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Journal of Neuroradiology (2014) xxx, xxx—xxx

Available online at

ScienceDirect
www.sciencedirect.com

REVIEW

Imaging of acute stroke: CT and/or MRI

Karl-Olof Lövblad a,∗,b, Stephen Altrichter a,b,
Vitor Mendes Pereira a,b, Maria Vargas a,b,
Ana Marcos Gonzalez a,b, Sven Haller a,b, Roman Sztajzel a,b

a
Service neuro-diagnostique et neuro-interventionnel, DISIM, 4, rue Gabrielle-Perret-Gentil, 1211 Genève,
Switzerland
b
Service de neurologie, Genève, Switzerland

KEYWORDS Summary Acute ischemic stroke is now clearly recognized as a medical emergency. As such
Stroke; diagnosis has to be done quickly and in a precise way during the therapeutic window. Both com-
Imaging; puted tomography and magnetic resonance imaging are tools that can adequately demonstrate
Magnetic resonance ischemia really very early on. MRI using diffusion techniques has a much higher sensitivity for
imaging; acute lesions but its implementation has not been unproblematic due to initial resistance and
Computed some technical problems. Thus, very often CT is still preferred with MR used for situations
tomography where the answer given is not sufficient as well as for follow-up of lesions. However, the par-
allel development of new therapeutic strategies have rendered the precision of the tools more
and more sophisticated and their combined use can help to improve patient outcomes in ways
never imagined previously. No matter which technique is used, be it alone or in combination,
the idea is to speed up and optimize management in order to provide early revascularization
and reperfusion.
© 2014 Published by Elsevier Masson SAS.

Introduction neuroprotective agents have unfortunately proven to be only

Since cerebral ischemia has been declared to be at least par-
tially treatable within the therapeutic window, stroke has
now become a clearly defined medical emergency [1—3].
Indeed, the trend started by the NINDS trials was followed
by an increasing interest in both pharmacological and inter-
ventional therapies for acute ischemia. While almost all
∗ Corresponding author.
E-mail address: karl-olof.lovblad@hcuge.ch (K.-O. Lövblad).
successful in the laboratory setting [4], thrombolysis and
thrombectomy have proven to have their benefits in patients
treated within a clearly defined therapeutic window [5]. Ini-
tially, brain imaging has been done on an exclusion basis
only, meaning that unenhanced CT was used mainly to deter-
mine if there was hemorrhage or some other kind of easily
visible brain pathology (e.g. tumour) that caused the acute
neurological deficit [5—10]. While this was an initial success
and worked for the first trial it is also true that this did not
per se determine that all these patients really had ischemia;
indeed, the exclusion of hemorrhage is per se not equiva-
lent with the presence of a stroke; thus, most new imaging

http://dx.doi.org/10.1016/j.neurad.2014.10.005
0150-9861/© 2014 Published by Elsevier Masson SAS.

Please cite this article in press as: Lövblad K-O, et al. Imaging of acute stroke: CT and/or MRI. J Neuroradiol (2014),
http://dx.doi.org/10.1016/j.neurad.2014.10.005
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techniques also revolve around determining if there is some
kind of stroke mimic. One major issue is that since there
is very little time available (4.5 hours currently for MCA
ischemia using rTPA), the patient needs to be acutely
treated within this therapeutic window. Since any given
stroke protocol is very complicated and imaging only rep-
resents a portion of any kind of acute management, it is
imperative that imaging provides both a quick and precise
answer, thus not prolonging the time needed to make a
decision on treatment. A majority of patients with acute
stroke still arrive outside the therapeutic window but those
who do still need a full work-up with a neurological exam-
ination, full laboratory tests etc. Indeed, and much to the
distress of many traditional neurologists and even neuro-
radiologists, imaging has become an inherent part of the
early work-up and as such represents a little part, but a
part that is technology intensive and personnel intensive.
The main aims of primary neuroimaging are manifold: first
of all the overall aim even before imaging is to exclude
another pathology: the main pathology to be excluded is
of course hemorrhage (since thrombolysis is the treatment
being proposed) but it also encompasses diseases such as
multiple sclerosis, epilepsy, functional states. Thus, after
having simply looked at the parenchyma it is necessary to
look at some more parameters that can be obtained with
either CT or MRI. The next logical step is to see if there
really is cerebral ischemia: indeed, treatment should not be
done only when nothing is seen but offered to patients who
actually are harboring an acute cerebrovascular event: this
can be done by looking for further signs of ischemia on DWI
with MR or for the acute signs of ischemia on CT; then when
that is done the level of occlusion can be looked for: here
CT can sometimes often demonstrate an acute hyperdense
artery and T2* will show a thrombus as well. When this is
done one will also look at the proximal vessels in order to
provide almost a one stop shopping approach: one is also to
look at the level of the carotids and possibly of the aortic
arch in order to see if there is any plaque or calcification that
may be the cause of embolism. Also, adding perfusion imag-
ing will allow assessing the perfusion status of the tissue.
While this was only initially possible with nuclear medicine
techniques such as PET and SPECT, and PET with O still
remains the gold standard, techniques using CT and MRI have
progressed greatly over the last decades. These techniques
have allowed determining a model of the penumbra based
on either the diffusion-perfusion mismatch and on a match
or mismatch of the perfusion maps. Imaging will also be used
to detect any kind of complication due directly or indirectly
to the treatment or procedure: CT will demonstrate an early
bleeding well but may be more problematic when it comes
to demonstrating the presence of small ischemic changes.
Here, MRI with diffusion has a major role. Final outcome is
of course based on measures such as clinical status and clini-
cal scores but also by imaging: here CT can demonstrate final
lesions but less well that T2 images done at 3 months. While
FLAIR after a few weeks will often provide a lesion defini-
tion that approximates the final size, imaging at 3 months
with T2 MRI is mandatory. MRI can also be done in order
to assess the possibility and success of any preadaptation
measures. This review mainly aims to look at the differences
between CT and MRI for the acute detection of ischemia
and looks at some current novel methods such as arterial
Please cite this article in press as: Lövblad K-O, et al. Imaging of acute stroke: CT and/or MRI. J Neuroradiol (2014),
http://dx.doi.org/10.1016/j.neurad.2014.10.005
spin labeling or dual source CT that can be added to current
protocols.
Computed tomography
Computed tomography has been the cornerstone of brain
imaging since its introduction in the early 1970s [11,12].
Besides its use for the diagnosis of any brain pathology, in
stroke it was primarily used for lesion exclusion then became
a strong diagnostic tool once the NINDS studies proved that
therapy was feasible. It was also the main neuroradiological
tool until the emergence of MR and it was marred by ques-
tions of low resolution especially in the posterior fossa until
recently. However, the technique that set things in motion
was the development of spiral CT [13], then volumetric CT
and also of scanners with more and more rows of detectors.
CT in our opinion has the easiest capacity to detect hemor-
rhage, be it intraparenchymal or subarachnoid. It can also
in well-trained hands demonstrate rather well the presence
of ischemic changes [14] (Figs. 1—3).
The acute signs on CT [15,16], when read by experienced
readers are quite accurate: one can see the dense artery
which corresponds to the clot, as well as signs of early
swelling and edema: this will lead to smaller sulci on the
affected side; also as soon as there is slight water accumula-
tion one will have a loss of the capacity of CT to differentiate
between white and grey matter. This is especially well seen
in the basal ganglia and in the insula but can be seen every-
where. Additionally, where CT has proven to be of prime
importance is the capacity to demonstrate the presence of
early hypo density: indeed, this was shown at least for tap to
be an early sign of potential malignant hemorrhagic trans-
formation, especially if the hypo density was more than 30%
of the affected territory. Where CT played an important role
was in showing that when one third or more of the affected
territory was hypo dense there is an acute danger of increas-
ing fatal hemorrhage by initiating treatment with rTPA [17].
This may create the need for other drugs or approaches such
as other thrombolytic or even other mechanical practices.
While very useful, the one-third approach has not been
without limitations or criticisms. Thus, scoring systems have
been developed that try to address this. One of the more
known ones is the ASPECTS score [18] where a number of
points is allocated to the MCA territory and points subtracted
for each hypodense area. The aspects score is used more and
more and has even been applied to DWI [19—21].
Brain hemodynamics are at the core of the cerebral
ischemic event: indeed, initially the drop in cerebral blood
flow (CBF) will be compensated by an increase in collateral
blood flow and in the local cerebral blood volume (CBV); this
will maintain some kind of penumbra or tissue at risk. While
the hemodynamic models do not reflect the electrophysi-
ological model initially postulated in the penumbra, they
have proven to be perfectly usable working models for daily
clinical practice. Then, when both CBF and SBV drop, tissue
will be considered lost. Thus, adding perfusion techniques
can help identify the hypoperfused territory (Fig. 4) as well
as an infarcted core (Fig. 5). This can be done by looking
for a match or a mismatch visually between the perfusion
maps of CBF and CBV; when both are decreased and there is
a match, there will often be massive infarction whereas in
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Imaging of acute stroke: CT and/or MRI 3

Figure 1 Patient with left-sided symptoms and right cerebral ischemia. Right hyperdense MCA (a), with occlusion seen on CTA
(b: arrow, c), there is loss of white grey differentiation: the right-sided striatum is no longer visible (d: arrow, e), as well as loss of
sulcal effacement (f, g).

Figure 2 Predictive effect of CT; this is the same case as figure

1. One can see that the area affected by the sulcal effacement
and slight hypodensity on the early CT (A) corresponds to the
final infarction almost perfectly on follow-up CT (B).
a mismatch when only CBF is decreased, a lesser infarct is
to be expected (Figs. 4 and 5).
However due to its very high increase in usage, CT has
become an important factor in the irradiation of the popu-
lation so that care must be taken when using it in order not
to do unnecessary studies.
Dual source CT is a technique that has been available
for some time but which has known recent resurgence. Ini-
tially used for bone density measurement, it has recently
Figure 3 Predictive effect of CT: patient with infarction in
the basal ganglia on the left: the area where there is acute loss
of differentiation of white and grey matter with disappearance
of the striatum (A) becomes hypodense on the late CT (B).
been introduced in clinical practice to subtract calcifica-
tions (Fig. 6) or provide more objective measures of insular
density. It has been used to differentiate hemorrhage from
contrast extravasation inpatients after interventional stroke
therapy [22]. Indeed, very often after interventional thera-
pies, contrast extravasation has been problematic in that
it will either mimic blood or even obscure an underlying
pathology such as an ischemic region.

Please cite this article in press as: Lövblad K-O, et al. Imaging of acute stroke: CT and/or MRI. J Neuroradiol (2014),
http://dx.doi.org/10.1016/j.neurad.2014.10.005
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Figure 4 Patient with a right hemispheric stroke and a mismatch on perfusion CT: there is a decrease in CBF (c) in the right MCA
territory but the CBV is normal (b). MTT is increased (d). The final CT on the right show very little lesion (e).

Figure 5 Patient with a left hemispheric stroke and matching hypoperfusion: there is a match in the surfaces of decreased CBV
(b) and CBF (c). MTT is increased (d). There is a large final lesion (e).

The combined use of techniques such as PET and CT or
PET and MRI has known a great increase over the last few
years but while not really usable in the emergency situation
we describe here, PET CT will be of use on the work-up of
patients with carotid disease. Indeed, it may well demon-
strate the presence of activity in plaques that are sometimes
morphologically not suspicious and may thus help to provide
treatment to some patients [23]. These techniques are gain-
ing in acceptance quickly since sometimes plaques that are
not significant may be found to be inflammatory and thus
the cause of embolism.
Magnetic resonance imaging
Magnetic resonance imaging has proven itself to be a revolu-
tionary and evolutionary tool, maybe even more so than CT.
While the advantages of its non-ionising nature are evident,

Please cite this article in press as: Lövblad K-O, et al. Imaging of acute stroke: CT and/or MRI. J Neuroradiol (2014),
http://dx.doi.org/10.1016/j.neurad.2014.10.005
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Imaging of acute stroke: CT and/or MRI
Figure 6 Dual source energy CT of a patient after intra-
arterial thrombolysis for a left MCA stroke: on the left one
can see some blood (A) but on the right there is more contrast
extravasation visible (B) thus allowing differentiation between
acute blood and contrast on the same examination.
the examinations were initially extremely time consuming
and ill suited to acutely ill patients. It would be the advent
of echo-planar imaging that was the revolution not just for
stroke but for many areas that required an increase in imag-
ing speed and a reduction in overall acquisition time [24,25].
Indeed, echo-planar meant that diffusion and perfusion MRI
would be finally clinically feasible [26]. Conventional MR
has been in use from the start but more to demonstrate
the presence of established ischemic lesions that will be
hypo-intense on T1 and hyper on T2 due to water accumu-
lation these conventional techniques are still used for the
follow-up of patients where they remain the standard.
Diffusion techniques are MR techniques that image water
movement [27—30]. These techniques are now more than 20
years old. Le Bihan et al. developed them; his team made a
Stejskal-Tanner modification of a spin echo technique. Thus,
the protons were given an impulsion and if they moved more
or less would transmit more or less signal back. The tech-
nique was initially very sensitive to motion and it was only
with the development of clinically available echo-planar
Figure 7 Acute CT in a patient with a right hemisyndrome and aphasia: slight hypodensity in left hemisphere visible on CT (A),
but there is a large DWI lesion (B) on the MRI performed afterwards on the same day.
Please cite this article in press as: Lövblad K-O, et al. Imaging of acute stroke: CT and/or MRI. J Neuroradiol (2014),
http://dx.doi.org/10.1016/j.neurad.2014.10.005
5
Figure 8 Patient with acute posterior fossa infarction: on the
acute CT (A) there is no visible lesion while on the DWI one has
clearly a lesion of the left pons (B).
scanners that this technique could translate from the lab
to the clinical site. Once it was clinically applied to patients
with acute stroke, it showed itself to have a high sensitiv-
ity and specificity [31—34]. As in animal models the capacity
for detection of acute ischemic changes starts minutes after
stroke onset only [35]. Comparison studies have shown DWI
to be far superior to CT [36—42] (Figs. 7 and 8). Of interest
also is the capacity of DWI volumes to correlate with clinical
status and outcome [43]; this implies that at least for stud-
ies implicating drugs it can be used as a surrogate marker of
ischemia. It is also known that diffusion lesions tend to grow
with time and this can be used more when using the so-called
diffusion-perfusion mismatch [44]. The diffusion-perfusion
mismatch is a rather simplistic model but which clinically
works at times: one supposes that at an early time point
the diffusion lesion is the core and around that the hypop-
erfused area represents the penumbra [45]. The problem is
that from a historical perspective at least the penumbra is
a physiological definition of an area between thresholds of
dysfunction and definitive damage, Thresholds of ischemia
are also present in the diffusion image and most certainly on
the ADC maps: while this has not been as well reproduced
in humans as in the animal models it seems that there is a
definable threshold [46,47]. Also, another area where diffu-
sion imaging has helped to do a lot of progress is its capacity
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Figure 9 Patient with proximal origin of embolic lesions
of cardiac origin: there are bilateral lesions on the diffusion
images.
to locate more precisely the lesions: this can even allow dif-
ferentiating between lesions that are due to a more distal
(Fig. 9) or a more proximal (Figs. 10 and 11) cause [48].
Those that have a more proximal origin will be more dis-
tributed widely with at times a starry sky appearance of the
emboli on the DWI images (Fig. 9). For patients who some-
times wake-up with a stroke, a mismatch between FLAIR
and diffusion can be sought: if the lesions are of same size,
it is highly probably that the lesion is more than the allowed
therapeutic window (Fig. 12).
Perfusion techniques have been available for a long time
using MR scanners [49—51]. These techniques can be per-
formed in a multitude of ways. The most frequent way is
to use T2* imaging techniques: images are repeated quickly
using echo-planar technology and images covering the whole
brain are done: a gadolinium based chelate is then injected
and when this enters into the blood there is a decrease in
Figure 10 Patient a left-sided carotid stenosis on contrast-enhanced MRA (A) embolic lesions are only present in the ipsilateral
left hemisphere (B).
Please cite this article in press as: Lövblad K-O, et al. Imaging of acute stroke: CT and/or MRI. J Neuroradiol (2014),
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contrast that is due to the induction of local changes in mag-
netic susceptibility: this will allow to calculate maps of mean
transit time as well as of relative cerebral blood flow and
volume [52]. Additionally, T1-weighted techniques can be
used but are far less common but could be advantageous.
Another technique that has been available for a number of
years but has been underutilized is the so-called arterial
spin labeling technique [53—60]; this relies on the tagging
of blood flow at the cervical level with creation of maps of
cerebral blood flow at the distal cerebral level. This allows
obtaining perfusion maps without any contrast agent, which
could cause toxic allergic or nephrologic problems. Also with
advances in MR technology, it has been possible to obtain
multi-slice data sets covering the whole brain. The disad-
vantage is fewer signals but there are many advantages of
ASL besides the non-utilization of contrast such the possible
demonstration of collaterals and selective demonstration of
vascular territories. Thus, contradictory series have shown
data that is slightly contradictory with either concurrence
or overestimation of hypoperfusion; this may be due in part
to the lower signal but also due to a lack in consensus on the
use of technical parameters used for ASL in clinical practice
across vendor platforms [61—67].
While conventional T2* imaging has been playing a major
role in imaging of hemorrhage and calcifications, the advent
of so-called susceptibility-weighted imaging has changed
this even further: indeed, these SWI images now allow to
obtain high-resolution images of e.g. the brain. While good
for the detection of hemorrhage these sequences could also
improve our knowledge about the presence of trans cerebral
veins in acute stroke [68,69].
MR Angiography techniques: these techniques have
evolved greatly over the last decade. At first images based
on either time-of-flight or phase contrast techniques were
used. These did not involve any contrast agent but used
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Imaging of acute stroke: CT and/or MRI 7

Figure 11 Patient with carotid occlusion and stroke: there is a typical flame-like tapering of the carotid (A), compatible with a
dissection and there are internal watershed lesions due to occlusion (B).

Figure 12 Patient presenting in the morning with a wake-up stroke: there is a match in the size between the diffusion (A) and
the FLAIR image (B). Thus this patient is not eligible for thrombolysis.

inherent movement of intravascular fluids. One may also
look for a matching between the occlusion seen as with the
diffusion lesion: this is called the MRA-diffusion mismatch
[70,71].
Discussion
Since therapeutic options have emerged for acute ischemic
stroke there has been an increased pressure to develop tools
for an early diagnosis. Indeed, the era when stroke was syn-
onymous with death or lengthy stays in recovery are now far
gone. The main diagnostic tool over the first decades when
treatment was initiated was computed tomography. Indeed,
the early thrombolysis trials were done base don the use of
unenhanced CT alone. This was in a way sufficient to exclude
a hematoma or a mass as well as to demonstrate early severe
ischemia but was unfortunately insufficient for a more accu-
rate work-up. Nuclear medicine tools such as PET and SPECT
while they were able to demonstrate hypoperfusion and
even the penumbra were not usable due to the difficulty
of use in the clinical setting. PET and SPECT had initially
been used to establish the clinical data we have about brain
perfusion and has established the baseline blood flow and
volume values that we use today but the techniques, while
very precise were difficult to implement clinically and they
have been partially abandoned; this is unfortunate because
as validation tools especially using PET with oxygen, they are
still irreplaceable and could be used to validate new tech-
niques more seriously. Also, the use of MRI was restricted in

Please cite this article in press as: Lövblad K-O, et al. Imaging of acute stroke: CT and/or MRI. J Neuroradiol (2014),
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the early phase due to the fact that it could only detect T2
changes in the late phase and also due to the fact that early
scanners were closed and that patients could not take the
long examination times. Thus, there was a first technological
revolution when MR saw the development of early clinical
echo-planar scanners; this allowed implementing sequences
such as diffusion and perfusion that allowed modeling the
first human penumbra. Indeed, these techniques, which had
been in development for a while had been almost impos-
sible to use clinically due to time constraints and duet o
sensibility to motion. The two techniques that got a boost
from echo-planar technology were diffusion and perfusion
MR techniques. Diffusion-weighted MRI, which was indeed
a revolution, was initially met by much resistance due to a
multitude of factors: on the one hand radiologists were not
enthusiastic about performing emergency MRI and on the
other hand neurologists doubted its capacity to adequately
represent the neuronal damage and thus be an equivalent
if not replacement of an accurate clinical examination. This
led to a delay in the adequate utilization of these tools.
Then the development of computed tomography techniques
such as CT perfusion made the acceptance of multimodality
imaging much more widespread. With treatment modalities
becoming more and more sophisticated with intravenous and
intra-arterial thrombolysis as well as mechanical techniques
being proposed such as the MERCI device or the current mod-
ern stentrievers, it has become possible to open vessels that
could not be before. Thus, in more and more situations, the
practical issue initially posed by MRI techniques has been
overcome and more and more centers tend to propose the
technique in first intention. In other places, MRI will still be
done but either in cases where it is unclear or as a follow-
up method. The main problem may be sometimes blood:
even though in theory MR techniques are known to have a
much higher sensitivity to the detection of hemosiderin and
blood degradation products, it is sometimes a question of
experience with the appearance of acute hemorrhage that
is an issue when using the method. Much data points to the
fact that both techniques can be used almost equally but
may also be used together: in some instances CT will be
used primarily to exclude hemorrhage and perfusion and
angiographic techniques will demonstrate hemodynamics
and occlusion with an MR done as follow-up; MR can also
be used when there is a clinically very strong suspicion of
stroke but with no real CT parameters; on the other hand
when using MR in first intention, very often CT can be used
to detect early hemorrhage or pooling of contrast in case an
intra-arterial intervention has been done. Thus, both tech-
niques tend now to become complementary and not so much
exclusive [72,73].
Conclusions
Neuroradiological tools such as CT or MRI have become
an indispensable part of the examination and work-up of
patients with acute cerebrovascular insults. The patient who
comes into the emergency department must be examined
as quickly as possible since factors as time to needle play
a more and more important role. What type of imaging is
used is very often dependent on local organizational factors.
Overall, MRI is more sensitive to ischemic changes and thus
Please cite this article in press as: Lövblad K-O, et al. Imaging of acute stroke: CT and/or MRI. J Neuroradiol (2014),
http://dx.doi.org/10.1016/j.neurad.2014.10.005
a more powerful tool especially when looking for smaller
lesions that may not even be seen on CT.
Disclosure of interest
The authors declare that they have no conflicts of interest
concerning this article.
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