Stroke
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This pathway provides guidance on the imaging of adult patients following a suspected cerebrovascular accident (stroke).
Date reviewed: May 2016
Date of next review: May 2023
Published: May 2017
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The relative radiation level (RRL) of each imaging investigation is displayed in the pop up box.
SYMBOL | RRL | EFFECTIVE DOSE RANGE |
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None | 0 |
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Minimal | < 1 millisieverts |
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Low | 1-5 mSv |
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Medium | 5-10 mSv |
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High | >10 mSv |
Images
Teaching Points
Teaching Points
- Imaging in the setting of suspected stroke serves a number of purposes
- To distinguish between haemorrhagic and ischaemic stroke
- To determine vascular territory of stroke and location and extent of intravascular clot
- To determine presence and extent of ischaemic core and penumbra
- To determine aetiology of the stroke
- To identify alternative causes of clinical symptoms
- A non-contrast CT is the initial imaging modality of choice in suspected stroke. The main value of CT in the acute setting is to exclude haemorrhage or tumour
- Further imaging is dictated by the clinical situation and includes CTA (CT Angiogram) +/- CTP (CT Perfusion) depending on resources and expertise available. CTA/CTP should can be performed while recombinant tissue plasminogen activator (rtPA) is being prepared and should not delay the administration of recombinant tissue plasminogen activator
- For patients who are outside the time window for acute reperfusion therapies [ > 4.5 hours at sites where only IV recombinant tissue plasminogen activator (rtPA) is being considered; > 8hours at sites where endovascular therapy is considered] and for patients with Transient Ischaemic Attack (TIA) , emphasis is on secondary prevention and their imaging work-up should be focused on vascular imaging (MRA or Carotid Doppler or CTA) to assess carotid arteries as a possible source of emboli with secondary prevention in mind. If MRA is obtained, DWI, T1, T2 sequences should be performed as well at the same time
References
References
Date of literature search: May 2016
The search methodology is available on request. Email
References are graded from Level I to V according to the Oxford Centre for Evidence-Based Medicine, Levels of Evidence. Download the document
- Patel SC, Levine SR, Tilley BC, Grotta JC, Lu M, Frankel M, et al. Lack of clinical significance of early ischemic changes on computed tomography in acute stroke. JAMA. 2001;286(22):2830-8 (Level II Evidence). View the reference
- Schriger DL, Kalafut M, Starkman S, Krueger M, Saver JL Cranial computed tomography interpretation in acute stroke: physician accuracy in determining eligibility for thrombolytic therapy. JAMA. 1998;279(16):1293-7 (Level II Evidence). View the reference
- Grotta JC, Chiu D, Lu M, Patel S, Levine SR, Tilley BC, et al. Agreement and variability in the interpretation of early CT changes in stroke patients qualifying for intravenous rtPA therapy. Stroke; a journal of cerebral circulation. 1999;30(8):1528-33. (Level II Evidence). View the reference
- Wardlaw JM, Lewis SC, Dennis MS, Counsell C, McDowall M. Is visible infarction on computed tomography associated with an adverse prognosis in acute ischemic stroke? Stroke; a journal of cerebral circulation. 1998;29(7):1315-9. (Level III Evidence). View the reference
- Vo KD, Lin W, Lee JM. Evidence-based neuroimaging in acute ischemic stroke. Neuroimaging clinics of North America. 2003;13(2):167-83. (Review Article). View the reference
- Truwit CL, Barkovich AJ, Gean-Marton A, Hibri N, Norman D. Loss of the insular ribbon: another early CT sign of acute middle cerebral artery infarction. Radiology. 1990;176(3):801-6 (Level III Evidence). View the reference
- Tomura N, Uemura K, Inugami A, Fujita H, Higano S, Shishido F. Early CT finding in cerebral infarction: obscuration of the lentiform nucleus. Radiology. 1988;168(2):463-7 (Level III Evidence). View the reference
- Tomsick T, Brott T, Barsan W, Broderick J, Haley EC, Spilker J, et al. Prognostic value of the hyperdense middle cerebral artery sign and stroke scale score before ultraearly thrombolytic therapy. AJNR American journal of neuroradiology. 1996;17(1):79-85. (Level II Evidence). View the reference
- Sanelli PC, Sykes JB, Ford AL, Lee JM, Vo KD, Hallam DK. Imaging and treatment of patients with acute stroke: an evidence-based review. AJNR American journal of neuroradiology. 2014;35(6):1045-51. (Review Article). View the reference
- Anderson GB, Steinke DE, Petruk KC, Ashforth R, Findlay JM. Computed tomographic angiography versus digital subtraction angiography for the diagnosis and early treatment of ruptured intracranial aneurysms. Neurosurgery. 1999;45(6):1315-20 (Level II Evidence). View the reference
- Tomandl BF, Klotz E, Handschu R, Stemper B, Reinhardt F, Huk WJ, et al. Comprehensive imaging of ischemic stroke with multisection CT. Radiographics. 2003;23(3):565-92 (Review Article). View the reference
- Katz DA, Marks MP, Napel SA, Bracci PM, Roberts SL. Circle of Willis: evaluation with spiral CT angiography, MR angiography, and conventional angiography. Radiology. 1995;195(2):445-9 (Level II Evidence). View the reference
- Knauth M, von Kummer R, Jansen O, Hahnel S, Dorfler A, Sartor K Potential of CT angiography in acute ischemic stroke. AJNR American journal of neuroradiology. 1997;18(6):1001-10. (Level II Evidence). View the reference
- Shrier DA, Tanaka H, Numaguchi Y, Konno S, Patel U, Shibata D. CT angiography in the evaluation of acute stroke. AJNR American journal of neuroradiology. 1997;18(6):1011-20. (Level III Evidence). View the reference
- Wildermuth S, Knauth M, Brandt T, Winter R, Sartor K, Hacke W. Role of CT angiography in patient selection for thrombolytic therapy in acute hemispheric stroke. Stroke; a journal of cerebral circulation. 1998;29(5):935-8. (Level III Evidence). View the reference
- Verro P, Tanenbaum LN, Borden NM, Sen S, Eshkar N. CT angiography in acute ischemic stroke: preliminary results. Stroke; a journal of cerebral circulation. 2002;33(1):276-8 (Level III Evidence). View the reference
- National Health and Medical Research Council, Australian Government. Clinical guidelines for acute stroke management. National Stroke Foundation 2010.(Guidelines). View the reference
- Wintermark M, Sanelli PC, Albers GW, Bello JA, Derdeyn CP, Hetts SW, et al Imaging recommendations for acute stroke and transient ischemic attack patients: a joint statement by the American Society of Neuroradiology, the American College of Radiology and the Society of NeuroInterventional Surgery. Journal of the American College of Radiology : JACR. 2013;10(11):828-32. (Guidelines). View the reference
- Gonzalez RG, Copen WA, Schaefer PW, Lev MH, Pomerantz SR, Rapalino O, et al. The Massachusetts General Hospital acute stroke imaging algorithm: an experience and evidence based approach. Journal of neurointerventional surgery. 2013;5 Suppl 1:i7-12. (Guidelines). View the reference
- Vachha BA, Schaefer PW. Imaging patterns and management algorithms in acute stroke: an update for the emergency radiologist. Radiologic clinics of North America. 2015;53(4):801-26. (Review Article). View the reference
- Devlin TG, Phade SV, Hutson RK, Fugate MW, Major GR, 2nd, Albers GW, et al. Computed tomography perfusion imaging in the selection of acute stroke patients to undergo emergent carotid endarterectomy. Annals of vascular surgery. 2015;29(1):125.e1-11. (Level III Evidence). View the reference
- Brinjikji W, Rabinstein A, Cloft HJ, Lanzino G, Kallmes DF. Recently published stroke trials: what the radiologist needs to know. Radiology. 2015;276(1):8-11 (Review Article). View the reference
- Menon BK, Demchuk AM. Computed tomography angiography in the assessment of patients with stroke/TIA. Neurohospitalist. 2011;1(4):187-99 (Review Article). View the reference
- Menon BK, Goyal M Imaging paradigms in acute ischemic stroke: a pragmatic evidence-based approach. Radiology. 2015;277(1):7-12 (Review Article). View the reference
- Smith WS, Roberts HC, Chuang NA, Ong KC, Lee TJ, Johnston SC, et al. Safety and feasibility of a CT protocol for acute stroke: combined CT, CT angiography, and CT perfusion imaging in 53 consecutive patients. AJNR American journal of neuroradiology. 2003;24(4):688-90. (Level II Evidence). View the reference
- Knoepfli AS, Sekoranja L, Bonvin C, Delavelle J, Kulcsar Z, Rufenacht D, et al. Evaluation of perfusion CT and TIBI grade in acute stroke for predicting thrombolysis benefit and clinical outcome. Journal of neuroradiology Journal de neuroradiologie. 2009;36(3):131-7. (Level II Evidence). View the reference
- Lovblad KO, Baird AE. Computed tomography in acute ischemic stroke. Neuroradiology. 2010;52(3):175-87 (Review Article). View the reference
- Thierfelder KM, von Baumgarten L, Baumann AB, Meinel FG, Helck AD, Opherk C, et al. Penumbra pattern assessment in acute stroke patients: comparison of quantitative and non-quantitative methods in whole brain CT perfusion. PLoS One. 2014;9(8):e105413 (Level III Evidence). View the reference
- Wintermark M, Reichhart M, Thiran JP, Maeder P, Chalaron M, Schnyder P, et al. Prognostic accuracy of cerebral blood flow measurement by perfusion computed tomography, at the time of emergency room admission, in acute stroke patients. Annals of neurology. 2002;51(4):417-32. (Level II Evidence). View the reference
- Wintermark M, Meuli R, Browaeys P, Reichhart M, Bogousslavsky J, Schnyder P, et al. Comparison of CT perfusion and angiography and MRI in selecting stroke patients for acute treatment. Neurology. 2007;68(9):694-7 (Level III Evidence). View the reference
- Sohn CH, Sevick RJ, Frayne R. Contrast-enhanced MR angiography of the intracranial circulation. Magnetic resonance imaging clinics of North America. 2003;11(4):599-614. (Review Article). View the reference
- Clifton AG. MR angiography British medical bulletin. 2000;56(2):367-77. (Review Article). View the reference
- Hirai T, Korogi Y, Ono K, Nagano M, Maruoka K, Uemura S, et al. Prospective evaluation of suspected stenoocclusive disease of the intracranial artery: combined MR angiography and CT angiography compared with digital subtraction angiography. AJNR American journal of neuroradiology. 2002;23(1):93-101. (Level III Evidence). View the reference
- Korogi Y, Takahashi M, Mabuchi N, Miki H, Shiga H, Watabe T, et al. Intracranial vascular stenosis and occlusion: diagnostic accuracy of three-dimensional, Fourier transform, time-of-flight MR angiography. Radiology. 1994;193(1):187-93 (Level III Evidence). View the reference
- Stock KW, Radue EW, Jacob AL, Bao XS, Steinbrich W. Intracranial arteries: prospective blinded comparative study of MR angiography and DSA in 50 patients. Radiology. 1995;195(2):451-6 (Level III Evidence). View the reference
- White PM, Teasdale EM, Wardlaw JM, Easton V. Intracranial aneurysms: CT angiography and MR angiography for detection prospective blinded comparison in a large patient cohort. Radiology. 2001;219(3):739-49 (Level II Evidence). View the reference
- White PM, Wardlaw JM, Easton V. Can noninvasive imaging accurately depict intracranial aneurysms? A systematic review. Radiology. 2000;217(2):361-70 (Level I Evidence). View the reference
- Lee LJ, Kidwell CS, Alger J, Starkman S, Saver JL. Impact on stroke subtype diagnosis of early diffusion-weighted magnetic resonance imaging and magnetic resonance angiography. Stroke; a journal of cerebral circulation. 2000;31(5):1081-9. (Level III/IV Evidence). View the reference
- Korogi Y, Takahashi M, Nakagawa T, Mabuchi N, Watabe T, Shiokawa Y, et al. Intracranial vascular stenosis and occlusion: MR angiographic findings. AJNR American journal of neuroradiology. 1997;18(1):135-43. (Level III Evidence). View the reference
- Latchaw RE, Alberts MJ, Lev MH, Connors JJ, Harbaugh RE, Higashida RT, et al. Recommendations for imaging of acute ischemic stroke: a scientific statement from the American Heart Association. Stroke; a journal of cerebral circulation. 2009;40(11):3646-78. (Guidelines). View the reference
- Johnston DC, Chapman KM, Goldstein LB Low rate of complications of cerebral angiography in routine clinical practice. Neurology. 2001;57(11):2012-4 (Level III Evidence). View the reference
- Willinsky RA, Taylor SM, TerBrugge K, Farb RI, Tomlinson G, Montanera W. Neurologic complications of cerebral angiography: prospective analysis of 2,899 procedures and review of the literature. Radiology. 2003;227(2):522-8 (Level II Evidence). View the reference
- Kent KC, Kuntz KM, Patel MR, Kim D, Klufas RA, Whittemore AD, et al Perioperative imaging strategies for carotid endarterectomy. An analysis of morbidity and cost-effectiveness in symptomatic patients. JAMA. 1995;274(11):888-93 (Level III Evidence). View the reference
- Nederkoorn PJ, Mali WP, Eikelboom BC, Elgersma OE, Buskens E, Hunink MG, et al. Preoperative diagnosis of carotid artery stenosis: accuracy of noninvasive testing. Stroke; a journal of cerebral circulation. 2002;33(8):2003-8. (Level II Evidence). View the reference
- Blakeley DD, Oddone EZ, Hasselblad V, Simel DL, Matchar DB. Noninvasive carotid artery testing. A meta-analytic review. Annals of internal medicine. 1995;122(5):360-7. (Level I Evidence). View the reference
- Goyal M, Menon BK, van Zwam WH, Dippel DW, Mitchell PJ, Demchuk AM, et al. Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials. Lancet (London, England). 2016;387(10029):1723-31. (Level I Evidence). View the reference
- Berlis A, Lutsep H, Barnwell S, Norbash A, Wechsler L, Jungreis CA, et al. Mechanical thrombolysis in acute ischemic stroke with endovascular photoacoustic recanalization. Stroke; a journal of cerebral circulation. 2004;35(5):1112-6. (Level III Evidence). View the reference
- Furlan A, Higashida R, Wechsler L, Gent M, Rowley H, Kase C, et al. Intra-arterial prourokinase for acute ischemic stroke. The PROACT II study: a randomized controlled trial. Prolyse in Acute Cerebral Thromboembolism. JAMA. 1999;282(21):2003-11 (Level II Evidence). View the reference
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