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Stroke is a clinical term referring to a nontraumatic brain insult resulting in a sudden loss of neurologic function
Infarction represents about 75% and Hemorrhage about 25% of strokes Radiologist plays a critical role in evaluation and triage of EVERY stroke patient
Ischemic Strokes
Thromboembolic events are the principle causes of ischemic events
i.e. Large artery atherosclerosis has a higher mortality than lacunes and are amendable to Carotid Endarectomy
MRI Sequencing
DWI: Uses a strong gradient pair that sensitizes images to microscopic BROWNIAN WATER MOTION
Brain water diffusion rapidly falls during acute ischemia. Early infarct = BRIGHT SIGNAL ON DWI
ADC: reflects pure diffusion behavior free of any shine through and appears = DARK SIGNAL ** DDX: pyogenic abscess and tumors
MR
Anterior Circulation
Internal Carotid Arteryatherosclerotic disease near the carotid bifurcation is responsible for majority ICA territory events
ACA
Represent 5% of infarcts 3 subgroups of Branches: 1. Medial Lenticulostriates 2. Hemispheric 3. pericallosal
MCA
Represents 2/3 of Infarcts
Branches: 1. Lateral Hemispheric 2. Lateral lenticulostirates
Cerebellar Stroke
Often Neurosurgical emergencies and require posterior fossa decompression
1. multiple foci of deep white matter/basal ganglia lacunar infarcts (black arrow), typical in small vessel ischemic disease
Venous Infarction
Uncommon, but affects younger, OCPS, dehydration, infections Blockage of outflow leads to stasis--neuronal death Lesions tend to spare cortex, dont follow normal vascular territories
CT- Empty Delta Sign; Spin Echo and MRV best imaging modality
Venous Infarction
Manifest as serpiginous line of petechial blood following gyral contours of the infarcted cortex
Catastrophic hemorrhagic transformation can follow TPA
Subacute Infarction
Subacute Infarction
wedge-shaped abnormality involving gray and white matter within vascular distribution
Gyriform Enhancement
Chronic Infarction
Chronic Infarction
Hemorrhages
Divided: Subarachnoid vs Intraparenchymal
CT presents as high attenuation and MR is based on iron oxidation state
MR pattern signal
Subarachnoid Hemorrhage
Parenchymal Hemorrhage
Hemorrhage has a higher mortality than infarction but less deficits on recovery
Trauma excluded DDX considerations: hypertensive, drugs, AVM, amyloid, tumors
Cases
Case 1
Case 2
Case 3
Case 4
Case 5