Stroke: Intracranial Abnormalities With Hetal Verma, MD

Stroke
Intracranial Abnormalities
With Hetal Verma, MD
Rawabi Madkhali , rawabiy1997@gmail.com

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Learning Objectives
• In this lecture, you will learn the

role of imaging in identifying stroke
• You will review the imaging features

of acute stroke

© by Hetal Verma, MDMadkhali , rawabiy1997@gmail.com
Rawabi
What is a Stroke?
Compromise of the blood supply to a portion of the brain

parenchyma, resulting in loss of neurologic function.
High-yield
This may be embolic or Diagnosis is based on

thrombotic. clinical symptoms.

Treatment
• In the setting of an acute ischemic

stroke, tissue plasminogen activator
(t-PA) can provide the most benefit High-yield
if administered within 3 hours of the
onset of stroke.
• There is moderate benefit if

administered between 3 to 4.5
hours of the onset of stroke.

Role of Imaging in Acute Stroke?
High-yield
Exclude hemorrhage. t-PA is contraindicated with hemorrhage.
Exclude other causes of symptoms such as mass.

Types of Stroke
Ischemic Hemorrhagic

Watershed Territory
• The area of brain parenchyma at the

junction of two vascular territories
High-yield
• Most susceptible to ischemia
• Common watershed areas: at the

junction of the ACA/MCA and the
MCA/PCA

Stroke Imaging
• Begin with CT due to quick access High-yield

and ability to exclude hemorrhage.
• Ischemic stroke may not be visible

for several hours on CT.

Stroke Imaging
MRI is most sensitive for early ischemic stroke with High-yield

the diffusion weighted images (DWI) demonstrating
changes within 20 30 minutes of onset.

CT Findings of Ischemic Stroke
< 24 hours 12 24 hours > 24 hours

• Negative • Vague low • Better defined low
density area density area with:
• Early signs include: High-yield
• Loss of gray-white
• Decreased density
differentiation
in the basal ganglia
• Adjacent edema
• Loss of gray/white
and mass effect
differentiation
• Changes last for
• Hyperdense
up to 4 weeks
Acute Stroke

William Herring, Learning
Rawabi Radiology,
Madkhali 3rd Edition, 2016, p. 290, Saunders (Elsevier)
, rawabiy1997@gmail.com
Acute Stroke
• CT image on the left is negative in

patient presenting with symptoms
for 2 hours.
• DWI image on the right

demonstrates a bright area in the
right frontoparietal region, indicating
acute stroke.

Rawabi Radiology,
Acute Stroke
• CT image on the left is negative in

patient presenting with symptoms
for 2 hours.
• DWI image on the right

demonstrates a bright area in the
right frontoparietal region, indicating
acute stroke.

Rawabi Radiology,
Stroke Imaging Change Over Time

• This image depicts the imaging

findings of a stroke at about 24
hours.
• There is loss of gray white

differentiation with compression of
the ventricles and shift of the
midline.

Rawabi Radiology,
• This image depicts the imaging

findings of a stroke several weeks
after the initial event.
• The low density area is more

sharply marginated and there is no
longer any significant mass effect.

Rawabi Radiology,
Hemorrhagic Stroke
Hemorrhage into the brain parenchyma or subarachnoid space
Risk increases with hypertension.

Case Study

Describe the Findings
65-year-old male presents with right-sided weakness which began
2 hours ago.

Rawabi
Rawabi
2 hours ago.
CT is normal.
How do you treat this patient?

Rawabi
2 hours ago.
• Patient is clinically
diagnosed with ischemic
stroke and treated with t-PA
and admitted to the ICU.
• He loses consciousness the

next day.
What do you do and why?

Rawabi
© By Hetal Verma, MDMadkhali , rawabiy1997@gmail.com
Rawabi
Rawabi
Case-study Continued
65 year-old male presents with right-sided weakness.
• CT demonstrates
intracerebral, subarachnoid
and subdural hemorrhage
with resultant subfalcine
herniation.
• Stroke has now become

hemorrhagic.
What do you do next?

Rawabi
Case-study Continued
65 year-old male presents with right-sided weakness.
Call neurosurgery for urgent

surgical decompression to
relieve mass effect!

Rawabi
Learning Outcomes
 You have reviewed the imaging

findings and management of acute
stroke.

This document is a property of: Rawabi Madkhali
Note: This document is copyright protected. It may not be copied, reproduced, used, or
distributed in any way without the written authorization of Lecturio GmbH.


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Stroke

With Hetal Verma, MD

Rawabi Madkhali , rawabiy1997@gmail.com

• In this lecture, you will learn the

• You will review the imaging features

Rawabi Madkhali , rawabiy1997@gmail.com

Compromise of the blood supply to a portion of the brain

This may be embolic or Diagnosis is based on

Rawabi Madkhali , rawabiy1997@gmail.com

• In the setting of an acute ischemic

• There is moderate benefit if

Rawabi Madkhali , rawabiy1997@gmail.com

Exclude other causes of symptoms such as mass.

Rawabi Madkhali , rawabiy1997@gmail.com

Rawabi Madkhali , rawabiy1997@gmail.com

• The area of brain parenchyma at the

• Most susceptible to ischemia

• Common watershed areas: at the

Rawabi Madkhali , rawabiy1997@gmail.com

• Begin with CT due to quick access High-yield

• Ischemic stroke may not be visible

Rawabi Madkhali , rawabiy1997@gmail.com

MRI is most sensitive for early ischemic stroke with High-yield

Rawabi Madkhali , rawabiy1997@gmail.com

< 24 hours 12 24 hours > 24 hours

Rawabi Madkhali , rawabiy1997@gmail.com

• CT image on the left is negative in

• DWI image on the right

William Herring, Learning

• CT image on the left is negative in

• DWI image on the right

William Herring, Learning

Rawabi Madkhali , rawabiy1997@gmail.com

• This image depicts the imaging

• There is loss of gray white

William Herring, Learning

• This image depicts the imaging

• The low density area is more

William Herring, Learning

Hemorrhage into the brain parenchyma or subarachnoid space

Risk increases with hypertension.

Rawabi Madkhali , rawabiy1997@gmail.com

Rawabi Madkhali , rawabiy1997@gmail.com

© by Hetal Verma, MDMadkhali , rawabiy1997@gmail.com

© by Hetal Verma, MDMadkhali , rawabiy1997@gmail.com

• He loses consciousness the

What do you do and why?

© by Hetal Verma, MDMadkhali , rawabiy1997@gmail.com

65 year-old male presents with right-sided weakness.

• Stroke has now become

What do you do next?

65 year-old male presents with right-sided weakness.

Call neurosurgery for urgent

© By Hetal Verma, MDMadkhali , rawabiy1997@gmail.com

 You have reviewed the imaging

Rawabi Madkhali , rawabiy1997@gmail.com

Rawabi Madkhali , rawabiy1997@gmail.com

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