Stroke: Intracranial Abnormalities With Hetal Verma, MD

Stroke
Intracranial Abnormalities
With Hetal Verma, MD
Rawabi Madkhali , [email protected]

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Learning Objectives
• In this lecture, you will learn the

role of imaging in identifying stroke
• You will review the imaging features

of acute stroke

© by Hetal Verma, MDMadkhali , [email protected]
Rawabi
What is a Stroke?
Compromise of the blood supply to a portion of the brain

parenchyma, resulting in loss of neurologic function.
High-yield
This may be embolic or Diagnosis is based on

thrombotic. clinical symptoms.

Treatment
• In the setting of an acute ischemic

stroke, tissue plasminogen activator
(t-PA) can provide the most benefit High-yield
if administered within 3 hours of the
onset of stroke.
• There is moderate benefit if

administered between 3 to 4.5
hours of the onset of stroke.

Role of Imaging in Acute Stroke?
High-yield
Exclude hemorrhage. t-PA is contraindicated with hemorrhage.
Exclude other causes of symptoms such as mass.

Types of Stroke
Ischemic Hemorrhagic

Watershed Territory
• The area of brain parenchyma at the

junction of two vascular territories
High-yield
• Most susceptible to ischemia
• Common watershed areas: at the

junction of the ACA/MCA and the
MCA/PCA

Stroke Imaging
• Begin with CT due to quick access High-yield

and ability to exclude hemorrhage.
• Ischemic stroke may not be visible

for several hours on CT.

Stroke Imaging
MRI is most sensitive for early ischemic stroke with High-yield

the diffusion weighted images (DWI) demonstrating
changes within 20 30 minutes of onset.

CT Findings of Ischemic Stroke
< 24 hours 12 24 hours > 24 hours

• Negative • Vague low • Better defined low
density area density area with:
• Early signs include: High-yield
• Loss of gray-white
• Decreased density
differentiation
in the basal ganglia
• Adjacent edema
• Loss of gray/white
and mass effect
differentiation
• Changes last for
• Hyperdense
up to 4 weeks
Acute Stroke

William Herring, Learning
Rawabi Radiology,
Madkhali 3rd Edition, 2016, p. 290, Saunders (Elsevier)
, [email protected]
Acute Stroke
• CT image on the left is negative in

patient presenting with symptoms
for 2 hours.
• DWI image on the right

demonstrates a bright area in the
right frontoparietal region, indicating
acute stroke.

Rawabi Radiology,
, [email protected]
Acute Stroke
• CT image on the left is negative in

patient presenting with symptoms
for 2 hours.
• DWI image on the right

demonstrates a bright area in the
right frontoparietal region, indicating
acute stroke.

Rawabi Radiology,
, [email protected]
Stroke Imaging Change Over Time

• This image depicts the imaging

findings of a stroke at about 24
hours.
• There is loss of gray white

differentiation with compression of
the ventricles and shift of the
midline.

Rawabi Radiology,
, [email protected]
• This image depicts the imaging

findings of a stroke several weeks
after the initial event.
• The low density area is more

sharply marginated and there is no
longer any significant mass effect.

Rawabi Radiology,
, [email protected]
Hemorrhagic Stroke
Hemorrhage into the brain parenchyma or subarachnoid space
Risk increases with hypertension.

Case Study

Describe the Findings
65-year-old male presents with right-sided weakness which began
2 hours ago.

Rawabi
Rawabi
2 hours ago.
CT is normal.
How do you treat this patient?

Rawabi
2 hours ago.
• Patient is clinically
diagnosed with ischemic
stroke and treated with t-PA
and admitted to the ICU.
• He loses consciousness the

next day.
What do you do and why?

Rawabi
© By Hetal Verma, MDMadkhali , [email protected]
Rawabi
Rawabi
Case-study Continued
65 year-old male presents with right-sided weakness.
• CT demonstrates
intracerebral, subarachnoid
and subdural hemorrhage
with resultant subfalcine
herniation.
• Stroke has now become

hemorrhagic.
What do you do next?

Rawabi
Case-study Continued
65 year-old male presents with right-sided weakness.
Call neurosurgery for urgent

surgical decompression to
relieve mass effect!

Rawabi
Learning Outcomes
 You have reviewed the imaging

findings and management of acute
stroke.

This document is a property of: Rawabi Madkhali
Note: This document is copyright protected. It may not be copied, reproduced, used, or
distributed in any way without the written authorization of Lecturio GmbH.


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Stroke

With Hetal Verma, MD

Rawabi Madkhali , [email protected]

• In this lecture, you will learn the

• You will review the imaging features

Rawabi Madkhali , [email protected]

Compromise of the blood supply to a portion of the brain

This may be embolic or Diagnosis is based on

Rawabi Madkhali , [email protected]

• In the setting of an acute ischemic

• There is moderate benefit if

Rawabi Madkhali , [email protected]

Exclude other causes of symptoms such as mass.

Rawabi Madkhali , [email protected]

Rawabi Madkhali , [email protected]

• The area of brain parenchyma at the

• Most susceptible to ischemia

• Common watershed areas: at the

Rawabi Madkhali , [email protected]

• Begin with CT due to quick access High-yield

• Ischemic stroke may not be visible

Rawabi Madkhali , [email protected]

MRI is most sensitive for early ischemic stroke with High-yield

Rawabi Madkhali , [email protected]

< 24 hours 12 24 hours > 24 hours

Rawabi Madkhali , [email protected]

• CT image on the left is negative in

• DWI image on the right

William Herring, Learning

• CT image on the left is negative in

• DWI image on the right

William Herring, Learning

Rawabi Madkhali , [email protected]

• This image depicts the imaging

• There is loss of gray white

William Herring, Learning

• This image depicts the imaging

• The low density area is more

William Herring, Learning

Hemorrhage into the brain parenchyma or subarachnoid space

Risk increases with hypertension.

Rawabi Madkhali , [email protected]

Rawabi Madkhali , [email protected]

© by Hetal Verma, MDMadkhali , [email protected]

© by Hetal Verma, MDMadkhali , [email protected]

• He loses consciousness the

What do you do and why?

© by Hetal Verma, MDMadkhali , [email protected]

65 year-old male presents with right-sided weakness.

• Stroke has now become

What do you do next?

65 year-old male presents with right-sided weakness.

Call neurosurgery for urgent

© By Hetal Verma, MDMadkhali , [email protected]

 You have reviewed the imaging

Rawabi Madkhali , [email protected]

Rawabi Madkhali , [email protected]

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