Journal Reading Radiologi Ella
Journal Reading Radiologi Ella
Journal Reading Radiologi Ella
DISUSUN OLEH
Ella Putri Saptari - 1161050203
DOKTER PEMBIMBING
dr. Tri Harjanto Sp.Rad
KEPANITERAAN KLINIK BAGIAN ILMU RADIOLOGI
PERIODE 14 DESEMBER 2015 – 23 JANUARI 2016
FAKULTAS KEDOKTERAN
UNIVERSITAS KRISTEN INDONESIA
JAKARTA
2015- 1161050203
ELLA PUTRI SAPTARI
Imaging in Acute Stroke
Western Journal of Emergency Medicine
Volume XII, no. 1 : February 2011
• Acute stroke represents cytotoxic edema, and the changes can be subtle but are
significant. They are also termed “early ischemic changes“ and were formerly termed
“hyper-acute”. It is intracellular edema and causes loss of the normal gray
matter/white matter interface (differentiation) and effacement of the cortical sulci.
• A thrombus in the proximal middle cerebral artery (MCA) is sometimes seen in the
acute phase and appears as hyperattenuation. A subacute stroke represents
vasogenic edema, with greater mass effect, hypoattenuation and well-defined
margins. Mass effect and risk of herniation is greatest at this stage. Chronic strokes
have loss of brain tissue and are hypoattenuating.
• This tool’s availability and speed make it very useful in the initial
evaluation of suspected stroke patients.
• In addition to identifying stenotic and occluded blood vessels the CTA can provide images of
aneurysms (Figures 6 and 7) and other vascular abnormalities such as arterio-venous malformation
(AVM) and their feeding arteries and veins (Figure 8). Rotation of these images can also assist stroke
neurologist, interventional neuroradiologist and surgeons in planning operations and procedures.
• Many comprehensive stroke centers are beginning to use this technique in all acute stroke patients.
The most important limitations to contrast enhanced CT are prior allergic reactions and patients
with underlying renal insufficiency.
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Figure 6. Basilar tip artery aneurysm. Computed tomography angiogram in the axial projection
demonstrates a focal basilar tip artery aneurysm (arrow).
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Figure 7. Anterior communicating artery (ACoA) aneurysm.
(A) Cerebal computed tomography angiogram (CTA) in three-dimensional projection with skull
surface overlay demonstrates an anterior communicating artery aneurysm.
(B) Dedicated images from CTA of the Circle of Willis isolates the aneurysm (arrow).
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Figure 8. Subarachnoid and intraventricular hemorrhage due to vascular malformation.
Sagital reformatted images from computed tomography angiogram demonstrates the enhancing
vascular malformation (arrow), which was the etiology of the intraventricular hemorrhage
ELLA PUTRI SAPTARI - 1161050203
(same patient in Figure 2).
COMPUTED TOMOGRAPHY
PERFUSION
• CT perfusion is more widely available than magnetic resonance imaging (MRI) and can be performed
quickly on any standard helical CT scanner right after unenhanced CT. During CT perfusion a rapid
intravenous infusion of contrast is administered and sections of the brain are repeatedly imaged.
Based on the total amount and speed that blood flows to different vascular territories of the brain this
technique can assist in identifying a stroke and potential areas of reversible and salvageable brain
tissue in the ischemic penumbra.
• The cerebral blood flow (CBF) is equal to the cerebral blood volume (CBV) divided by the mean transit
time (MTT). The MTT is the time difference between the arterial inflow and venous outflow. MTT is
the most sensitive measure used to evaluate for flow abnormalities. It is prolonged in conditions such
as hypotension along with occluded and stenotic blood vessels. Time –to –peak (TTP) is sometimes
used in place of MTT.
• Areas of the brain that are at risk for injury known as the ischemic penumbra show
decreased CBF with normal to increased CBV. This potentially salvageable area of
the brain must have an intact cerebral autoregulation system to maintain
homeostasis. Cerebral autoregulation causes the dilation of the collateral blood
vessels and increases the CBV to the areas of the brain that are compromised by
decreased CBF. (Figure 9).
• CT perfusion does have some limitations for it requires multi-detector CT (MDCT) and a special software
package which needs to be set up by trained technologist. The software package that is used for CT
perfusion analyzes the images obtained and color coded maps representing many levels of the brain are
produced to help differentiate the potential cause of the flow abnormalities. Current CT perfusion
technology is limited to two slices through the brain. (Higher row MDCT= 64 slice or greater) will be able
to image a greater volume of brain tissue. CT perfusion produces a greater amount of radiation exposure
to the levels being imaged- roughly 40 CT slices through the same level of the cranium. If the perfusion
CT software and equipment is not set up correctly, massive radiation doses may result.
• Standard MRI images (T1 and T2) are good at detecting vasogenic edema
that is present in the subacute phase of stroke and is seen at greater
than 24 hours to several days. Fast spin echo T2- weighted sequences can
clearly demonstrate areas of edema not visible on the CT and can help
identify a subacute stroke as seen in (Figure 10).
• The gradient recalled echo (GRE) sequence is also useful for the detection of blood
products. Hypointensity due to paramagnetic effect of the hemosiderin, otherwise
known as “blooming,” affects the magnetic field and decreases the signal.
Therefore blood appears “black” on GRE images (Figure 11).
• DWI is used to detect early ischemic changes (acute stroke; early ischemic change;
cytotoxic edema) with greater conspicuity than standard MRI.
• MRI with diffusion is quickly becoming the gold standard in acute stroke imaging.
Once a hemorrhagic stroke has been excluded by CT, MR diffusion improves stroke
detection from 50% to more than 95%. Diffusion MR noninvasively detects
ischemic changes within minutes of stroke onset.
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• It is the ability to quantify the motion of water molecules that makes the
process of diffusion weighted MRI possible. Normal uninjured neuronal cells
allow for the equal movement of water between healthy cells. During an acute
ischemic stroke cytotoxic intracellular injury to the neuronal cell occurs and
intracellular water accumulates in the injured cells as the cells ability to allow
for the water to diffuse out is decreased. The difference in the water content
and the diffusion of water between injured and uninjured cells can be
measured and allows for the identification of ischemic cells on diffusion MRI
images. These areas of damage appear bright on MR diffusion images.
• CT and MRI perfusion imaging can assist in identifying a stroke and potential areas of reversible and
salvageable brain tissue in the ischemic penumbra. Identifying patients initially outside of the three
hour window or in those which the time of onset is uncertain who have an area of potentially
reversible ischemia may still benefit by intravenous, intra-arterial or mechanical reperfusion.
• MRA is helpful for detecting less common cause of ischemic stroke such as carotid
and vertebral artery dissection, fibromuscular dysplasia, and venous thrombosis. It
also aides in the detection of underlying aneurysms.
• While the ACR prefers MRI to CT for acute stroke it is not currently available and
practical for most centers. The recommended MRI sequences are T1,T2, FLAIR,
GRE (for Blood), DWI for acute ischemia, MRA, and PWI ( for penumbra
imaging). Most United States emergency departments do not have MR available
for acute stroke .It is not uncommon in the ED to use DWI- MRI when the
diagnosis of an acute stroke is unclear and it can help confirm the diagnosis.
ELLA PUTRI SAPTARI - 1161050203
ELLA PUTRI SAPTARI - 1161050203