet2000355:1670.Copyright
2000TheLancet.
Graphic72190Version1.0

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ASPECTSstudyformandMCAvariants

(AandB)Righthemisphere,observervariations:lowerandupper
ASPECTSslicesshowasshadedareastheminimalandmaximal
variationsinsizeofthecorticalareasoftheMCA(M1M6)chosenby
sixexpertobservers.Lefthemisphere,ASPECTSstudyform:A=
anteriorcirculationP=posteriorcirculationC=caudateheadL=
lentiformnucleusIC=internalcapsuleI=insularribbonMCA=
middlecerebralarteryM1=anteriorMCAcortexM2=MCAcortex
lateraltoinsularribbonM3=posteriorMCAcortexM4,M5,andM6
areanterior,lateral,andposteriorMCAterritories,respectively,
approximately2cmsuperiortoM1,M2,andM3,respectively,rostral
tobasalganglia.(CandD)CorticalMCAareavariationswithchange
ofbaseline.Intherighthemisphere,thebaselineisparalleltothe
inferiorOMLinthelefthemisphere,thebaselineisthesuperiorOML.
OML=orbitomeatalline.(EandF)NormalvascularvariationsinMCA
sizeonthetwoASPECTSslices.Therighthemisphereshowsthe
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largernormalvariationsdescribedbyvanderZwan*(lightshading).
Thelefthemisphereofeachshowsthesmaller,textbook,variations
(darkshading).
References
*vanderZwan,A,Hillen,B,Tulleken,AF,etal.Variabilityoftheterritoriesor
themajorcerebralarteries.JNeurosurg199277:927.
Osborn,AG.Neuroradiology,Mosby,St.Louis1995.
Reproducedwithpermissionfrom:Pexman,JH,Barber,PA,Hill,MD,etal.Use
oftheAlbertaStrokeProgramEarlyCTScore(ASPECTS)forassessingCT
scansinpatientswithacutestroke.AJNRAmJNeuroradiol200122:1534.
Copyright2001AmericanSocietyofNeuroradiology.
Graphic63480Version1.0

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AcuteischemicstrokeonCTangiographysourceimage

An88yearoldwomanadmittedwithacutelefthemiparesisanddysarthria90
minutesaftertheonsetofsymptoms.BaselinenoncontrastheadCT(A)shows
earlyischemicchangesintherightMCAterritory(arrows).CTASIimage(B)
revealshypoattenuationintherightMCAterritory(arrows),whichcorrespondsto
thefinalinfarct(C)onfollowupCTscan(arrows).
MCA:middlecerebralarteryCTASI:CTangiographysourceimage.
Reproducedwithpermissionfrom:BhatiaR,BalSS,ShobhaN,etal.CTangiographicsource
imagespredictoutcomeandfinalinfarctvolumebetterthannoncontrastCTinproximal
vascularocclusions.Stroke201142:1575.Copyright2011LippincottWilliams&
Wilkins.
Graphic54188Version4.0

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ClassicpatternofDWIPWImismatch

Representativecasewithclassicpatternofmismatch.
(A)Diffusionweightedimage(DWI).
(B)DWIabnormallesion(showninred)andhypoperfusionlesion(showningreen)
superimposedonDWI.
(C)DWIabnormallesionandhypoperfusionlesionwithbrainimage(DWI)removed.
DWI:diffusionweightedimagePWI:perfusionweightedimage.
Reproducedwithpermissionfrom:OgataT,NagakaneY,ChristensenS,etal.Atopographic
studyoftheevolutionoftheMRDWI/PWImismatchpatternanditsclinicalimpact:astudyby
theEPITHETandDEFUSEInvestigators.Stroke201142:1596.Copyright2011Lippincott
Williams&Wilkins.
Graphic82701Version4.0

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NonclassicpatternofDWIPWImismatch

Representativecasewithnonclassicpatternofmismatch.
(A)Diffusionweightedimage(DWI).
(B)DWIabnormallesion(red)andhypoperfusionlesion(green)superimposedon
DWI.Notefragmentationofthepattern.
(C)DWIabnormallesionandhypoperfusionlesionwithbrainimage(DWI)removed.
DWI:diffusionweightedimagePWI:perfusionweightedimage.
Reproducedwithpermissionfrom:OgataT,NagakaneY,ChristensenS,etal.Atopographic
studyoftheevolutionoftheMRDWI/PWImismatchpatternanditsclinicalimpact:astudyby
theEPITHETandDEFUSEInvestigators.Stroke201142:1596.Copyright2011Lippincott
Williams&Wilkins.
Graphic72178Version4.0

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NationalInstitutesofHealthStrokeScale(NIHSS)
Administerstrokescaleitemsintheorderlisted.Recordperformanceineachcategoryaftereach
subscaleexam.Donotgobackandchangescores.Followdirectionsprovidedforeachexam
technique.Scoresshouldreflectwhatthepatientdoes,notwhattheclinicianthinksthepatient
cando.Theclinicianshouldrecordanswerswhileadministeringtheexamandworkquickly.Except
whereindicated,thepatientshouldnotbecoached(ie,repeatedrequeststopatienttomakea
specialeffort).

Instructions

Scaledefinition

1a.Levelofconsciousness:The

0=Alertkeenlyresponsive.

investigatormustchoosearesponseifa
fullevaluationispreventedbysuch
obstaclesasanendotrachealtube,

1=Notalertbutarousablebyminor
stimulationtoobey,answer,orrespond.

languagebarrier,orotracheal
trauma/bandages.A3isscoredonlyifthe
patientmakesnomovement(otherthan
reflexiveposturing)inresponsetonoxious
stimulation.

Score

2=Notalertrequiresrepeated
stimulationtoattend,orisobtundedand
requiresstrongorpainfulstimulationto
makemovements(notstereotyped).

_____

3=Respondsonlywithreflexmotoror
autonomiceffectsortotallyunresponsive,
flaccid,andareflexic.

1b.LOCquestions:Thepatientisasked

0=Answersbothquestionscorrectly.

themonthandhis/herage.Theanswer
mustbecorrectthereisnopartialcredit
forbeingclose.Aphasicandstuporous
patientswhodonotcomprehendthe
questionswillscore2.Patientsunableto
speakbecauseofendotrachealintubation,
orotrachealtrauma,severedysarthria
fromanycause,languagebarrier,orany
otherproblemnotsecondarytoaphasia
aregivena1.Itisimportantthatonlythe

1=Answersonequestioncorrectly.
2=Answersneitherquestioncorrectly.

_____

initialanswerbegradedandthatthe
examinernot"help"thepatientwith
verbalornonverbalcues.
1c.LOCcommands:Thepatientisasked
toopenandclosetheeyesandthento
gripandreleasethenonparetichand.
Substituteanotheronestepcommandif
thehandscannotbeused.Creditisgiven
ifanunequivocalattemptismadebutnot
completedduetoweakness.Ifthepatient
doesnotrespondtocommand,thetask
shouldbedemonstratedtohimorher
(pantomime),andtheresultscored(ie,
followsnone,oneortwocommands).
Patientswithtrauma,amputation,or
otherphysicalimpedimentsshouldbe
givensuitableonestepcommands.Only

0=Performsbothtaskscorrectly.
1=Performsonetaskcorrectly.
2=Performsneithertaskcorrectly.

_____

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thefirstattemptisscored.
2.Bestgaze:Onlyhorizontaleye
movementswillbetested.Voluntaryor
reflexive(oculocephalic)eyemovements
willbescored,butcalorictestingisnot
done.Ifthepatienthasaconjugate
deviationoftheeyesthatcanbe
overcomebyvoluntaryorreflexive
activity,thescorewillbe1.Ifapatient
hasanisolatedperipheralnerveparesis
(CNIII,IVorVI),scorea1.Gazeis
testableinallaphasicpatients.Patients
withoculartrauma,bandages,preexisting
blindness,orotherdisorderofvisualacuity
orfieldsshouldbetestedwithreflexive
movements,andachoicemadebythe
investigator.Establishingeyecontactand
thenmovingaboutthepatientfromside

0=Normal.
1=Partialgazepalsygazeisabnormal
inoneorbotheyes,butforceddeviationor
totalgazeparesisisnotpresent.
2=Forceddeviation,ortotalgaze
paresisnotovercomebytheoculocephalic
maneuver.
_____

tosidewilloccasionallyclarifythepresence
ofapartialgazepalsy.
3.Visual:Visualfields(upperandlower
quadrants)aretestedbyconfrontation,
usingfingercountingorvisualthreat,as
appropriate.Patientsmaybeencouraged,
butiftheylookatthesideofthemoving
fingersappropriately,thiscanbescoredas
normal.Ifthereisunilateralblindnessor
enucleation,visualfieldsintheremaining

0=Novisualloss.
1=Partialhemianopia.
2=Completehemianopia.
3=Bilateralhemianopia(blind
includingcorticalblindness).
_____

eyearescored.Score1onlyifaclearcut
asymmetry,includingquadrantanopia,is
found.Ifpatientisblindfromanycause,
score3.Doublesimultaneousstimulation
isperformedatthispoint.Ifthereis
extinction,patientreceivesa1,andthe
resultsareusedtorespondtoitem11.
4.Facialpalsy:Askorusepantomime
toencouragethepatienttoshowteeth
orraiseeyebrowsandcloseeyes.Score
symmetryofgrimaceinresponseto
noxiousstimuliinthepoorlyresponsiveor
noncomprehendingpatient.Iffacial
trauma/bandages,orotrachealtube,tape
orotherphysicalbarriersobscuretheface,
theseshouldberemovedtotheextent
possible.

0=Normalsymmetricalmovements.
1=Minorparalysis(flattenednasolabial
fold,asymmetryonsmiling).
2=Partialparalysis(totalorneartotal
paralysisoflowerface).

_____

3=Completeparalysisofoneorboth
sides(absenceoffacialmovementinthe
upperandlowerface).

5.Motorarm:Thelimbisplacedinthe

0=Nodriftlimbholds90(or45)

appropriateposition:extendthearms
(palmsdown)90degrees(ifsitting)or45
degrees(ifsupine).Driftisscoredifthe

degreesforfull10seconds.
1=Driftlimbholds90(or45)degrees,
butdriftsdownbeforefull10seconds

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armfallsbefore10seconds.Theaphasic

doesnothitbedorothersupport.

patientisencouragedusingurgencyinthe
voiceandpantomime,butnotnoxious
stimulation.Eachlimbistestedinturn,
beginningwiththenonpareticarm.Only
inthecaseofamputationorjointfusionat

2=Someeffortagainstgravitylimb
cannotgettoormaintain(ifcued)90(or

theshoulder,theexaminershouldrecord
thescoreasuntestable(UN),andclearly
writetheexplanationforthischoice.

45)degrees,driftsdowntobed,buthas
someeffortagainstgravity.

_____

3=Noeffortagainstgravitylimbfalls.
4=Nomovement.
UN=Amputationorjointfusion,
explain:________________
5a.Leftarm
5b.Rightarm

6.Motorleg:Thelimbisplacedinthe
appropriateposition:holdthelegat30
degrees(alwaystestedsupine).Driftis
scoredifthelegfallsbefore5seconds.The
aphasicpatientisencouragedusing
urgencyinthevoiceandpantomime,but
notnoxiousstimulation.Eachlimbis
testedinturn,beginningwiththenon
pareticleg.Onlyinthecaseofamputation
orjointfusionatthehip,theexaminer
shouldrecordthescoreasuntestable
(UN),andclearlywritetheexplanationfor
thischoice.

0=Nodriftlegholds30degreeposition
forfull5seconds.
1=Driftlegfallsbytheendofthe5
secondperiodbutdoesnothitbed.
2=Someeffortagainstgravityleg
fallstobedby5seconds,buthassome
effortagainstgravity.
3=Noeffortagainstgravitylegfallsto

_____

bedimmediately.
4=Nomovement.
UN=Amputationorjointfusion,
explain:________________
6a.Leftleg
6b.Rightleg

7.Limbataxia:Thisitemisaimedat
findingevidenceofaunilateralcerebellar
lesion.Testwitheyesopen.Incaseof
visualdefect,ensuretestingisdonein
intactvisualfield.Thefingernosefinger
andheelshintestsareperformedonboth
sides,andataxiaisscoredonlyifpresent
outofproportiontoweakness.Ataxiais
absentinthepatientwhocannot

0=Absent.
1=Presentinonelimb.
2=Presentintwolimbs.
UN=Amputationorjointfusion,
explain:________________

_____

understandorisparalyzed.Onlyinthe
caseofamputationorjointfusion,the
examinershouldrecordthescoreas
untestable(UN),andclearlywritethe
explanationforthischoice.Incaseof
blindness,testbyhavingthepatienttouch
nosefromextendedarmposition.
8.Sensory:Sensationorgrimaceto
pinprickwhentested,orwithdrawalfrom
noxiousstimulusintheobtundedor

0=Normalnosensoryloss.
1=Mildtomoderatesensoryloss
patientfeelspinprickislesssharporisdull

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aphasicpatient.Onlysensoryloss
attributedtostrokeisscoredasabnormal
andtheexaminershouldtestasmany
bodyareas(arms[nothands],legs,trunk,
face)asneededtoaccuratelycheckfor
hemisensoryloss.Ascoreof2,"severeor
totalsensoryloss,"shouldonlybegiven
whenasevereortotallossofsensation
canbeclearlydemonstrated.Stuporous
andaphasicpatientswill,therefore,
probablyscore1or0.Thepatientwith
brainstemstrokewhohasbilaterallossof

ontheaffectedsideorthereisalossof
superficialpainwithpinprick,butpatientis
awareofbeingtouched.
2=Severetototalsensoryloss
patientisnotawareofbeingtouchedin
theface,arm,andleg.

_____

sensationisscored2.Ifthepatientdoes
notrespondandisquadriplegic,score2.
Patientsinacoma(item1a=3)are
automaticallygivena2onthisitem.
9.Bestlanguage:Agreatdealof
informationaboutcomprehensionwillbe
obtainedduringtheprecedingsectionsof
theexamination.Forthisscaleitem,the
patientisaskedtodescribewhatis
happeningintheattachedpicture,to
nametheitemsontheattachednaming
sheetandtoreadfromtheattachedlistof
sentences.Comprehensionisjudgedfrom
responseshere,aswellastoallofthe
commandsintheprecedinggeneral
neurologicalexam.Ifvisuallossinterferes
withthetests,askthepatienttoidentify
objectsplacedinthehand,repeat,and
producespeech.Theintubatedpatient
shouldbeaskedtowrite.Thepatientina
coma(item1a=3)willautomaticallyscore
3onthisitem.Theexaminermustchoose
ascoreforthepatientwithstuporor
limitedcooperation,butascoreof3should
beusedonlyifthepatientismuteand
followsnoonestepcommands.

0=Noaphasianormal.
1=Mildtomoderateaphasiasome
obviouslossoffluencyorfacilityof
comprehension,withoutsignificant
limitationonideasexpressedorformof
expression.Reductionofspeechand/or
comprehension,however,makes
conversationaboutprovidedmaterials
difficultorimpossible.Forexample,in
conversationaboutprovidedmaterials,
examinercanidentifypictureornaming
cardcontentfrompatient'sresponse.

_____

2=Severeaphasiaallcommunication
isthroughfragmentaryexpressiongreat
needforinference,questioning,and
guessingbythelistener.Rangeof
informationthatcanbeexchangedis
limitedlistenercarriesburdenof
communication.Examinercannotidentify
materialsprovidedfrompatientresponse.
3=Mute,globalaphasianousable
speechorauditorycomprehension.

10.Dysarthria:Ifpatientisthoughtto
benormal,anadequatesampleofspeech
mustbeobtainedbyaskingpatienttoread
orrepeatwordsfromtheattachedlist.If
thepatienthassevereaphasia,theclarity
ofarticulationofspontaneousspeechcan
berated.Onlyifthepatientisintubatedor
hasotherphysicalbarrierstoproducing
speech,theexaminershouldrecordthe
scoreasuntestable(UN),andclearlywrite
anexplanationforthischoice.Donottell

0=Normal.
1=Mildtomoderatedysarthria
patientslursatleastsomewordsand,at
worst,canbeunderstoodwithsome
difficulty.
2=Severedysarthriapatient'sspeech
issoslurredastobeunintelligibleinthe
absenceoforoutofproportiontoany
dysphasia,orismute/anarthric.

_____

UN=Intubatedorotherphysicalbarrier,

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thepatientwhyheorsheisbeingtested.

explain:________________

11.Extinctionandinattention
(formerlyneglect):Sufficient
informationtoidentifyneglectmaybe
obtainedduringthepriortesting.Ifthe

0=Noabnormality.

patienthasaseverevisuallosspreventing
visualdoublesimultaneousstimulation,
andthecutaneousstimuliarenormal,the
scoreisnormal.Ifthepatienthasaphasia
butdoesappeartoattendtobothsides,
thescoreisnormal.Thepresenceofvisual
spatialneglectoranosognosiamayalsobe
takenasevidenceofabnormality.Since

1=Visual,tactile,auditory,spatial,or
personalinattentionorextinctionto
bilateralsimultaneousstimulationinoneof
thesensorymodalities.
2=Profoundhemiinattentionor
extinctiontomorethanonemodality
doesnotrecognizeownhandororientsto
onlyonesideofspace.

_____

theabnormalityisscoredonlyifpresent,
theitemisneveruntestable.

_____

Adaptedfrom:GoldsteinLB,SamsaGP,Stroke199728:307.
Graphic61698Version4.0

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Disclosures
Disclosures:JamaryOliveiraFilho,MD,MS,PhDNothingtodisclose.ScottEKasner,MD
Grant/Research/ClinicalTrialSupport:WLGoreandAssociates[PFO,stroke(HELEX,GSOdevices)]
AstraZeneca[Stroke(Ticagrelor)].Consultant/AdvisoryBoards:Medtronic[Stroke,atrialfibrillation
(CoreValve,REVEAL)]Merck[Stroke]Pfizer[Stroke]Novartis[Stroke]GSK[Stroke]AbbVie[Stroke]
DaiichiSankyo[Stroke]BoehringerIngelheim[Stroke].EricDSchwartz,MDNothingtodisclose.John
FDashe,MD,PhDNothingtodisclose.
Contributordisclosuresarereviewedforconflictsofinterestbytheeditorialgroup.Whenfound,theseare
addressedbyvettingthroughamultilevelreviewprocess,andthroughrequirementsforreferencestobe
providedtosupportthecontent.Appropriatelyreferencedcontentisrequiredofallauthorsandmust
conformtoUpToDatestandardsofevidence.
Conflictofinterestpolicy

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