Computed tomography early signs of acute ischemic brain

infarction.

Poster No.: C-1158

Congress: ECR 2011
Type: Scientific Exhibit
Authors: 1 2 2
I. Georgiou , E. Tsokou , A. ZOURLA , S. Papakostas , P.
2

3 3 2 1
STAVRAKAS , M. TSALIKIS , A. N. Chalazonitis ; ATHENS/GR,
2 3
Athens/GR, ATHENS/GR
Keywords: Neuroradiology brain, CT
DOI: 10.1594/ecr2011/C-1158

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Purpose

The goals of imaging in a patient with acute strokes are to exclude hemorrhage,
differentiate between irreversibly affected brain tissue and reversibly impaired tissue and
identify stenosis or occlusion of major extra and intracranial arteries. In this way we can
select patients who are candidates for thrombolytic therapy. Assessment of
early infarction signs is now included in some guidelines and approval documents for
thrombolysis. Thrombolysis is not widely implemented for treatment of acute ischemic
stroke and uncertainty about the interpretation of early infarction signs on CT scans may
be slowing its implementation.

Magnetic resonance (MR) diffusion-weighted imaging and perfusion imaging may help
to identify patients for thrombolysis, but there is still a need to determine how best to use
CT, as CT is likely to remain the primary modality for assessment of stroke because of
its wide availability, easy of use, and speed.
On purpose is evaluate the role of CT in demonstrating early signs of acute cerebral
ischemia, shown to help differentiate between irreversibly affected brain tissue (dead
tissue) and reversibly impaired tissue (tissue at risk).

Methods and Materials

Brain CT findings of 192 patients examined for clinical symptoms of acute brain stroke
were retrospectively studied. All patients underwent an initial brain CT on the time of
presenting to our Hospital and second CT 48 hours later. Presence or absence of the
following early signs was documented: hypoattenuating brain tissue, obscuration of
lentiform nucleus, dense middle cerebral artery (MCA), "insular ribbon" sign, loss
of sulcal effacement.
Importantly, hypoattenuation on CT is highly specific for irreversible ischemic brain
damage, if detected within first 6 hours. These patients display larger infarct volumes,
more severe symptoms, less favorable clinical courses and even have a greater risk of
hemorrhage.
Obscuration of lentiform nucleus is one of the earliest and most frequently seen signs.
The basal ganglia are almost always involved in MCA-infarction.

"Insular Ribbon" sign is a very indicative and subtle early CT-sign of infarction in the
territory of the MCA and dense MCA sign is a result of thrombus or embolus in the vessel.

Results

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CT scans were analyzed for the following:
• Hypoattenuating brain tissue in 82 patients (Fig.1)
• Obscuration of lentiform nucleus in 16 patients (Fig.2)
• Dense middle cerebral artery in 27 patients(Fig.3)
• 'Insular ribbon' sign in 35 patients (Fig.4)
• Loss of sulcal effacement in 32 patients (Fig.5)

Images for this section:

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Fig. 1: Right MCA infarction. On CT an area of hypoattenuation appearing within six
hours.

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Fig. 2: Obscuration of the lentiform nucleus or blurred basal ganglia.

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Fig. 3: Dense MCA sign appears on the right brain hemisphere.

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Fig. 4: Insular ribbon sign.

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Fig. 5: Loss of grey-white junction. Sulcal effacement.

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Conclusion

CT has the advantage of being available 24 hours a day and is the gold standard for
hemorrhage. On CT 60% of infarcts are seen within 3-6 hrs and virtually all are seen in
24 hours. The overall sensitivity of CT in diagnosing stroke is 64% and the specificity is
85%. The sensitivity and specificity of early infarction signs on CT scans are generally not
good. It would appear, however, that the sensitivity of early infarction signs on CT scans
is poorer than the specificity. In other words, signs are not generally well detected,but
when seen, they are likely to be present.

References

1. Joanna M. Wardlaw and Orell Mielke. Early Signs of Brain Infarction at CT: Observer
Reliability and Outcome after Thrombolytic Treatment-Systematic Review. Radiology
May 2005 235:444-453.

2. Diederik M. Somford, Paul J. Nederkoorn, Dirk R. Rutgers, L. Jaap Kappelle, Willem P.

T. M. Mali, Jeroen van der Grond. Proximal and Distal Hyperattenuating Middle Cerebral
Artery Signs at CT: Different Prognostic Implications. Radiology June 2002 223:667-671.

3. Enrique Marco de Lucas,Elena Sánchez, Agustín Gutiérrez, Andrés González Mandly,

Eva Ruiz, Alejandro Fernández Flórez, et al. CT Protocol for Acute Stroke: Tips and
Tricks for General Radiologists. Radiographics October 2008 28:1673-1687.

4. Ashok Srinivasan, Mayank Goyal, Faisal Al Azri, Cheemun Lum. State-of-the-Art

Imaging of Acute Stroke. Radiographics October 2006 26:S75-S95.

5. Bernd F. Tomandl, Ernst Klotz, Rene Handschu, Brigitte Stemper, Frank Reinhardt,
Walter J. Huk, et al. Comprehensive Imaging of Ischemic Stroke with Multisection CT.
Radiographics May 2003 23:565-592

Personal Information

I. Georgiou, MD

Radiology Department, "St. Savvas" Oncologic Hospital, Athens, Greece

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E. Tsokou, MD

Radiology Department, "Alexandra" General Hospital, Athens, Greece

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