The role of computed tomography in evaluation of the early signs of acute ischemic stroke
Abstract
A stroke is a sudden loss of brain function which happens due to the disruption of cerebral blood flow. It is characterized by expeditious development of clinical symptoms during first few minutes or hours after which symptoms progress and in some patients lead to death. In more than 80% of patients with stroke, the cause is vascular insufficiency and this type of stroke is called ischemic. It is an emergent condition which needs accelerated management so that optimum care and prognosis can be reached. Evaluation of the ischemic stroke is managed with noncontrast computed tomography in most cases, thanks to its widespread avalability.
A detailed literature search through the Medline and Ebsco databases was performed, using the following terms: (computed tomography) AND (acute ischemic stroke) AND (early signs).We selected original investigations, meta-analyses and reviews from the past 10 years, with accessible full-texts, in the English language, as well as significant reference lists of articles which could contribute to the readers’ comprehension. After detailed review of the literature, we have segregated and described following early signs in acute ischemic stroke: insular ribbon sign, obscuration of the lentiform nucleus, hyperdense artery sign, hemispherical sulcal effacement and focal hypoattenuation. . These signs are related to consequences of cellular hypoperfusion and cytotoxic oedema.
The aim of this paper was to review the literature regarding the role of computed tomography in patients with early signs of acute ischemic stroke and to serve as an educational material that illustrates those findings.
References
Alawneh JA, Clatworthy PL, Morris RS, Warburton E. Stroke management. Clin Evid 2011;6:201.
World Health Organization. The world health report. Geneva, Switzerland 2004.
Lloyd-Jones D, Adams RJ, Brown TM, et al. Executive summary: heart disease and stroke statistics--2010 update: a report from the American Heart Association. Circulation 2010;121(7):948–54.
Malaysian Society of Neuroscience. Clinical Practice Guidelines: Management of ischaemic stroke. second edition ed. 2011.
Tharakan J. Stroke registry-relevance and contributions. Medical Journal of Malaysia 2012; 67: 251-2.
Astrup J, Siesjo BK, Symon L. Thresholds in cerebral ischemia - the ischemic penumbra. Stroke 1981;12(6):723–5.
Hossmann KA. Viability thresholds and the penumbra of focal ischemia. Ann Neurol 1994;36(4):557–65.
Hossmann KA. Neuronal survival and revival during and after cerebral ischemia. Am J Emerg Med 1983;1(2):191–7.
Leiva-Salinas C, Wintermark M. Imaging of Ischemic Stroke. Neuroimaging Clin N Am 2010 ; 20(4): 455–468.
Mayer TE, Hamann GF, Baranczyk J, et al. Dynamic CT perfusion imaging of acute stroke. AJNR Am J Neuroradiol 2000;21(8):1441–9.
Read SJ, Hirano T, Abbott DF, et al. The fate of hypoxic tissue on 18F fluoromisonidazole positron emission tomography after ischemic stroke. Ann Neurol 2000;48(2):228–35.
Schröder J, Thomalla G. A critical review of alberta stroke program early CT score for evaluation of acute stroke imaging. Front Neurol 2017; 7:245.
Darby DG, Barber PA, Gerraty RP, et al. Pathophysiological topography of acute ischemia by combined diffusion-weighted and perfusion MRI. Stroke 1999;30(10):2043–52.
Hacke W, Donnan G, Fieschi C, et al. Association of outcome with early stroke treatment: pooled analysis of ATLANTIS, ECASS, and NINDS rt-PA stroke trials. Lancet 2004; 363(9411):768–74.
Abul-Kasim K, Brizzi M, Petersson J, Sundgren PC. Added diagnostic utility of CT perfusion and CT angiography in acute ischemic stroke. Evaluation of three different patient categories. Funct Neurol 2009;24(2):93-8.
Bader MK, Palmer S. What's the "hyper" in hyperacute stroke? Strategies to improve outcomes in ischemic stroke patients presenting within 6 hours. AACN Adv Crit Care 2006;17(2):194-214.
Schellinger PD, Warach S. Therapeutic time window of thrombolytic therapy following stroke. Curr Atheroscler Rep 2004;6(4):288–94.
Sperber C, Karnath HO. Topography of acute stroke in a sample of 439 right brain damaged patients. Neuroimage Clin 2015; 10:124-8.
González RG, Schwamm LH. Imaging acute ischemic stroke. Handb Clin Neurol 2016;135:293-315.
Ambrose J. Computerized transverse axial scanning (tomography): part 2. Clinical application. Br J Radiol 1973; 46:1023-47.
Ambrose J. Computerized x-ray scanning of the brain. J Neurosurg 1974; 40:679-95.
Cronquist S, Brismar J, Jellin K. Computer assisted axial tomography in cerebrovascular lesions. Acta Radiol Diagn 1975; 16:135-41.
Rodríguez-Rivera IV, Santiago F, Estapé ES, González-Sepúlveda L, Brau R. Impact of day of the week and time of arrival on ischemic stroke management. P R Health Sci J 2015; 34(3):164-9.
Eastwood JD, Lev MH, Azhari T et al. CT perfusion scanning with deconvolution analysis: pilot study in patients with acute middle cerebral artery stroke. Radiology 2002; 222:227-36.
Kloska SP, Fischer T, Nabavi DG, Dittrich R, Ditt H, Klotz E, Fischbach R, Ringelstein EB, Heindel W. Color-coded perfused blood volume imaging using mutidetector CT: initial results of whole-brain perfusion analysis in acute cerebral ischemia. Eur Radiol, 2007; 17(9):2352-8.
Lev MH, Farkas J, Rodriguez VR et al. CT angiography in the rapid triage of patients with hyperacute stroke to intraarterial thrombolysis: accuracy in the detection of large vessel thrombus. J Comput Assist Tomogr 2001; 25:520-8
Camargo EC, Furie KL, Singhal AB, Roccatagliata L, Cunnane ME, Halpern EF, Harris GJ, Smith WS, Gonzalez RG, Koroshetz WJ, Lev MH. Acute brain infarct: detection and delineation with CT angiographic source images versus nonenhanced CT scans. Radiology 2007; 244(2):541-8.
Radhiana H, Syazarina S O, Shahizon Azura M M, Hilwati H, Sobri M A. Non-contrast computed tomography in acute ischaemic stroke: a pictorial review. Med J Malaysia 2013 ;68(1):93-100.
Schaefer PW, Ozsunar Y, He J, Hamberg LM, Hunter GJ, Sorensen AG, Koroshetz WJ, Gonzalez RG. Assessing tissue viabillity with MR diffusion and perfusion imaging. Am J Neuroradiol 2003; 24:436-43.
Wu O, Koroshetz WJ, Ostergaard L et al. Predicting tissue outcome in acute human cerebral ischemia using combined diffusion- and perfusion-weighted MR imaging. Stroke 2001; 32:933-42.
Dimic N, Vojinovic R. Rani CT znaci infarkta mozga – ucestalost i znacaj. PONS 2012; 10(1):3-6.
Hacke W, Kaste M, Fieschi C, et al. Randomised double-blind placebo controlled trial of thrombolytic therapy with intravenous alteplase in acute ischaemic stroke (ECASS II): Second Europian-Australian acute stroke study investigators. Lancet 1998; 352: 1245-51.
Qureshi AI, Saleem MA, Aytaç E, Malik AA. The effect of diagnostic catheter angiography on outcomes of acute ischemic stroke patients being considered for endovascular treatment. J Vasc Interv Neurol 2017; 9(3):45-50.
Pavabvash S, Taleb S, Majidi S, Qureshi AI. Correlation of acute M1 middle cerebral artery thrombus location with endovascular treatment success and clinical outcome. J Vasc Interv Neurol 2017; 9(3):17-22.
Coutts SB, O`Reilly C, Hill MD, Steffenhagen N, Poppe AY, Boyko MJ, Puetz VJ, Demchuk AM. Calgari study group. Computed tomography and computed tomography angiography findings predict functional impairment in patients with minor stroke and transient ischemic attack. Int J Stroke 2009; 4(6):448-53.
Salomon EJ, Barfett J, Willems PW, et al. Dynamic CT angiography and CT perfusion employing a 320-detector row CT: protocol and current clinical applications. Klin Neuroradiol 2009;19(3):187–96.
Gomolka RS, Chrzan RM, Urbanik A, Nowinski WL. A quantitative method using head noncontrast CT scans to detect hyperacute nonvisible ischemic changes in patients with stroke. J Neuroimaging 2016; 26(6):581-7.
Noguchi K, Itoh T, Naruto N, Takashima S, Tanaka K, Kuroda S. A novel imaging technique (x-map) to identify acute ischemic lesions using noncontrast dual-energy computed tomography. J Stroke Cerebrovasc Dis 2017; 26(1):34-41.
Wardlaw JM, Mielke O. Early signs of brain infarction at CT: observer reliability and outcome after thrombolytic treatment-systematic review. Radiology 2005; 235: 444-53.
Vojinovic R. Mogućnosti kompjuterizovane tomografije u ranoj dijagnostici infarkta mozga. Doktorska disertacija. Fakultet medicinskih nauka u Kragujevcu, 2012.
Gacs G, Fox AJ, Barnett HJM et al. CT visualization of intracranial arterial thromboembolism. Stroke 1983; 14:756-62.
Somford DM, Nederkoorn PJ, Rutgers DR, Kappelle LJ, Mali WP, van der Grond J. Proximal and distal hyperattenuating middle cerebral artery signs at CT: different prognostic implications. Radiology 2002; 223(3):667-71.
Koga M, Saku Y, Toyoda K, Takaba H, Ibayashi S, Iida M. Reappraisal of early CT signs to predict the arterial occlusion site in acute embolic stroke. J Neurol Neurosurg Psychiatry 2003; 74: 649-53.
Truwit CL, Barkovich AJ, Gean-Marton A, Hibri B, Norman D. Loss of the insular ribbon: another early CT sign of acute middle cerebral artery infarction. Radiology 1990; 176: 801-06.
Furlan AJ, Eyding D, Albers GW, et al. Dose escalation of desmoteplase for acute ischemic stroke (DEDAS): evidence of safety and efficacy 3 to 9 hours after stroke onset. Stroke 2006;37(5):1227–31.
Jensen UR, Weiss M, Zimmermann P, Jansen O, Riedel C. The hyperdense anterior cerebral artery sign (HACAS) as a computed tomography marker for acute ischemia in the anterior cerebral artery territory. Cerebrovasc Dis 2010; 29(1):62-7.
Leary MC, Kidwell CS, Villablanca JP, Starkman S. Jahan R, Duckwiler GR et al. Validation of computed tomographic middle cerebral artery «dot» sign: an angiographyc correlation study. Stroke 2003; 34(11):2636-40.
Jha B, Kothari M. Pearls & oy-sters: hyperdense or pseudohyperdense MCA sign: a Damocles sword? Neurology 2009; 72(23):e116-7.
Pikija S, Magdic J, Trkulja V, et al. Intracranial thrombus morphology and composition undergoes time-dependent changes in acute ischemic stroke: a CT densitometry study. Int J Mol Sci 2016;17(11). pii: E1959.