European Journal of Radiology 96 (2017) 162–172

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European Journal of Radiology

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Review : CT and MRI techniques in acute ischemic MARK ⁎ Pedro Vilelaa, , Howard A. Rowleyb a Serviço de Neurorradiologia, Hospital Beatriz Ângelo, Loures, Portugal b University of Wisconsin, 600 Highland Avenue, Mail code 3252, Madison, WI 53792, United States

ARTICLE INFO ABSTRACT

Keywords: Imaging plays a central role for intravenous and intra-arterial arterial ischemic stroke treatment patient selec- Acute ischemic stroke tion. Core Computed tomography (CT) / CT angiography or magnetic resonance (MR) / MR angiography imaging are used to exclude stroke mimics and haemorrhage, to determine the cause and mechanism of stroke, to define the CT extension of brain infarct and to identify the arterial occlusion. Imaging may identify the patients that will be MR perfusion benefit more from revascularization therapies independently of the conventional therapeutic time window al- Collateral circulation CT angiography lowing individualized treatment decisions and improving individual patient outcome. Multiparametric CT/MR MR angiography imaging may be used to identify the extension of potential viable brain tissue (penumbra) and of irreversible brain lesion (core) using CT perfusion and/or diffusion weighed and perfusion weighted MR imaging. The status of the arterial collateral circulation and the type and extension of the clot may be assessed by imaging. The accuracy and the clinical significance for treatment and patient clinical outcome of different imaging techniques are reviewed.

1. Introduction revascularization, either by stent clot retrieval and/or clot aspiration, during the first 6–8 h after symptom onset [2,3]. The objective of these Stroke is one of the most frequent causes of and disability in treatments is to promote the rapid revascularization of the brain tissue, developed countries, having an estimated overall adult prevalence of impeding the evolution of the viable (reversible) ischemic brain tissue 2.5%, which rises with increasing age, being estimated to be 45% for (penumbra) into death (irreversible) brain tissue (core). age group of more than 85 years if silent infarcts are also taken into Imaging is the cornerstone for the diagnosis of ischemic stroke, not consideration [1]. Arterial ischemic stroke (AIS) is one the three leading only for the AIS but also subacute and chronic ischemic brain lesions. In causes of death in developed countries; with one death caused by stroke AIS, it is also crucial for treatment patient selection. Therefore, not for each 15–18 total [1]. Stroke represents also a tremendous surprisingly, over the last years, the major focus of imaging research social burden, not only by the associate mortality but also by the has been the AIS evaluation, aiming better and faster diagnosis and morbidity associated with this disease. As a consequence of the popu- optimized individual patient selection for treatment, selecting those lation ageing it is expected that the health costs with stroke will con- patients with a potential good outcome after treatment and excluding tinue to rise exponentially over the next decades. the poor candidates for treatment. Most of the are ischemic, more than 80% of cases, being “Time is brain” is a central concept that underlies the importance of thromboembolic due to large artery atherosclerosis, cardio-embolic, the prompt AIS diagnosis and treatment. It is estimated that there is a and small vessel occlusion the commonest causes of AIS [1]. The other loss o