Acute focal cerebral ischemia, with brain perfusion below 20 ml/min per 100 g tissue, causes an immediate loss of function of the affected brain area and a cascade of pathologic events including tissue water uptake resulting in tissue necrosis if perfusion declines further. Patients with acute cerebral ischemia present with hemiparesis, hemianopia, speech disturbance, or impairment of consciousness. The differential diagnosis includes intracranial hemorrhage, congestive or hypertensive cerebral edema, focal encephalitis, demyelination disorder, metabolic disturbance, or tumor. Brain imaging is absolutely necessary for an exact diagnosis and to assess the acute pathology of the brain. Information provided by computed tomography (CT) and magnetic resonance imaging (MRI) should guide the management of stroke patients and can thus finally influence clinical outcome if the applied treatment is effective.


Apparent Diffusion Coefficient Magnetic Resonance Angiography Acute Stroke Acute Ischemic Stroke Compute Tomography Attenuation 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.


  1. 1.
    Kent D, Larson E (1992) Disease, level of impact, and quality of research methods; three dimensions of clinical efficacy assessment applied to magnetic resonance imaging. Invest Radiol 27:245–254PubMedCrossRefGoogle Scholar
  2. 2.
    Powers W (2000) Testing a test. A report card for DWI in acute stroke. Neurology 54:1549–1551PubMedCrossRefGoogle Scholar
  3. 3.
    NINDS Stroke Study Group (1995) Tissue plasminogen activator for acute ischemic stroke. N Engl J Med 333:1581–1587CrossRefGoogle Scholar
  4. 4.
    Hacke W, Kaste M, Fieschi C, Toni D, Lesaffre E, von Kummer R, Boysen G, Bluhmki E, Höxter G, Mahagne M, Hennerici M (1995) Intravenous thrombolysis with recombinant tissue Plasminogen activator for acute hemispheric stroke. The European Cooperative Acute Stroke Study (ECASS). JAMA 274:1017–1025PubMedCrossRefGoogle Scholar
  5. 5.
    Hacke W, Kaste M, Fieschi C, von Kummer R, Davalos A, Meier D, Larrue V, Bluhmki E, Davis S, Donnan G, Schneider D, Diez-Tejedor E, Trouillas P (1998) Randomised doubleblind placebo-controlled trial of thrombolytic therapy with intravenous alteplase in acute ischaemic stroke (ECASS II). Lancet 352:1245–1251PubMedCrossRefGoogle Scholar
  6. 6.
    Furlan A, Higashida R, Wechsler L, Gent M, Rowley H, Kase C, Pessin M, Ahuja A, Callahan F, Clark W, Silver F, Rivera F (1999) Intra-arterial prourokinase for acute ischemic stroke. JAMA 282:2003–2011PubMedCrossRefGoogle Scholar
  7. 7.
    Jansen O, Schellinger P, Fiebach J, Hacke W, Sartor K (1999) Early recanalisation in acute ischaemic stroke saves tissue at risk defined by MRI. Lancet 353:2036–2037PubMedCrossRefGoogle Scholar
  8. 8.
    Parsons M, Barber A, Chalk J, Darby D, Rose S, Desmond P, Gerraty R, Tress B, Wright P, Donnan G, Davis S (2002) Diffusion-and perfusion-weighted MRI response to thrombolysis in stroke. Ann Neurol 51:28–37PubMedCrossRefGoogle Scholar
  9. 9.
    Dzialowski I, Weber J, Dörfler A, Forsting M, von Kummer R (2002) CT monitoring of ischemic edema during reperfusion after transient middle cerebral artery occlusion. Stroke 33:408Google Scholar
  10. 10.
    Schriger D, Kalafut M, Starkman S, Krueger M, Daver J (1998) Cranial computed tomographic interpretation in acute stroke. Physician accuracy in determining eligibility for thrombolytic therapy. JAMA 279:1293–1297PubMedCrossRefGoogle Scholar
  11. 11.
    Wardlaw J, Statham P (2000) How often is haemosiderin not visible on routine MRI following traumatic intracerebral haemorrhage? Neuroradiology 42:81–84PubMedCrossRefGoogle Scholar
  12. 12.
    Linfante I, Llinas R, Caplan L, Warach S (1999) MRI features of intracerebral hemorrhage within 2 hours from symptom onset. Stroke 30:2263–2267PubMedCrossRefGoogle Scholar
  13. 13.
    Kidwell C, Saver J, Villablance J, Duckwiler G, Fredieu A, Gough K, Leary M, Starkman S, Gobin Y, Jahan R, Vespa P, Liebeskind D, Alger I, Vinuela F (2002) Magnetic resonance imaging detection of microbleeds before thrombolysis: an emerging application. Stroke 33:95–98PubMedCrossRefGoogle Scholar
  14. 14.
    Nighoghossian N, Hermier M, Adeleine P, Blanc-Laserre K, Derex I, Honnorat J, Phillipeau F, Dugor J, Froment J, Trouillas P (2002) Old microbleeds are a potential risk factor for cerebral bleeding after ischemic stroke. A gradient-echo T2*-weighted brain MRI study. Stroke 33:735–742PubMedCrossRefGoogle Scholar
  15. 15.
    Tomsick T, Brott T, Chambers A, Fox A, Gaskill M, Lukin R, Pleatman C, Wiot J, Bourekas E (1990) Hyperdense middle artery sign on CT: efficacy in detecting middle cerebral artery thrombosis. AJNR Am J Neuroradiol 11:473–477PubMedGoogle Scholar
  16. 16.
    von Kummer R, Holle R, Grzyska U, Hofmann E, Jansen O, Petersen D, Schumacher M, Sartor, K (1996) Interobserver agreement in assessing early CT signs of middle cerebral artery infarction. AJNR Am J Neuroradiol 17:1743–1748Google Scholar
  17. 17.
    Marks M, Holmgren E, Fox A, Patel S, von Kummer R, Froehlich J (1999) Evaluation of early computed tomographic findings in acute ischemic stroke. Stroke 30:389–392PubMedCrossRefGoogle Scholar
  18. 18.
    Knauth M, von Kummer R, Jansen O, Hähnel S, Dörfler A, Sartor K (1997) Potential of CT angiography in acute ischemic stroke. AJNR Am J Neuroradiol 18:1001–1010PubMedGoogle Scholar
  19. 19.
    Gibbs J, Wise R, Leenders K, Jones T (1984) Evaluation of cerebral perfusion reserve in patients with carotid-artery occlusion. Lancet 8372:310–314CrossRefGoogle Scholar
  20. 20.
    Yuh W, Simonson T, Wang A, Koci T, Tali E, Fisher D, Simon J, Jinkins J, Tsai F (1999) Venous sinus occlusive disease: MR findings. AJNR Am J Neuroradiol 15:309–316Google Scholar
  21. 21.
    Essig M, von Kummer R, Egelhof T, Winter R, Sartor K (1996) Magnetic resonance imaging of vascular contrast enhancement in cerebrovascular disease. AJNR Am J Neuroradiol 17:887–894PubMedGoogle Scholar
  22. 22.
    Rempp K, Brix G, Wenz F, Becker C, Gückel F, Lorenz W (1994) Quantification of regional cerebral blood flow and volume with dynamic susceptibility contrast-enhanced MR imaging. Radiology 193:637–641PubMedGoogle Scholar
  23. 23.
    Koenig M. Klotw E, Luka B, Venderink D, Spittler J, Heuser L (1998) perfusion CT of the brain: diagnostic approach for early detection of ischeic stroke. Radiology 209:85–93PubMedGoogle Scholar
  24. 24.
    Garcia J, Liu KF, Ho KL (1995) Neuronal necrosis after middle cerebral artery occlusion in Wistar rats progresses at different time intervals in the caudoputamen and the cortex. Stroke 26:636–643PubMedCrossRefGoogle Scholar
  25. 25.
    Hossmann KA (1994) Viability thresholds and the penumbra of focal ischemia. Ann Neurol 36:557–565PubMedCrossRefGoogle Scholar
  26. 26.
    Watanabe O, West CR, Bremer A (1977) Experimental regional cerebral ischemia in the middle cerebral artery territory in primates. Part 2: Effects on brain water and electrolytes in the early phase of MCA stroke. Stroke 8:71–76PubMedCrossRefGoogle Scholar
  27. 27.
    Schuier FJ, Hossmann KA (1980) Experimental brain infarcts in cats. II. Ischemic brain edema. Stroke 11:593–601PubMedCrossRefGoogle Scholar
  28. 28.
    Todd N, Picozzi P, Crockard, A, Ross Russel R (1986) Duration of ischemia influences the development and resolution of is-chemic brain edema. Stroke 17:466–471PubMedCrossRefGoogle Scholar
  29. 29.
    Todd N, Picozzi P, Crockard A, Ross Russel R (1986) Reperfusion after cerebral ischemia: Influence of duration of ischemia. Stroke 17:460–465PubMedCrossRefGoogle Scholar
  30. 30.
    von Kummer R, Bourquain H, Bastianello S, Bozzao L, Manelfe C, Meier D, Hacke W (2001) Early prediction of irreversible brain damage after ischemic stroke by computed tomography. Radiology 219:95–100Google Scholar
  31. 31.
    Rieth KG, Fujiwara K, Di Chiro G, Klatzo I, Brooks RA, Johnston GS, O’Connor CM, Mitchell LG (1980) Serial measurements of CT attenuation and specific gravity in experimental cerebral edema. Radiology 135:343–348PubMedGoogle Scholar
  32. 32.
    Unger E, Littlefield J, Gado M (1988) Water content and water structure in CT and MR signal changes: possible influence in detection of early stroke. AJNR Am J Neuroradiol 9:687–691PubMedGoogle Scholar
  33. 33.
    Grond M, von Kummer R, Sobesky J, Schmülling S, Heiss WD (1997) Early computed tomography abnormalities in acute stroke. Lancet 350:1595–1596PubMedCrossRefGoogle Scholar
  34. 34.
    Firlik A, Kaufmann A, Wechsler L, Firlik K, Fukui M, Yonas H (1997) Quantitative cerebral blood flow determinations in acute ischemic stroke. Relationship to computed tomography and angiography. Stroke 28:2208–2213PubMedCrossRefGoogle Scholar
  35. 35.
    Grotta J, Chiu D, Lu M, Patel S, Levine S, Tilley B, Brott T, Haley E, Lyden P, Kothari R, Frankel, M, Lewandowski C, Libman R, Kwiatkowski T, Broderick J, Marler J, Corrigan J, Huff S, Mitsias P, Talati S, Tanne D (1999) Agreement and variability in the interpretation of early CT changes in stroke patients qualifying for intravenous rtPA therapy. Stroke 30:1528–1533PubMedCrossRefGoogle Scholar
  36. 36.
    von Kummer R (1998) Effect of training in reading CT scans on patient selection for ECASS II. Neurology 51[Suppl 3]:S50–S52CrossRefGoogle Scholar
  37. 37.
    Bendszus, M, Urbach H, Meyer B, Schultheiß R, Solymosi L (1997) Improved CT diagnosis of acute middle cerebral artery territory infarcts with density-difference analysis. Neuroradiology 39:127–131PubMedCrossRefGoogle Scholar
  38. 38.
    Lev M, Farkas J, Gemmete J, Hossain S, Hunter G, Koroshetz W, Gonzalez R (1999) Acute stroke: improved nonenhanced CT detection — Benefits of soft-copy interpretation by using variable window width and center level settings. Radiology 213:150–155PubMedGoogle Scholar
  39. 39.
    Barber P, Demchuk A, Zhang J, Buchan A (2000) Validity and reliability of a quantitative computed tomography score in predicting outcome of hyperacute stroke before thrombolytic therapy. Lancet 355:1670–1674PubMedCrossRefGoogle Scholar
  40. 40.
    Moseley M, Cohen Y, Mintorovitch J, Chileuitt L, Shimizu H, Kucharczyk J, Wendland M, Weinstein P (1990) Early detection of regional cerebral ischemia in cats: comparison of diffusion-and T2-weighted MRI and spectroscopy. Magn Reson Med 14:330–346PubMedCrossRefGoogle Scholar
  41. 41.
    Kuroiwa T, Nagaoka T, Ueki M, Yamada I, Miyasaki N, Akimoto H (1998) Different apparent diffusion coefficient. Water content correlations of gray and white matter during early ischemia. Stroke 29:859–865PubMedCrossRefGoogle Scholar
  42. 42.
    Busza A, Allen K, King M, van Bruggen N, Williams S, Gadian D (1992) Diffusion-weighted imaging studies of cerebral ischemia in gerbils. Potential relevance to energy failure. Stroke 23:1602–1612PubMedCrossRefGoogle Scholar
  43. 43.
    Wang Y, Hu W, Perez-Trepichio A, Ng T, Furlan A, Majors A Jones S (2000) Brain tissue sodium is a ticking clock telling time after arterial occlusion in rat focal cerebral ischemia. Stroke 31:1386–1392PubMedCrossRefGoogle Scholar
  44. 44.
    Mintorovitch J, Yang G, Shimizu H, Kucharczyk J, Chan P, Weinstein P (1994) Diffusion-weighted magnetic resonance imaging of acute focal cerebral ischemia: comparison of signal intensity with changes in brain water and Na+, K+-ATPase activity. J Cereb Blood Flow Metab 14:332–336PubMedCrossRefGoogle Scholar
  45. 45.
    Back T, Hoehn-Berlage M, Kohno K, Hossmann K (1994) Diffusion NMR imaging in experimental stroke: correlation with cerebral metabolites. Stroke 25:494–500PubMedCrossRefGoogle Scholar
  46. 46.
    Lövblad K, Laubach H, Baird A, Curtin F, Schlaug G, Edelman R, Warach S (1998) Clinical experience with diffusion-weighted MR in patients with acute stroke. AJNR Am J Neuroradiol 19:1061–1066PubMedGoogle Scholar
  47. 47.
    Kidwell C, Alger J, Di Salle F, Starkman S, Villabianca P, Bentson J, Saver J (1999) Diffusion MRI in patients with transient ischemic attacks. Stroke 30:1174–1180PubMedCrossRefGoogle Scholar
  48. 48.
    Kidwell C, Saver J, Mattielloo J, Starkman S, Vinuela F, Duckwiler G, Gobin Y (2000) Thrombolytic reversal of acute human cerebral ischemic injury shown by diffusion/perfusion magnetic resonance imaging. Ann Neurol 47:462–469PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag Italia 2004

Authors and Affiliations

  • R. von Kummer
    • 1
  1. 1.Department of NeuroradiologyUniversitätsklinikum Carl-Gustav-CarusDresdenGermany

Personalised recommendations