Journal Reading

Magnetic Resonance
Imaging in Acute Ischemic
Stroke Treatment
(Bum Joon Kim,a Hyun Goo Kang,a Hye-Jin Kim,a Sung-Ho Ahn,a Na
Young Kim,a Steven Warach,b Dong-Wha Kanga)
Journal of Stroke 2014;16(3):131-145
http://dx.doi.org/10.5853/jos.2014.16.3.131

PEMBIMBING : Dr. Rahmat M Memet,

Sp.Rad
OLEH :
Ai Irma Nurmalasari
Mahasti Andrarini
Irfa Irawati
Taufik Nursidik

INTRODUCTION

Ischemic stroke is one of the major causes of

death and disability. For the last few decades,
many efforts have been made to improve the
outcome of acute ischemic stroke treatment.
However, thrombolytic therapy is still the only
proven treatment for patients following an acute
ischemic stroke within 3 or 4.5 hours of
symptom onset

 Multimodal magnetic resonance imaging (MRI) is useful

for diagnosing ischemic stroke and for determining
treatment strategies in the acute phase.
In the acute stage, early diagnosis of ischemic stroke and
its differentiation from stroke-mimics are important.
Various imaging findings from MRI sequences help
determine stroke mechanisms, which affect prognosis,
and thereby play an important role in treatment decisions.
Lesion mismatch profiles on MRI help us to assess
potential risks and benefits of thrombolysis by providing
information on salvageable tissue or ischemic lesion age.

OBJECTIVE
In this review, we discuss the clinical implication of
various MRI findings, specifically focusing on:
1) MRI for diagnosis of acute stroke and its mechanism
2) MRI-based patient selection for reperfusion therapy
3) MRI outcome measures
4) For practicality of using MRI for hyperacute stroke

Imaging for Acute Stroke Diagnosis

Diagnosis of acute
stroke

- Clinical persentation
- MRI:
The
lesions
appear
as
hyperintense areas
on DWI and as
correlative
hypointense
areas
on
apparent
diffusion coefficient
(ADC) maps, even
within 3 minutes of
stroke onset.

Assessing the mechanism

of stroke

Early assessment of the

etiology ischemic stroke in
the acute stage using MRI
is advantageous to guide
specific diagnostic workups and proper strategy
for hyperacute reperfusion
therapy and secondary
stroke prevention

Patient Selection for Acute Stroke Treatment

Evaluation of salvageable
tissue

1. Concept of
penumbra:
2. PWI parameters:
-. CBF and CBV
-. MTT, TTP, and
Tmax

3.
PWI
parameter
thresholds
in
discriminating between
penumbra and benign
oligemic area
4. PWI-DWI mismatch in
patient selection

Hemorrhagic Risk Stratification after

Thrombolysis
1. Mechanisms and clinical implication
2. Definition and classification of HT

3. Factors associated with HT

4. MRI predictors for HT

Assessing the Nature and Burden of

Clots

As the composition, size, and site of clot occluding cerebral arteries are important
factors for selecting the treatment strategy, GRE and SVS may be useful for treatment
decisions. Initial, long-standing, platelet-rich, and well-organized white thrombi in the
cerebral artery under high shear-stress are more resistant to thrombolytic therapy than
fresh, fibrin-rich red thrombi formed under static conditions. Therefore, SVS is known as
a marker with higher possibility of recanalization

Mri-based Thrombolysis in Unclearonset Patients

Mri-based Thrombolysis in Patients with

Minor
Stroke
MRI has been suggested as a tool to identify patients with minor
stroke who may benefit from thrombolysis. In patients that have
experienced a minor stroke, a significant mismatch can persist for
days and their symptoms may aggravate without recanalization
therapy. Recent studies have reported that treatment with tPA based
on PWI-DWI mismatch is safe and effective in patients with minor
stroke

MRI Outcome Measures

- The three main categories used in outcome measures

by MRI are, 1) DWI lesion volume change, 2) PWI lesion
volume change, and 3) recanalization of the occluded
vessel on MRA.

Correlation of MRI Parameters and

Clinical Outcome
In fact, it has been shown that early infarct growth within the first week
can predict long-term clinical outcome after thrombolysis. Moreover, it
was revealed that patients with good clinical outcomes (modified Rankin
scale 0-2) had smaller infarct growth, smaller perfusion growth, and good
revascularization

Practicality of MRI for use in Hyperacute

Stroke
Multimodal MRI reveals various useful parameters for deciding
treatment routes of acute stroke (Table 3). This technology is
especially useful when stroke diagnosis is uncertain (stroke-mimics),
stroke onset is unclear (wake-up or unwitnessed daytime strokes), or
clinic-imaging mismatches exist.

CONCLUSION

Multimodal imaging provides information that is

useful for diagnosing ischemic stroke, selecting
appropriate patients for thrombolytic therapy, and
predicting the prognosis of ischemic stroke.
Only depending on a single or a few parameters
may not be sufficient, instead comprehensively
combining the information from each MRI sequence
(i.e., DWI, FLAIR, GRE, and PWI) and using various
mismatch parameters (DWI-FLAIR mismatch and/or
PWI-DWI mismatch) may be more helpful in
establishing
an
indication
of
MRI-based
thrombolysis.

THANK YOU