Current concepts in imaging and endovascular treatment of acute ischemic stroke: implications for the clinician

Role of arterial spin labeling magnetic resonance perfusion in acute ischemic stroke

Background

Arterial spin labeling (ASL) is a recently used magnetic resonance imaging (MRI) perfusion technique in acute cerebrovascular stroke conditions; it can detect the hypo perfused areas on basis of qualitative and quantitative measurements and also identify the area at risk known as penumbra by detecting the diffusion/perfusion mismatch. The purpose of this study was to assess the role of ASL perfusion technique in management of acute ischemic stroke and its ability to predict the clinical outcome of acute stroke patients. The study was prospectively carried out on 33 patients clinically presented with acute stroke from the first of August 2020 till the first of August 2021. All cases were clinically assessed by stroke consultant followed by brain imaging including conventional MRI and ASL perfusion technique, based upon which management was established. These imaging data were correlated with the clinical outcome after 3 months using Modified Rankin Scale.

Results

Sixteen cases (48.48%) showed ischemic penumbra with diffusion perfusion mismatch with three cases presenting within the first 4 h managed by intravenous thrombolytic therapy and 13 cases presenting later than 4 h, 10 of whom were managed by endovascular intervention. The group with ischemic penumbra showed significant positive correlation with favorable clinical outcome while the group without ischemic penumbra showed significant positive correlation with poor clinical outcome. Quantitative ASL values were statistically significantly higher (p ≤ 0.05) in patients with favorable clinical outcome than those with poor clinical outcome. The estimated cut off values of ASL absolute cerebral blood flow and relative cerebral blood flow to predict favorable or poor outcome using ROC curve analysis were 19 ml/100gm/min and 74% compared to the contralateral side respectively.

Conclusion

The use of MRI as a primary diagnostic tool in arterial ischemic stroke with the application of non-contrast ASL perfusion sequence allows precise detection of perfusion deficit and diffusion perfusion mismatch (penumbra) and provides a reliable insight into outcome prediction.

How to improve access to medical imaging in low- and middle-income countries ?

Imaging has become key in the care pathway of communicable and non-communicable diseases. Yet, there are major shortages of imaging equipment and workforce in low- and middle-income countries (LMICs). The International Society of Radiology outlines a plan to upscale the role of imaging in the global health agenda and proposes a holistic approach for LMICs. A generic model for organising imaging services in LMICs via regional Centres of Reference is presented. The need to better exploit IT and the potential of artificial intelligence for imaging, also in the LMIC setting, is highlighted. To implement the proposed plan, involvement of professional and international organisations is considered crucial. The establishment of an International Commission on Medical Imaging under the umbrella of international organisations is suggested and collaboration with other diagnostic disciplines is encouraged to raise awareness of the importance to upscale diagnostics at large and to foster its integration into the care pathway globally.

Early Brain Imaging Shows Increased Severity of Acute Ischemic Strokes With Large Vessel Occlusion in COVID-19 Patients

BACKGROUND AND PURPOSE

Reports are emerging regarding the association of acute ischemic strokes with large vessel occlusion and coronavirus disease 2019 (COVID-19). While a higher severity of these patients could be expected from the addition of both respiratory and neurological injury, COVID-19 patients with strokes can present with mild or none respiratory symptoms. We aimed to compare anterior circulation large vessel occlusion strokes severity between patients with and without COVID-19.

METHODS

We performed a comparative cohort study between patients with COVID-19 who had anterior circulation large vessel occlusion and early brain imaging within 3 hours from onset, in our institution during the 6 first weeks of the COVID-19 outbreak and a control group admitted during the same calendar period in 2019.

RESULTS

Twelve COVID-19 patients with anterior circulation large vessel occlusion and early brain imaging were included during the study period and compared with 34 control patients with anterior circulation large vessel occlusion and early brain imaging in 2019. Patients in the COVID-19 group were younger (P=0.032) and had a history of diabetes mellitus more frequently (P=0.039). Patients did not significantly differ on initial National Institutes of Health Stroke Scale nor time from onset to imaging (P=0.18 and P=0.6, respectively). Patients with COVID-19 had more severe strokes than patients without COVID-19, with a significantly lower clot burden score (median: 6.5 versus 8, P=0.016), higher rate of multivessel occlusion (50% versus 8.8%, P=0.005), lower DWI-ASPECTS (Diffusion-Weighted Imaging-Alberta Stroke Program Early CT Scores; median: 5 versus 8, P=0.006), and higher infarct core volume (median: 58 versus 6 mL, P=0.004). Successful recanalization rate was similar in both groups (P=0.767). In-hospital mortality was higher in the COVID-19 patients' group (41.7% versus 11.8%, P=0.025).

CONCLUSIONS

Early brain imaging showed higher severity large vessel occlusion strokes in patients with COVID-19. Given the massive number of infected patients, concerns should be raised about the coming neurovascular impact of the pandemic worldwide.

Prophylaxis with a multicomponent nutraceutical abates transient cerebral ischemia/reperfusion injury

The effect of a multicomponent nutraceutical on cerebral ischemia/reperfusion injury in male Wistar rats was investigated. Animals were administered with the nutraceutical, Trévo™, for 7 days before 30 min of bilateral common carotid artery occlusion-induced cerebral ischemia and 24 hr of reperfusion. Behavioral assessment, biochemical estimations in the brain cortex, striatum, and hippocampus, and hippocampal histopathological evaluation were carried out after treatments. Results showed that ischemia/reperfusion-induced motor and cognitive deficits were abated in rats pretreated with Trévo™. Additionally, prophylaxis with Trévo™ blunted ischemia/reperfusion-induced redox stress, proinflammatory events, disturbances in neurotransmitter metabolism, mitochondrial dysfunction, and histoarchitectural aberrations in the discreet brain regions. In summary, supplementation with Trévo™ provided neuroprotection to rats against transient cerebral ischemia/reperfusion injury and could be explored as a promising approach in stroke prevention. PRACTICAL APPLICATIONS: There is a worldwide increase in the incidence of cerebral ischemia or stroke. Although an advanced health care system and effective control of risk factors have led to the declining incidence in developed nations, a definitive cure for stroke remains elusive and the situation is growing worse in developing nations. The results of the present study revealed that supplementation with Trévo™ ameliorated neurobehavioral, neurochemical, and histopathological consequences of brain ischemia/reperfusion injury and could, therefore, be beneficial in stroke prevention and management.

CT Imaging of Acute Ischemic Stroke [Formula: see text]

Although acute ischemic stroke remains one of the most common causes of death and disability worldwide, it is a potentially treatable condition if appropriately managed in a timely manner. The goals of acute stroke imaging include establishing a diagnosis as fast as possible with (1) accurate infarct quantification, (2) intracranial and cervical vasculature assessment, and (3) brain perfusion analysis for detection of infarct core and potentially salvageable penumbra allowing optimal patient selection for appropriate therapy. Given the extensive number of images generated from acute stroke imaging studies and as "time is brain," this article aims to highlight a logical approach for the radiologist in acute stroke computed tomography imaging in order to accurately interpret and communicate results in a timely manner.