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MR imaging
H R Jager
Institute of Neurology and The National Hospital of Neurology and Neurosurgery, London, UK
Queen square, London All modern CT scanners provide now a facility for spiral CT scanning. In
WCW3BC.UK conventional incremental CT scanning, slices are acquired individually
British Medical Bulletin 2000, 56 (No 2) 318-333
CT perfusion imaging
319
with a time delay between them for table repositioning and tube cooling.
Spiral (or helical) scanning is performed with a continuous rotation of
the X-ray tube during simultaneous movement of the CT table at a preselected speed. This allows the acquisition of a volumetric 3D data set,
which can subsequently be divided into individual slices of variable
thickness1. Spiral scanning provides a considerable increase in scanning
speed and allows coverage of the entire head in approximately 15 s. This
can be of advantage in restless patients with acute stroke and represents
a prerequisite for CT angiography where imaging is performed during
the relatively short intravascular phase of a contrast medium (see
below). The most recent developments in this field are multi-slice spiral
CT scanners, which use multiple detectors for simultaneous data
collection at different locations and can acquire images at 3 times the
speed of single detector spiral CT scanners2.
Stroke
Advances in MR imaging
MR perfusion imaging
Selective imaging of blood vessels with CT has become possible with the
introduction of spiral CT scanners. The image quality of CT angiography
is likely to improve dramatically with the advent of the new multi-slice
spiral CT scanners5. Data are acquired during the vascular phase of an
lodinated contrast, which is injected intravenously, typically at a rate of 3
ml/s. The enhanced blood vessels are extracted from 3D data sets by
applying specific density thresholds during the post-processing. The vessels
can then be displayed as 2D projectional images, which resemble conventional angiograms, or as 3D surface rendered structures6. CT angiography
can be performed rapidly and can be easily 'tagged onto' a routine
diagnostic CT. It has the disadvantage of using iodinated contrast medium,
which carries a small risk of adverse reactions. It may also be difficult to
isolate blood vessels running close to bone during post processing.
Fig. 1 MR perfusion
study in a patient with
bilateral carotid artery
occlusion An MRA of the
intracranial circulation (a)
does not demonstrate
any internal carotid
arteries. Both middle
meningeal arteries
(arrows) are prominent
and provide collateral
supply to the brain The
right posterior cerebral
artery (curved arrow) is
normal but only the
proximal part of the left
posterior cerebral artery
is seen T2* weighted EP1
images before (b) and 20 s
after injection of a
gadolinium bolus (c)
demonstrate the magnetic
susceptibility effects of the
passing gadolinium bolus,
which leads to a decrease
in signal intensity of the
blood vessels and brain
parenchyma in (c) compared to (b). The time
course of this signal
change is shown in a
time-signal intensity
graph (d) for two separate regions of interest
the nght occipital lobe
(region 1) and left frontal
lobe (region 2). The signal
drop in the right occipital
occurs much earlier and is
more marked than in the
left frontal region, where
perfusion is impaired.
A colour map (e) of the
mean transit time (MTT)
shows areas with a
prolonged transit time in
green and red. Prolongation of the MTT, which
corresponds to a delayed
passage of the bolus, is
found in watershed areas
at the boundaries
between the anterior and
middle and between the
middle and posterior
cerebral arteries.
321
Stroke
Fig. 2 Diffusion-weighted and T2 spin-echo images in a patient with a right subcortical infarct
Although the lesion is seen on the T2-weighted image (a), it is much more conspicuous on the
diffusion-weighted image (b), which confirms that the lesion is acute The diffusion of water
molecules is restricted in an area of acute ischaemia, which appears therefore a bnght on
diffusion-weighted images ('light bulb sign") Note that the CSF, which has a high degree of
molecular motion, appears dark.
gradient, which is expressed by the 'b value'. B-values used for imaging of
acute stroke lie typically around 1000 s/mm2. Quantitative analysis of the
apparent diffusion coefficient (ADC) requires scanning with at least two
different b-values and additional postprocessing. ADC maps are solely
based on differences of tissue diffusion, independent of any T2 effects9.
The ADC in the normal brain ranges from 2.94 x 10~3 mm2/s for CSF to
0.22 x 10~3 mm2/s for white matter; grey matter lying in between with a
ADC of 0.76 x 10~3 mm2/s10. Areas with a decreased ADC appear dark on
ADC maps, which is the converse to diffusion-weighted images where
areas of decreased diffusion appear bright9.
MR angiography
323
Stroke
324
CT scanning has been the modality of choice for imaging patients with
acute stroke. Its major advantage, apart from wide-spread accessibility, is
its reliability in detecting intracerebral and subarachnoid haemorrhage. It
is, therefore, highly sensitive in distinguishing haemorrhagic from nonhaemorrhagic stroke. Rare exceptions are very anaemic patients with a
haematocrit of 20% or less, in whom haematomas can be isointense13. All
major thrombolysis trial to date have used CT as primary imaging
modality to exclude haemorrhage or extended infarction14.
325
Stroke
MR diffusion imaging
Fig. 3 34-year-old
patient with a lockedin syndrome. The
frontal projection of
an MRAof the
posterior circulation
(a) shows occlusion of
the basilar artery
distal to the right
anterior inferior
cerebellar artery
(curved arrow) with
filling of the posterior
cerebral arteries
through collaterals
(arrows) The T2weighted image in the
hyperacute phase
(b) is normal but the
diffusion-weighted
image shows high
signal in the pons
(c), which is becomes
visible on T2-weighted
image after 48 h (d).
327
Stroke
Fig. 4 CT scans of a
75-year-old patient at
the level of the lateral
ventricles (a) and the
vertex (b) showing
evidence of small vessel
ischaemic disease and
two mature cortical
infarcts, in the left and
right frontal lobes. The
T2*-weighted gradientecho images at corresponding levels (cd)
show areas of low
signal, consistent with
haemosiderin staining,
which indicates previous haemorrhage
The presence of
multiple lobar
haemorrhages is typical
of amyloid angiopathy
Additional penventncular high signal areas
are consistent with
small vessel ischaemic
disease.
329
Stroke
330
clots become hypodense within a few weeks and may resemble infarcts.
MRI is much more sensitive in showing evidence of previous
haemorrhage because haemosiderin is taken up by macrophages and can
persist for years, appearing as a characteristic low signal area on T2weighted images. The sensitivity for detection of haemosiderin can be
increased by using T2*-weighted gradient-echo or echo planar imaging
(EPI) sequences. Evidence of multiple peripheral haemorrhages in elderly
patients is suggestive of amyloid angiopathy (Fig. 4)36.
Small vessel ischaemic disease may be evident as hypodense white
matter lesions on CT, but MRI is more sensitive to small vessel ischaemic
changes, particularly if a FLAIR sequence is used39. White matter lesions
are more frequently seen in patients with hypertension, but may also be
a feature of vasculitic diseases37-38.
To determine the vascular territory of an infarct, one has to take into
account variations of the circle of Willis, which can be readily assessed
with MRA. One of the more frequently encountered variants is a fetal
origin of the posterior cerebral artery from the internal carotid artery,
which has been described in up to 31% of subjects40. It is worth
remembering that, in patients with this variant, occipital infarcts can be
caused by carotid stenosis rather than vertebrobasilar disease.
Watershed infarcts at the boundaries between the anterior, middle and
posterior cerebral artery territories (and between the deep and superficial
cerebral circulation) may be the result of global ischaemia following an
episode of hypotension or represent haemodymanic failure distal to a
critically stenosed carotid artery.
Multiple infarcts in different vascular territories suggest cardiogenic
emboh. Infarcts, which do not correspond to an arterial territory, have to
raise the suspicion of venous infarcts, particularly if there is evidence of
extensive haemorrhagic transformation. Patency of the major dural
sinuses can be easily assessed with phase-contrast MR venography in
these cases41.
Assessment of the carotid bifurcation is crucial in the diagnostic workup of chronic stroke and secondary prevention of a recurrent stroke.
This can be performed non-invasively with Doppler ultrasound and MR
angiography, which are discussed elsewhere in this issue.
Dissection of the carotid arteries is an important cause of stroke in
young and middle aged adults. The characteristic MRI findings are a rim
of high signal expanding the outer diameter of the artery and narrowing
its lumen. The high signal represents subacute intramural haematoma,
which becomes apparent after a few days. In the acute stage, the
intramural haematoma is isointense to muscle and may be more difficult
to detect42.
MR perfusion imaging can also be useful in patients with chronic
cerebrovascular disease and severe carotid artery stenosis43. In cases with
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