Final infarct size after acute stroke: prediction with flow heterogeneity

Transit time homogenization in ischemic stroke - A novel biomarker of penumbral microvascular failure?

Cerebral ischemia causes widespread capillary no-flow in animal studies. The extent of microvascular impairment in human stroke, however, is unclear. We examined how acute intra-voxel transit time characteristics and subsequent recanalization affect tissue outcome on follow-up MRI in a historic cohort of 126 acute ischemic stroke patients. Based on perfusion-weighted MRI data, we characterized voxel-wise transit times in terms of their mean transit time (MTT), standard deviation (capillary transit time heterogeneity - CTH), and the CTH:MTT ratio (relative transit time heterogeneity), which is expected to remain constant during changes in perfusion pressure in a microvasculature consisting of passive, compliant vessels. To aid data interpretation, we also developed a computational model that relates graded microvascular failure to changes in these parameters. In perfusion-diffusion mismatch tissue, prolonged mean transit time (>5 seconds) and very low cerebral blood flow (≤6 mL/100 mL/min) was associated with high risk of infarction, largely independent of recanalization status. In the remaining mismatch region, low relative transit time heterogeneity predicted subsequent infarction if recanalization was not achieved. Our model suggested that transit time homogenization represents capillary no-flow. Consistent with this notion, low relative transit time heterogeneity values were associated with lower cerebral blood volume. We speculate that low RTH may represent a novel biomarker of penumbral microvascular failure.

Capillary dysfunction: its detection and causative role in dementias and stroke

In acute ischemic stroke, critical hypoperfusion is a frequent cause of hypoxic tissue injury: As cerebral blood flow (CBF) falls below the ischemic threshold of 20 mL/100 mL/min, neurological symptoms develop and hypoxic tissue injury evolves within minutes or hours unless the oxygen supply is restored. But is ischemia the only hemodynamic source of hypoxic tissue injury? Reanalyses of the equations we traditionally use to describe the relation between CBF and tissue oxygenation suggest that capillary flow patterns are crucial for the efficient extraction of oxygen: without close capillary flow control, "functional shunts" tend to form and some of the blood's oxygen content in effect becomes inaccessible to tissue. This phenomenon raises several questions: Are there in fact two hemodynamic causes of tissue hypoxia: Limited blood supply (ischemia) and limited oxygen extraction due to capillary dysfunction? If so, how do we distinguish the two, experimentally and in patients? Do flow-metabolism coupling mechanisms adjust CBF to optimize tissue oxygenation when capillary dysfunction impairs oxygen extraction downstream? Cardiovascular risk factors such as age, hypertension, diabetes, hypercholesterolemia, and smoking increase the risk of both stroke and dementia. The capillary dysfunction phenomenon therefore forces us to consider whether changes in capillary morphology or blood rheology may play a role in the etiology of some stroke subtypes and in Alzheimer's disease. Here, we discuss whether certain disease characteristics suggest capillary dysfunction rather than primary flow-limiting vascular pathology and how capillary dysfunction may be imaged and managed.

Modeling and correction of bolus dispersion effects in dynamic susceptibility contrast MRI

PURPOSE

Bolus dispersion in DSC-MRI can lead to errors in cerebral blood flow (CBF) estimation by up to 70% when using singular value decomposition analysis. However, it might be possible to correct for dispersion using two alternative methods: the vascular model (VM) and control point interpolation (CPI). Additionally, these approaches potentially provide a means to quantify the microvascular residue function.

METHODS

VM and CPI were extended to correct for dispersion by means of a vascular transport function. Simulations were performed at multiple dispersion levels and an in vivo analysis was performed on a healthy subject and two patients with carotid atherosclerotic disease.

RESULTS

Simulations showed that methods that could not address dispersion tended to underestimate CBF (ratio in CBF estimation, CBFratio = 0.57-0.77) in the presence of dispersion; whereas modified CPI showed the best performance at low-to-medium dispersion; CBFratio = 0.99 and 0.81, respectively. The in vivo data showed trends in CBF estimation and residue function that were consistent with the predictions from simulations.

CONCLUSION

In patients with atherosclerotic disease the estimated residue function showed considerable differences in the ipsilateral hemisphere. These differences could partly be attributed to dispersive effects arising from the stenosis when dispersion corrected CPI was used. It is thus beneficial to correct for dispersion in perfusion analysis using this method.

The role of the microcirculation in delayed cerebral ischemia and chronic degenerative changes after subarachnoid hemorrhage

The mortality after aneurysmal subarachnoid hemorrhage (SAH) is 50%, and most survivors suffer severe functional and cognitive deficits. Half of SAH patients deteriorate 5 to 14 days after the initial bleeding, so-called delayed cerebral ischemia (DCI). Although often attributed to vasospasms, DCI may develop in the absence of angiographic vasospasms, and therapeutic reversal of angiographic vasospasms fails to improve patient outcome. The etiology of chronic neurodegenerative changes after SAH remains poorly understood. Brain oxygenation depends on both cerebral blood flow (CBF) and its microscopic distribution, the so-called capillary transit time heterogeneity (CTH). In theory, increased CTH can therefore lead to tissue hypoxia in the absence of severe CBF reductions, whereas reductions in CBF, paradoxically, improve brain oxygenation if CTH is critically elevated. We review potential sources of elevated CTH after SAH. Pericyte constrictions in relation to the initial ischemic episode and subsequent oxidative stress, nitric oxide depletion during the pericapillary clearance of oxyhemoglobin, vasogenic edema, leukocytosis, and astrocytic endfeet swelling are identified as potential sources of elevated CTH, and hence of metabolic derangement, after SAH. Irreversible changes in capillary morphology and function are predicted to contribute to long-term relative tissue hypoxia, inflammation, and neurodegeneration. We discuss diagnostic and therapeutic implications of these predictions.

The role of the cerebral capillaries in acute ischemic stroke: the extended penumbra model

The pathophysiology of cerebral ischemia is traditionally understood in relation to reductions in cerebral blood flow (CBF). However, a recent reanalysis of the flow-diffusion equation shows that increased capillary transit time heterogeneity (CTTH) can reduce the oxygen extraction efficacy in brain tissue for a given CBF. Changes in capillary morphology are typical of conditions predisposing to stroke and of experimental ischemia. Changes in capillary flow patterns have been observed by direct microscopy in animal models of ischemia and by indirect methods in humans stroke, but their metabolic significance remain unclear. We modeled the effects of progressive increases in CTTH on the way in which brain tissue can secure sufficient oxygen to meet its metabolic needs. Our analysis predicts that as CTTH increases, CBF responses to functional activation and to vasodilators must be suppressed to maintain sufficient tissue oxygenation. Reductions in CBF, increases in CTTH, and combinations thereof can seemingly trigger a critical lack of oxygen in brain tissue, and the restoration of capillary perfusion patterns therefore appears to be crucial for the restoration of the tissue oxygenation after ischemic episodes. In this review, we discuss the possible implications of these findings for the prevention, diagnosis, and treatment of acute stroke.

Magnetic resonance diffusion-perfusion mismatch in acute ischemic stroke: An update

The concept of magnetic resonance perfusion-diffusion mismatch (PDM) provides a practical and approximate measure of the tissue at risk and has been increasingly applied for the evaluation of hyperacute and acute stroke in animals and patients. Recent studies demonstrated that PDM does not optimally define the ischemic penumbra; because early abnormality on diffusion-weighted imaging overestimates the infarct core by including part of the penumbra, and the abnormality on perfusion weighted imaging overestimates the penumbra by including regions of benign oligemia. To overcome these limitations, many efforts have been made to optimize conventional PDM. Various alternatives beyond the PDM concept are under investigation in order to better define the penumbra. The PDM theory has been applied in ischemic stroke for at least three purposes: to be used as a practical selection tool for stroke treatment; to test the hypothesis that patients with PDM pattern will benefit from treatment, while those without mismatch pattern will not; to be a surrogate measure for stroke outcome. The main patterns of PDM and its relation with clinical outcomes were also briefly reviewed. The conclusion was that patients with PDM documented more reperfusion, reduced infarct growth and better clinical outcomes compared to patients without PDM, but it was not yet clear that thrombolytic therapy is beneficial when patients were selected on PDM. Studies based on a larger cohort are currently under investigation to further validate the PDM hypothesis.

Susceptibility Weighted Imaging and Cerebrovascular Disorders

To investigate the correlation between the SWI findings and prognosis of the cerebrovascular disorders. From July 2008 to July 2010, 299 ischemic stroke patients were found in our hospital. The gender ratio is as male and female being 157 to 142. The mean age of all patients is 65.4, mean female age is 69.1, and mean male age is 62.6. There were 86 patients who had satisfactory pre-and post-treatment of CT, MRI with SWI. 23 of these 86 patients had catheter cerebral angiography. 50 of these 86 patients had MR angiogram or CT angiogram. 13 of these 86 patients did not have angiogram. We have also collected 7 severe cardiac arrested and cessation of cerebral circulation and 2 patients with chronic venous hypertension. Among the 86 patients, 23 patients who had negative with deoxygenated vessel on SWI were with small infarction on DWI Thirty-one patients had negative on initial CT head scan. CT finding did not accord with presence of hypointense vessel on SWI. Sixty-three patients had varied degree of abnormal hypointense vessels on SWI as deoxygenated vessels. The initial small foci on DWI may result with a larger infarction if there were with prominent hypointense vessels.

Blood-brain barrier experiments with clinical magnetic resonance imaging and an immunohistochemical study

OBJECTIVE

The purpose of study was to evaluate the feasibility of brain magnetic resonance (MR) images of the rat obtained using a 1.5T MR machine in several blood-brain barrier (BBB) experiments.

METHODS

Male Sprague-Dawley rats were used. MR images were obtained using a clinical 1.5T MR machine. A microcatheter was introduced via the femoral artery to the carotid artery. Normal saline (group 1, n = 4), clotted autologous blood (group 2, n = 4), triolein emulsion (group 3, n = 4), and oleic acid emulsion (group 4, n = 4) were infused into the carotid artery through a microcatheter. Conventional and diffusion-weighted images, the apparent coefficient map, perfusion-weighted images, and contrast-enhanced MR images were obtained. Brain tissue was obtained and triphenyltetrazolium chloride (TTC) staining was performed in group 2. Fluorescein isothiocyanate (FITC)-labeled dextran images and endothelial barrier antigen (EBA) studies were performed in group 4.

RESULTS

The MR images in group 1 were of good quality. The MR images in group 2 revealed typical findings of acute cerebral infarction. Perfusion defects were noted on the perfusion-weighted images. The MR images in group 3 showed vasogenic edema and contrast enhancement, representing vascular damage. The rats in group 4 had vasogenic edema on the MR images and leakage of dextran on the FITC-labeled dextran image, representing increased vascular permeability. The immune reaction was decreased on the EBA study.

CONCLUSION

Clinical 1.5T MR images using a rat depicted many informative results in the present study. These results can be used in further researches of the BBB using combined clinical MR machines and immunohistochemical examinations.

Mapping Transient Hyperventilation Induced Alterations with Estimates of the Multi-Scale Dynamics of BOLD Signal

Temporal blood oxygen level dependent (BOLD) contrast signals in functional MRI during rest may be characterized by power spectral distribution (PSD) trends of the form 1/f(alpha). Trends with 1/f characteristics comprise fractal properties with repeating oscillation patterns in multiple time scales. Estimates of the fractal properties enable the quantification of phenomena that may otherwise be difficult to measure, such as transient, non-linear changes. In this study it was hypothesized that the fractal metrics of 1/f BOLD signal trends can map changes related to dynamic, multi-scale alterations in cerebral blood flow (CBF) after a transient hyperventilation challenge. Twenty-three normal adults were imaged in a resting-state before and after hyperventilation. Different variables (1/f trend constant alpha, fractal dimension D(f), and, Hurst exponent H) characterizing the trends were measured from BOLD signals. The results show that fractal metrics of the BOLD signal follow the fractional Gaussian noise model, even during the dynamic CBF change that follows hyperventilation. The most dominant effect on the fractal metrics was detected in grey matter, in line with previous hyperventilation vaso-reactivity studies. The alpha was able to differentiate also blood vessels from grey matter changes. D(f) was most sensitive to grey matter. H correlated with default mode network areas before hyperventilation but this pattern vanished after hyperventilation due to a global increase in H. In the future, resting-state fMRI combined with fractal metrics of the BOLD signal may be used for analyzing multi-scale alterations of cerebral blood flow.

Comparing two methods for assessment of perfusion-diffusion mismatch in a rodent model of ischaemic stroke: a pilot study

This stroke experiment was designed to define the mismatch between perfusion-weighted imaging (PWI) and diffusion-weighted imaging (DWI) in MRI by applying early or instantly acquired PWI. Eight rats were induced with stroke through photothrombotic occlusion of the middle cerebral artery and scanned serially between 1 h and day 3 after induction using DWI and PWI with a 1.5 T MR scanner. The relative lesion volumes (rLV) on MRI and triphenyl tetrazolium chloride-stained specimens were defined as the proportion of lesion volume over brain volume. Discrepancies in the rLV between PWI- and DWI-derived apparent diffusion coefficient (ADC) maps were expressed by subtraction of the ADC from PWI, resulting in three possible patterns: (i) (PWI-ADC > 10% of PWI) denoting a mismatch; (ii) (-(10% of PWI) <or= PWI-ADC <or= 10% of PWI) denoting a match; and (iii) (PWI-ADC < -(10% of PWI)) denoting a reverse mismatch. The differences were compared with the minuend being either early PWI (ePWI) or instant PWI (iPWI) and the subtrahend being instant ADC (iADC). The occurrence and evolution of PWI-ADC patterns were analysed. Over time, PWI-ADC discrepancies evolved from mismatch, through to match, to reversed mismatch. The PWI-ADC mismatch still existed 3 days after MCA occlusion in one to three of the eight cases. The rLVs and mismatch incidences between the ePWI-iADC and iPWI-iADC models were linear correlated. A higher mismatch rate occurred in iPWI-iADC within day 1 and in ePWI-iADC at day 3. Both ePWI and iPWI proved useful to define PWI-ADC patterns within day 1. At day 3, iPWI appeared more adequate.

Bayesian estimation of cerebral perfusion using a physiological model of microvasculature

Perfusion weighted MRI has proven very useful for deriving hemodynamic parameters such as CBF, CBV and MTT. These quantities are important diagnostically, e.g. in acute stroke, where they are used to delineate ischemic regions. Yet the standard method for estimating CBF based on singular value decomposition (SVD) has been demonstrated to underestimate (especially high) flow components and to be sensitive to delays in the arterial input function (AIF). Furthermore, the estimated residue functions often oscillate. This compromises their physiological interpretation/basis and makes estimation of related measures such as flow heterogeneity difficult. In this study, we estimate perfusion parameters based on a vascular model (VM) which represents heterogeneous capillary flow and explicitly leads to monotonically decreasing residue functions. We use a fully Bayesian approach to obtain posterior probability distributions for all parameters. In simulation studies, we show that the VM method has less bias in CBF estimates than the SVD based method for realistic SNRs. This also applies to cases where the AIF is delayed. We employ our method to estimate perfusion maps using data from (i) a healthy volunteer and (ii) from a stroke patient.

Technical aspects of perfusion-weighted imaging

There is increasing interest in using diffusion-weighted (DWI) MR imaging and perfusion-weighted MR imaging (PWI) to assist clinical decision-making in the management of acute stroke patients. Larger PWI than DWI lesions have been speculated to represent potentially salvageable tissue that is at risk of infarction unless nutritive flow is restored and presence of these mismatches have been proposed as inclusion criteria for identifying patients most likely to benefit from therapeutic intervention. Understanding the technical aspects of PWI may improve comprehension of the capabilities and limitations of this technique.

Do acute diffusion- and perfusion-weighted MRI lesions identify final infarct volume in ischemic stroke?

BACKGROUND AND PURPOSE

An acute mismatch on diffusion-weighted MRI (DWI) and perfusion-weighted MRI (PWI) may represent the "tissue-at-risk." It is unclear which "semiquantitative" perfusion parameter most closely identifies final infarct volume.

METHODS

Acute stroke patients underwent DWI and PWI (dynamic-susceptibility contrast imaging) on admission (baseline), and T2-weighted imaging (T2WI) at 1 or 3 months after stroke. "Semiquantitative" mean transit time (MTTsq=first moment of concentration/time curve), cerebral blood volume (CBVsq=area under concentration/time curve), and cerebral blood flow (CBFsq=CBVsq/MTTsq) were calculated. DWI and PWI lesions were measured at baseline and final infarct volume on T2WI acquired > or =1 month after stroke. Baseline DWI, CBFsq, and MTTsq lesion volumes were compared with final T2WI lesion volume.

RESULTS

Among 46 patients, baseline DWI and CBFsq lesions were not significantly different from final T2WI lesion volume, but baseline MTTsq lesions were significantly larger. The correlation with final T2WI lesion volume was strongest for DWI (Spearman rank correlation coefficient rho=0.68), intermediate for CBFsq (rho=0.55), and weakest for MTTsq (rho=0.49) baseline lesion volumes. Neither DWI/CBFsq nor DWI/MTTsq mismatch predicted lesion growth; lesion growth was equally common in those with and without mismatch.

CONCLUSIONS

Of the 2 PWI parameters, CBFsq lesions most closely identifies, and MTTsq overestimates, final T2WI lesion volume. "DWI/PWI mismatch" does not identify lesion growth. Patients without "DWI/PWI mismatch" are equally likely to have lesion growth as those with mismatch and should not be excluded from acute stroke treatment.

Midazolam sedation increases fluctuation and synchrony of the resting brain BOLD signal

The blood oxygen level-dependent (BOLD) magnetic resonance signal of functional brain cortices is dominated by very low frequency (VLF) fluctuations in anesthetized child patients. The temporal synchrony of the BOLD signal is also higher in anesthetized children compared with awake adults. The origin of the synchronous fluctuations can be related to maturation, pathological status or the anesthesia used in the imaging. Two of the three confounding variables (maturation and pathology) were controlled in this study. The effect of midazolam (4+/-0.8 mg) sedation on the BOLD signal was assessed in 12 healthy adults (aged 24+/-1.5 years) at 1.5 T. The VLF fluctuation power and temporal synchrony of the BOLD signal increased significantly after the sedation in the auditory and visual cortices. The fast Fourier transformation power spectral baseline fit parameters of the BOLD signal were also found to change significantly after sedation. It is concluded that the VLF fluctuation and temporal synchrony of the BOLD signal become increased after sedation in functional brain regions.

Dynamic susceptibility contrast-enhanced perfusion MR imaging at 1.5 T predicts final infarct size in a rat stroke model

The purpose of the present animal experiment was to determine whether source images from dynamic susceptibility contrast-enhanced perfusion weighted imaging (DSC-PWI) at a 1.5T MR scanner, performed early after photochemically induced thrombosis (PIT) of cerebral middle artery (MCA), is feasible to predict final cerebral infarct size in a rat stroke model. Fifteen rats were subjected to PIT of proximal MCA. T2 weighted imaging (T2WI), diffusion-weighted imaging (DWI), and contrast-enhanced PWI were obtained at 1 h and 24 h after MCA occlusion. The relative lesion size (RLS) was defined as lesion volume/brain volume x 100% and measured for MR images, and compared with the final RLS on the gold standard triphenyl tetrazolium chloride (TTC) staining at 24 h. One hour after MCA occlusion, the RLS with DSC-PWI was 24.9 +/- 6.3%, which was significantly larger than 17.6 +/- 4.8% with DWI (P < 0.01). At 24 h, the final RLS on TTC was 24.3 +/- 4.8%, which was comparable to 25.1 +/- 3.5%, 24.6 +/- 3.6% and 27.9 +/- 6.8% with T2WI, DWI and DSC-PWI respectively (P > 0.05). The fact that at 1 h after MCA occlusion only the displayed perfusion deficit was similar to the final infarct size on TTC (P > 0.05) suggests that early source images from DSC-PWI at 1.5T MR scanner is feasible to noninvasively predict the final infarct size in rat models of stroke.

Perfusion imaging of the brain using Z-score and dynamic images obtained by subtracting images from before and after contrast injection

Objective

The aim of this study was to examine the feasibility of perfusion imaging of the brain using the Z-score and subtraction dynamic images obtained from susceptibility contrast MR images.

Materials and Methods

Five patients, each with a normal MRI, Moya-moya, a middle cerebral artery occlusion, post-trauma syndrome, and a metastatic brain tumor, were selected for a presentation. A susceptibility-contrast echo-planar image after a routine MRI was taken as the source image with a rapid manual injection of 0.1 mmol/kg of Gd-DTPA. The inflow and washout patterns were observed from the time-signal intensity curve of the serial scans using the standard program of an MRI machine. The repeated Z-score images of the peak and late phases were made using the threshold Z-score values between 1.4 and 2.0 in four to five studies of the pre-contrast, peak, and late phases. Dynamic subtraction images were produced by subtracting sequential post-contrast images from a pre-contrast image and coloring these images using a pseudocolor mapping method.

Results

In the diseases with perfusion abnormalities, the Z-score images revealed information about the degree of perfusion during the peak and late phases. However, the quality varied with the Z-score threshold and the studies selected in a group. The dynamic subtraction images were of sufficient quality with no background noise and more clearly illustrated the temporal changes in perfusion and delayed perfusion.

Conclusion

The Z-scores and dynamic subtraction images illustrated the degree of perfusion and sequential changes in the pattern of perfusion, respectively. These images can be used as a new complimentary method for observing the perfusion patterns in brain diseases.

Partial rescue of the perfusion deficit area by thrombolysis

PURPOSE

To investigate the evolution of the perfusion deficit area following systemic thrombolysis with recombinant tissue plasminogen activator (rtPA) in a clinical study on acute cerebral ischemia.

MATERIALS AND METHODS

We performed volumetric measurements of the acute ischemic lesions in MR images of perfusion (TTP, MTT, and rCBV) and in diffusion-weighted (DW) images, as well as the manifest stroke lesions in T2-weighted MR images on day 8. We compared the data of 29 patients who were subjected to systemic thrombolysis with those of 18 patients who were not eligible for thrombolysis.

RESULTS

In the treated patients there were prominent MTT/DWI and TTP/DWI mismatches (P < 0.0006). The acute TTP volumes were smaller than the acute MTT volumes, but as large as the T2 lesions on day 8. The MTT/T2 lesion volume reduction was significant (P < 0.03) in patients who received the GPIIb/IIIa receptor antagonist tirofiban (N = 13) in addition to the low-dose rtPA. This corresponded to a greater neurological improvement compared to patients who received rtPA alone (P < 0.05). In contrast, in the nontreated patients the initial MTT and TTP lesion volumes were of similar magnitude and predicted the T2 lesions on day 8. In the treated and nontreated patients the TTP lesion signified the viability threshold of acute ischemia, which corresponded to a rCBF of 25 +/- 11 mL/100 g/min.

CONCLUSION

The perfusion deficit area comprises the ischemic core that is destined to undergo necrosis, and an ischemic rim that is salvageable by systemic thrombolysis.

Abnormal intravoxel cerebral blood flow heterogeneity in human ischemic stroke determined by dynamic susceptibility contrast magnetic resonance imaging

BACKGROUND AND PURPOSE

The determination of cerebral blood flow heterogeneity (FH) by dynamic susceptibility contrast (DSC) magnetic resonance imaging has recently been proposed as a tool to predict final infarct size in acute stroke. In this study, we describe the evolution of FH during the first week as well as its correlation to the patients' clinical status.

METHODS

Ten patients with ischemic stroke were studied with DSC MRI and diffusion-weighted imaging in hyperacute (<6 hours) phase, at 24 hours, and 1 week after symptom onset. In addition to intravoxel FH, cerebral blood volume (CBV), cerebral blood flow (CBF), and contrast agent mean transit time (MTT) were determined from DSC MRI. All patients were evaluated neurologically with National Institute of Health Stroke Scale concurrently with the imaging sessions.

RESULTS

All patients showed infarct growth, judged by diffusion-weighted imaging, during the week with simultaneous decrease in the sizes of FH, CBV, CBF, and MTT abnormalities. The FH abnormality was shown to be larger than CBV and CBF abnormalities at the hyperacute phase and 24 hours, but smaller than MTT abnormality in all 3 imaging sessions. The sizes of hyperacute FH, CBV, CBF, and MTT abnormalities correlated well with infarct size at 24 hours and at 1 week. Additionally, FH was the only perfusion parameter that correlated with the clinical score.

CONCLUSIONS

FH predicts infarct size equally well with the other perfusion parameters but is superior in correlation with the clinical score. FH can easily be incorporated to hyperacute stroke imaging without additional efforts.

Clinical perspectives in perfusion: neuroradiologic applications

Imaging of cerebral perfusion, particularly by the dynamic tracking of a bolus of gadolinium-based contrast agent, has emerged from the experimental laboratory and become a routine aspect of neuroradiologic practice. This article discusses the practical implementation of "perfusion" protocols into neuroradiologic examinations, as well as discussing the role of postprocessing and quantitative interpretation in terms of vascular physiology and function. Several key clinical indications are introduced, such as acute cerebral ischemia, chronic vascular disease, and tumors.

CT, MR Imaging, and MR Angiography in the Evaluation of Patients with Acute Stroke

The patient with acute stroke presents a full challenge to the diagnostic and therapeutic aspects of medicine in all forms, from community through tertiary care. Patients with brain damage in the ischemic, but not yet infarcted, phase have the greatest potential for recovery. Herein, the author reviews the most commonly employed diagnostic tools that are currently used before stroke therapy. The logistical demands of emergency evaluation of a patient at a given institution often dictate which modality can and should be practically applied. Any of the available modalities, when used well, can offer pertinent diagnostic and even predictive information to assist in the quick, accurate classification of patients to the most appropriate treatment group.