Magnetic Resonance Imaging in Acute Ischemic Stroke Patients with Mild Symptoms: An Opportunity to Standardize Intravenous Thrombolysis

Background Intravenous thrombolysis with alteplase within a time window up to 4.5 h is the only approved pharmacological treatment for acute ischemic stroke. We studied whether acute ischemic stroke patients with penumbral tissue identified on magnetic resonance imaging 4.5–9 h after symptom onset benefit from intravenous thrombolysis compared to placebo. Methods Acute ischemic stroke patients with salvageable brain tissue identified on a magnetic resonance imaging were randomly assigned to receive standard dose alteplase or placebo. The primary end point was disability at 90 days assessed by the modified Rankin scale, which has a range of 0–6 (with 0 indicating no symptoms at all and 6 indicating death). Safety end points included death, symptomatic intracranial hemorrhage, and other serious adverse events. Results The trial was stopped early for slow recruitment after the enrollment of 119 (61 alteplase, 58 placebo) of 264 patients planned. Median time to intravenous thrombolysis was 7 h 42 min. The primary endpoint showed no significant difference in the modified Rankin scale distribution at day 90 (odds ratio alteplase versus placebo, 1.20; 95% CI, 0.63–2.27, P = 0.58). One symptomatic intracranial hemorrhage occurred in the alteplase group. Mortality at 90 days did not differ significantly between the two groups (11.5 and 6.8%, respectively; P = 0.53). Conclusions Intravenous alteplase administered between 4.5 and 9 h after the onset of symptoms in patients with salvageable tissue did not result in a significant benefit over placebo. (Supported by Boehringer Ingelheim, Germany; ISRCTN 71616222).

Download Full-text

Reliability of fast magnetic resonance imaging for acute ischemic stroke patients using a 1.5-T scanner

European Radiology ◽

10.1007/s00330-018-5812-5 ◽

2018 ◽

Vol 29 (5) ◽

pp. 2641-2650 ◽

Cited By ~ 4

Author(s):

Mi Sun Chung ◽

Ji Ye Lee ◽

Seung Chai Jung ◽

Seunghee Baek ◽

Woo Hyun Shim ◽

...

Keyword(s):

Magnetic Resonance Imaging ◽

Ischemic Stroke ◽

Magnetic Resonance ◽

Acute Ischemic Stroke ◽

Resonance Imaging ◽

Stroke Patients ◽

Fast Magnetic Resonance Imaging

Download Full-text

Comparison of T2*GRE and DSC-PWI for hemorrhage detection in acute ischemic stroke patients: Pooled analysis of the EPITHET, DEFUSE 2, and SENSE 3 stroke studies

International Journal of Stroke ◽

10.1177/1747493019858781 ◽

2019 ◽

Vol 15 (2) ◽

pp. 216-225

Author(s):

Shalini A Amukotuwa ◽

Nancy J Fischbein ◽

Gregory W Albers ◽

Stephen Davis ◽

Geoffrey A Donnan ◽

...

Keyword(s):

Magnetic Resonance Imaging ◽

Ischemic Stroke ◽

Magnetic Resonance ◽

Confidence Interval ◽

Acute Ischemic Stroke ◽

Kappa Statistic ◽

Hemorrhagic Transformation ◽

Dynamic Susceptibility ◽

Resonance Imaging ◽

Stroke Patients

Aims The objective of this study was to compare the diagnostic performance of the baseline pre-contrast images of dynamic susceptibility contrast perfusion-weighted imaging (DSC-PWI) with conventional T2*gradient recalled echo (GRE) imaging for detection of hemorrhage in acute ischemic stroke patients. Material and methods T2*GRE and DSC-PWI from 393 magnetic resonance imaging scans from 221 patients enrolled in three prospective stroke studies were independently evaluated by two readers blinded to clinical and other imaging data. Agreement between T2*GRE and DSC-PWI for the presence of hemorrhage, and acute hemorrhagic transformation, was assessed using the kappa statistic. Inter-reader agreement was also assessed using the kappa statistic. Results Agreement between the baseline images of DSC-PWI and T2*GRE regarding the presence of hemorrhage was almost perfect (kreader 1 : 0.90, 95% confidence interval 0.86–0.95 and kreader 2 : 0.91, 95% confidence interval 0.87–0.96). Agreement between the sequences was still higher for detection of acute hemorrhagic transformation (kreader 1 : 0.94, 95% confidence interval 0.91–0.98 and kreader 2 : 0.95, 95% confidence interval 0.92–0.98). Inter-reader agreement for detection of hemorrhage was also almost perfect for both T2*GRE (k: 0.95, 95% confidence interval 0.91–0.98) and DSC-PWI (k: 0.96, 95% confidence interval 0.93–0.99). Acute hemorrhagic transformation detected on T2*GRE was missed on DSC-PWI by one or both readers in 5/393 (1.3%) scans. Conclusion The almost perfect statistical agreement between DSC-PWI and conventional T2*GRE suggests that DSC-PWI is sufficient for hemorrhage screening prior to thrombolysis in stroke patients. T2*GRE can therefore be omitted when DSC-PWI is included, thereby shortening the acute ischemic stroke magnetic resonance imaging protocol and expediting treatment. Trial registration: ClinicalTrials.gov Identifier: NCT02586415.

Download Full-text

Frequency, Determinants, and Outcomes of Emboli to Distal and New Territories Related to Mechanical Thrombectomy for Acute Ischemic Stroke

Stroke ◽

10.1161/strokeaha.120.033377 ◽

2021 ◽

Author(s):

Gregory J. Wong ◽

Bryan Yoo ◽

David Liebeskind ◽

Humain Baharvahdat ◽

Jeffrey Gornbein ◽

...

Keyword(s):

Magnetic Resonance Imaging ◽

Atrial Fibrillation ◽

Blood Pressure ◽

Ischemic Stroke ◽

Magnetic Resonance ◽

Acute Ischemic Stroke ◽

Diastolic Blood Pressure ◽

Odds Ratio ◽

Resonance Imaging ◽

Stroke Patients

Background and Purpose: Clot fragmentation and distal embolization during endovascular thrombectomy for acute ischemic stroke may produce emboli downstream of the target occlusion or in previously uninvolved territories. Susceptibility-weighted magnetic resonance imaging can identify both emboli to distal territories (EDT) and new territories (ENT) as new susceptibility vessel signs (SVS). Diffusion-weighted imaging (DWI) can identify infarcts in new territories (INT). Methods: We studied consecutive acute ischemic stroke patients undergoing magnetic resonance imaging before and after thrombectomy. Frequency, predictors, and outcomes of EDT and ENT detected on gradient-recalled echo imaging (EDT-SVS and ENT-SVS) and INT detected on DWI (INT-DWI) were analyzed. Results: Among 50 thrombectomy-treated acute ischemic stroke patients meeting study criteria, mean age was 70 (±16) years, 44% were women, and presenting National Institutes of Health Stroke Scale score 15 (interquartile range, 8–19). Overall, 21 of 50 (42%) patients showed periprocedural embolic events, including 10 of 50 (20%) with new EDT-SVS, 10 of 50 (20%) with INT-DWI, and 1 of 50 (2%) with both. No patient showed ENT-SVS. On multivariate analysis, model-selected predictors of EDT-SVS were lower initial diastolic blood pressure (odds ratio, 1.09 [95% CI, 1.02–1.16]), alteplase pretreatment (odds ratio, 5.54 [95% CI, 0.94–32.49]), and atrial fibrillation (odds ratio, 7.38 [95% CI, 1.02–53.32]). Classification tree analysis identified pretreatment target occlusion SVS as an additional predictor. On univariate analysis, INT-DWI was less common with internal carotid artery (5%), intermediate with middle cerebral artery (25%), and highest with vertebrobasilar (57%) target occlusions ( P =0.02). EDT-SVS was not associated with imaging/functional outcomes, but INT-DWI was associated with reduced radiological hemorrhagic transformation (0% versus 54%; P <0.01). Conclusions: Among acute ischemic stroke patients treated with thrombectomy, imaging evidence of distal emboli, including EDT-SVS beyond the target occlusion and INT-DWI in novel territories, occur in about 2 in every 5 cases. Predictors of EDT-SVS are pretreatment intravenous fibrinolysis, potentially disrupting thrombus structural integrity; atrial fibrillation, possibly reflecting larger target thrombus burden; lower diastolic blood pressure, suggestive of impaired embolic washout; and pretreatment target occlusion SVS sign, indicating erythrocyte-rich, friable target thrombus.

Download Full-text

Detection of Deoxygenation-Related Signal Change in Acute Ischemic Stroke Patients by T2*-Weighted Magnetic Resonance Imaging

Stroke ◽

10.1161/01.str.0000013672.70986.e2 ◽

2002 ◽

Vol 33 (4) ◽

pp. 967-971 ◽

Cited By ~ 48

Author(s):

Hajime Tamura ◽

Jun Hatazawa ◽

Hideto Toyoshima ◽

Eku Shimosegawa ◽

Toshio Okudera

Keyword(s):

Magnetic Resonance Imaging ◽

Ischemic Stroke ◽

Magnetic Resonance ◽

Acute Ischemic Stroke ◽

Resonance Imaging ◽

Stroke Patients ◽

Signal Change ◽

Weighted Magnetic Resonance Imaging

Download Full-text

Diagnosis of Acute Ischemic Stroke Based on Time-To-Peak and Diffusion-Weighted Magnetic Resonance Imaging.

Neurologia medico-chirurgica ◽

10.2176/nmc.42.281 ◽

2002 ◽

Vol 42 (7) ◽

pp. 281-288

Author(s):

Keisuke MARUYAMA ◽

Tsuneyoshi EGUCHI ◽

Shigeo SORA ◽

Masafumi IZUMI ◽

Hirofumi HIYAMA ◽

...

Keyword(s):

Magnetic Resonance Imaging ◽

Ischemic Stroke ◽

Magnetic Resonance ◽

Acute Ischemic Stroke ◽

Resonance Imaging ◽

Time To Peak ◽

Diffusion Weighted ◽

Weighted Magnetic Resonance Imaging ◽

And Diffusion

Download Full-text

Feasibility and Diagnostic Value of Cardiovascular Magnetic Resonance Imaging After Acute Ischemic Stroke of Undetermined Origin

Stroke ◽

10.1161/strokeaha.116.016227 ◽

2017 ◽

Vol 48 (5) ◽

pp. 1241-1247 ◽

Cited By ~ 13

Author(s):

Karl Georg Haeusler ◽

Christian Wollboldt ◽

Laura zu Bentheim ◽

Juliane Herm ◽

Sebastian Jäger ◽

...

Keyword(s):

Magnetic Resonance Imaging ◽

Cardiovascular Magnetic Resonance ◽

Ischemic Stroke ◽

Magnetic Resonance ◽

Acute Ischemic Stroke ◽

Cardiovascular Magnetic Resonance Imaging ◽

Diagnostic Value ◽

Resonance Imaging

Download Full-text

The computer and magnetic resonance imaging in the early assessment of the clinical course of ischemic stroke

Regional blood circulation and microcirculation ◽

10.24884/1682-6655-2019-18-2-35-40 ◽

2019 ◽

Vol 18 (2) ◽

pp. 35-40

Author(s):

R. Kh. Aldatov ◽

V. A. Fokin

Keyword(s):

Magnetic Resonance Imaging ◽

Ischemic Stroke ◽

Magnetic Resonance ◽

Intravenous Thrombolysis ◽

Neurological Symptoms ◽

Limiting Factor ◽

Resonance Imaging ◽

Early Assessment ◽

Stage Of Development ◽

The Moment

The most important benefit that imaging provides to a patient with ischemic stroke is the rapid identification of those patients who are most likely to benefit from emergency treatment. This group includes patients who suffer from severe neurological symptoms due to the occlusion of the main artery, and those who are candidates for recanalization by intravenous thrombolysis or intra-arterial intervention to remove blockage.Objective – to assess the sensitivity and significance of computed tomography and magnetic resonance imaging in early diagnosis of infarction foci.Material and methods. The results of radiologic studies of 89 patients with a clinical picture, suspected of acute ischemic cerebral circulation disorders, received in the first 24 hours from the moment of development of neurological symptoms were analyzed.Results. As a result of our study, it was shown that in the first group of patients received in the first 4.5 h from the moment of development of neurological symptoms of CT-signs of stroke were not detected in 16 (76 %) of 21 patients, while those received in the first 24 h from the moment of development of neurological symptoms of CT-signs of stroke were not detected in 14 (28 %) of 50 patients, determined by the symptom of strengthening of the artery, loss of differentiation between gray and white matter of the brain, smoothness of cortical furrows and the appearance of a zone of reduced densitometric density brain substances (<22HU). The difficulties of diagnosis in some patients on CT were the size and localization of ischemic areas (lacunar, stem strokes). In group II of 18 patients of the study, native MRI revealed signs of ischemic areas in 10 patients out of 10, complex CT and MRI to determined areas of hypoperfusion in 8 patients out of 8.Conclusion. CT is the most widely used imaging technique for cerebral infarction with high sensitivity to intracerebral hemorrhage, high specificity in ischemia, but low sensitivity to the detection of ischemic changes is a limiting factor. The data obtained confirm that MRI is a reliable method of diagnosing ischemic stroke. The most sensitive in the diagnosis of ischemic changes in the acute stage of development by using DWI (b1000).

Download Full-text

Abstract TP400: The Differences of Vessel Wall Features Between the Anterior and Posterior Brain Arteries Detected by High Resolution Magnetic Resonance Imaging in Patients With Acute Ischemic Stroke

Stroke ◽

10.1161/str.51.suppl_1.tp400 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Xiangyan Chen ◽

Lu Zheng ◽

Jia LI ◽

Wenjie Yang

Keyword(s):

Magnetic Resonance Imaging ◽

Ischemic Stroke ◽

Magnetic Resonance ◽

High Resolution ◽

Acute Ischemic Stroke ◽

Vessel Wall ◽

Posterior Circulation ◽

Intraplaque Hemorrhage ◽

Resonance Imaging ◽

Anterior Circulation

Backgrounds: The purpose of this study was to investigate vessel wall features visualization by high resolution magnetic resonance imaging (HRMRI) in a series of ischemic stroke patients and to identify differences between lesions in the anterior and posterior circulation. Methods: We consecutively recruited Chinese patients with acute ischemic stroke or transient ischemic attack from 2016 to 2018. All patients were scanned at 3T magnetic resonance imaging. We evaluated pre-and post-contrast cross-sectional views of M1 and M2 segments of middle cerebral arteries (MCAs), basilar arteries (BA) and V4 segments of vertebral arteries (VAs). Results: A total of 74 patients (males 52.3%; median age 62 years old) were included in this study, among which, 234 lesions were identified on HRMRI, including 117 MCA lesions, 26 BA lesions, and 91 VA lesions. The sensitivity and specificity of MRA for diagnosing stenosis in anterior circulation were 89.3% (95% CI, 81.8%- 94.2%) and 50.0 (95% CI, 9.2%- 90.8%). The sensitivity and specificity of MRA for diagnosing stenosis in posterior circulation were 73.2% (95% CI, 63.9%- 80.9%) and 40.0 (95% CI, 7.3%- 83.0%). VA had a significantly higher contrast enhancement index (43.71± 7.74, p <0.016) than MCA (23.32± 2.46) or BA (22.69± 5.31) . Anterior circulation plaques had higher degree of stenosis (anterior versus posterior: 68.5% vs. 62.9%, p =0.036), more eccentric distribution (anterior versus posterior: 70.1% versus 53.8%, p =0.015) and higher rate of intraplaque hemorrhage (anterior versus posterior: 17.1% versus 7.7%, p =0.046). The plaques in posterior circulation had a thicker lesion wall (posterior versus anterior 16.58± 8.25 mm 2 vs. 9.10± 4.07 mm 2 , p <0.001) and higher enhancement index (posterior versus anterior 39.04± 8.50 vs. 23.32± 2.46, p <0.001) than the plaques in anterior circulation. Conclusions: The lesions in posterior circulations could be obscure on MRA. The area stenosis, intraplaque hemorrhage and enhancement index differed between circulations.

Download Full-text

Thrombolysis Outcomes in Acute Ischemic Stroke by Fluid-Attenuated Inversion Recovery Hyperintense Arteries

Stroke ◽

10.1161/strokeaha.119.028550 ◽

2020 ◽

Vol 51 (7) ◽

pp. 2240-2243

Author(s):

Zien Zhou ◽

Sohei Yoshimura ◽

Candice Delcourt ◽

Richard I. Lindley ◽

Shoujiang You ◽

...

Keyword(s):

Magnetic Resonance Imaging ◽

Ischemic Stroke ◽

Magnetic Resonance ◽

Acute Ischemic Stroke ◽

Infarct Volume ◽

Inversion Recovery ◽

Modified Rankin Scale ◽

Resonance Imaging ◽

Scale Scores ◽

Fluid Attenuated Inversion Recovery

Background and Purpose: To determine factors associated with fluid-attenuated inversion recovery (FLAIR) hyperintense arteries (FLAIR-HAs) on magnetic resonance imaging and their prognostic significance in thrombolysis-treated patients with acute ischemic stroke from the ENCHANTED (Enhanced Control of Hypertension and Thrombolysis Stroke Study) trial alteplase-dose arm. Methods: Patients with acute ischemic stroke (N=293) with brain magnetic resonance imaging (FLAIR and diffusion-weighted imaging sequences) scanned <4.5 hours of symptom onset were assessed for location and extent (score) of FLAIR-HAs, infarct volume, large vessel occlusion (LVO), and other ischemic signs. Logistic regression models were used to determine predictors of FLAIR-HAs and the association of FLAIR-HAs with 90-day outcomes: favorable functional outcome (primary; modified Rankin Scale scores, 0–1), other modified Rankin Scale scores, and intracerebral hemorrhage. Results: Prior atrial fibrillation, LVO, large infarct volume, and anterior circulation infarction were independently associated with FLAIR-HAs. The rate of modified Rankin Scale scores 0 to 1 was numerically lower in patients with FLAIR-HAs versus without (69/152 [45.4%] versus 75/131 [57.3%]), as was the subset of LVO (37/93 [39.8%] versus 9/16 [56.3%]), but not in those without LVO (25/36 [69.4%] versus 60/106 [56.6%]). After adjustment for covariables, FLAIR-HAs were independently associated with increased primary outcome (adjusted odds ratio [95% CI]: overall 4.14 [1.63–10.50]; with LVO 4.92 [0.87–27.86]; no LVO 6.16 [1.57–24.14]) despite an increased risk of hemorrhagic infarct (4.77 [1.12–20.26]). Conclusions: FLAIR-HAs are more frequent in acute ischemic stroke with cardioembolic features and indicate potential for a favorable prognosis in thrombolysis-treated patients possibly mediated by LVO. Registration: URL: https://www.clinicaltrials.gov . Unique identifier: NCT01422616.

Download Full-text