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CHAPTER 2

Use of i maging in c erebrovascular d isease P. Irimia, 1 S. Asenbaum, 2 M. Brainin, 3 H. Chabriat, 4 E. Mart í nez - Vila, 1 K. Niederkorn, 5 P. D. Schellinger, 6 R. J. Seitz, 7 J. C. Masdeu 1 1 University of Navarra, Pamplona, Spain ; 2 Medical University of Vienna, Austria ; 3 Donauklinikum and Donau - Universit ä t, Maria Gugging, Austria ; 4 Lariboisiere Hospital, University of Paris, France ; 5 Karl Franzens University, Graz, Austria ; 6 University Clinic at Erlangen, Germany ; 7 University Hospital D ü sseldorf, Germany

neuroimaging techniques available for the evaluation

of stroke patients has increased the complexity of

decision making for physicians. Neurologists, who have

been educated to manage acute stroke patients, should

be trained in the use of neuroimaging, which allows

for the development of a pathophysiologically oriented

treatment.

Successful care of acute stroke patients requires a rapid

and accurate diagnosis because the time window for

treatment is narrow. In the case of intravenous throm-

bolysis for ischaemic stroke, the treatment is safer and

more effective the earlier it is given [3] . Current recom-

mendations call for a 4.5 - h time limit for intravenous

thrombolysis [4] that can be extended to 6 h for intra -

arterial thrombolysis [5] . Thus, the neuroimaging proto-

col designed to determine the cause of stroke should

delay treatment as little as possible. Neuroimaging can

provide information about the presence of ischaemic but

still viable and thus salvageable tissue (penumbra tissue)

and vessel occlusion in the hyperacute phase of ischemic

stroke. This information is critical for an improved selec-

tion of patients who could be treated with intravenous

thrombolysis up to the 4.5 - h limit and beyond [5] . Thus,

neuroimaging criteria have been used for patient selec-

tion and outcome in different trials, using thrombolysis

beyond 3 h after stroke onset [6, 7] . Determining stroke

type using neuroimaging goes well beyond separating

ischaemic from haemorrhagic stroke. For instance, the

depiction of multiple cortical infarcts may lead to a fuller

work - up for cardiogenic emboli [8, 9] . In arterial dissec-

tion, the characteristic semilunar high - intensity signal in

the vessel wall on high - resolution T1 - weighted magnetic

resonance imaging (MRI) alerts to the presence of this

cause of stroke [10] .

19

Objectives

The objective of the task force is to actualize the EFNS

Guideline on the use of neuroimaging for the manage-

ment of acute stroke published in 2006. The Guideline is

based on published scientifi c evidence as well as the con-

sensus of experts. The resulting report is intended to

provide updated and evidence - based recommendations

regarding the use of diagnostic neuroimaging techniques,

including cerebrovascular ultrasonography (US), in

patients with stroke and thus guide neurologists, other

healthcare professionals, and healthcare providers in

clinical decision making and in the elaboration of clinical

protocols. It is not intended to have legally binding

implications in individual situations.

Background

Stroke is the second most common cause of death world-

wide, and one of the major determining factors of hos-

pital admission and permanent disability in the developed

countries [1] . The proportion of the population over the

age of 65 years is growing and this trend is likely to

increase stroke incidence in the next decades [2] . Major

advances in the understanding of the mechanisms of

stroke and its management have been made thanks to

the substantial progress in neuroimaging techniques.

However, the multiplicity and continuous advances of

European Handbook of Neurological Management: Volume 1, 2nd Edition

Edited by N. E. Gilhus, M. P. Barnes and M. Brainin

© 2011 Blackwell Publishing Ltd. ISBN: 978-1-405-18533-2

20 SECTION 1 Investigations

Search s trategy

The Cochrane Library was consulted and no studies were

found regarding the use of neuroimaging techniques in

stroke. A comprehensive literature review using the

MEDLINE database has been conducted by searching for

the period 1965 – 2009. Relevant literature in English,

including existing guidelines, meta - analyses, systematic

reviews, randomized controlled trials, and observational

studies have been critically assessed. Selected articles have

been rated based on the quality of study design, and clini-

cal practice recommendations have been developed and

stratifi ed to refl ect the quality and the content of the

evidence according to EFNS criteria [11] .

Method for r eaching c onsensus

The author panel critically assessed the topic through

analysis of the medical literature. A draft guideline with

specifi c recommendations was circulated to all panel

members. Each panellist studied and commented in

writing on this draft, which was revised to progressively

accommodate the panel consensus. After the approval of

the panellists, two independent experts gave their opinion

on the fi nal version.

Results

Imaging of the b rain The primary objectives of brain imaging in acute stroke

are to exclude a non - vascular lesion as the cause of the

symptoms and to determine whether the stroke is caused

by an ischaemic infarction or a haemorrhage. It is not

possible to exclude stroke mimics, such as a neoplasm,

and distinguish between ischaemic and haemorrhagic

stroke based exclusively on the history and physical

examination [12] . Determining the nature of the lesion

by brain imaging is necessary before starting any treat-

ment, particularly thrombolysis and antithrombotic

drugs (Class I, Level A).

Secondary objectives of brain imaging are to facilitate

the identifi cation of stroke mechanisms, to detect sal-

vageable tissue, and to improve the selection of patients

who could be candidates for reperfusion therapies.

Computed t omography ( CT ) Conventional CT of the head is the examination most

frequently used for the emergent evaluation of patients

with acute stroke because of its wide availability and use-

fulness (Class II, Level B). It has been utilized as a screen-

ing tool in most of the major therapeutic trials conducted

to date [3] . It is useful to distinguish between ischaemic

stroke and intracerebral or subarachnoid haemorrhage

(SAH), and can also rule out other conditions that could

mimic stroke, such as brain tumours. Signs of early isch-

emia may be identifi ed as early as 2 hrs from stroke onset,

although they may appear much later [13] . Early infarct

signs include the hyperdense middle cerebral artery

(MCA) sign [14, 15] (indicative of a thrombus or embolus

in the M1 segment of the vessel), the MCA dot sign [16,

17] (indicating thrombosis of M2 or M3 MCA branches),

the loss of grey - white differentiation in the cortical

ribbon [18] or the lentiform nucleus [19] , and sulcal

effacement [20] . The presence of some of these signs has

been associated with poor outcome [20 – 22] . In the Euro-

pean Cooperative Acute Stroke Study (ECASS) I trial

those patients with signs of early infarction involving

more than one - third of the territory of the MCA had an

increased risk of haemorrhagic transformation following

treatment with thrombolysis [23] . A secondary analysis

of other thrombolytic trials with a 6 - h time window

(ECASS II and Multicentre Acute Stroke Trial – Europe

(MAST - E)) demonstrated that the presence of early CT

changes was a risk factor for intracerebral haemorrhage

(ICH) [24, 25] , and similar results have been observed in

larger series of patients [26] . However, in the National

Institute of Neurological Disease and Stroke (NINDS)

trial and the Australian Streptokinase Trial there was no

relation between intracranial haemorrhage and early CT

changes [27, 28] , and it has been argued that the poorer

outcome in patients with CT changes may have more to

do with delayed treatment than with the changes them-

selves, with additional damage of the potentially salvage-

able tissue in the larger, CT - visible infarcts [29] . Because

ischaemic changes are diffi cult to detect for clinicians

without an adequate training in reading CT [30, 31] ,

scoring systems have been developed to quantify early CT

changes, such as the Alberta Stroke Programme Early CT

Score (ASPECTS). More extensive early changes using

ASPECTS correlate with high rates of intracranial haem-

orrhage and poor outcome at long term. Therefore, its

use could improve the identifi cation of ischaemic stroke

CHAPTER 2 Imaging in cerebrovascular disease 21

patients who would particularly benefi t from thromboly-

sis and those at risk of symptomatic haemorrhage [32,

33] . However, given the confl icting evidence, the pres-

ence of decreased attenuation on early CT, even affecting

more than one - third of the MCA territory, cannot be

construed as an absolute contraindication for the use of

thrombolytic therapy in the fi rst 3 h after stroke (Class

IV, Good Clinical Practice Point (GCPP)).

Conventional CT contrast enhancement is not indi-

cated for the acute diagnosis of stroke, and seldom may

be helpful to show the infarcted area in the subacute stage

(2 – 3 weeks after stroke onset) when there may be obscu-

ration of the infarction by the ‘ fogging effect ’ [34, 35]

(Class IV, Level C).

Computed tomography shows acute ICHs larger than

5 mm in diameter as areas of increased attenuation. Not

depicted by CT are petechial haemorrhages and bleedings

in patients with very low haemoglobin levels [36] ,

because the high density of blood on CT is a function of

haemoglobin concentration. CT demonstrates the size

and topography of the haemorrhage and gives informa-

tion about the presence of mass effect, hydrocephalus,

and intraventricular extension of the bleeding. In addi-

tion, it may identify (although not as well as MRI) pos-

sible structural abnormalities (aneurysms, arteriovenous

malformations, or tumours) that caused the haemor-

rhage. The characteristic hyperdensity of ICH on CT

disappears with time, becoming hypodense after approx-

imately 8 – 10 days [37, 38] . For this reason, CT is not a

useful technique to distinguish between old haemorrhage

and infarction. With newer CT helical units, SAH can be

detected in 98 – 100% of patients in the fi rst 12 h from the

onset of symptoms [39, 40] and in 93% of patients

studied within the fi rst 24 h [41, 42] .

CT is the imaging procedure of choice to diagnose

SAH (Class I, Level A). Some experts recommend per-

forming the study with thin cuts (3 mm in thickness)

through the base of the brain, because small collections

of blood may be missed with thicker cuts [39, 43] (Class

IV, GCPP). CT cannot identify SAH in patients with low

haemoglobin levels, because blood may appear isodense,

and in those scanned after 3 weeks of the bleeding, when

blood has usually been metabolized [44] . Lumbar punc-

ture with CSF analysis should be performed when CT

scan is negative or doubtful [45] .

Cerebral venous thrombosis (CVT) is an uncommon

cause of stroke [46, 47] . CT can show direct signs of

venous thrombosis and other indirect non - specifi c signs,

but in about one - third of cases CT is normal [48, 49] .

Direct signs on unenhanced CT are the cord sign, cor-

responding to thrombosed cortical veins, and the dense

triangle sign, corresponding to a thrombus in the supe-

rior sagittal sinus, and, on enhanced CT of the sagittal

sinus, the delta sign [50] . Indirect signs such as local

hypodensities caused by oedema or infarction, hyperden-

sities secondary to haemorrhagic infarction, or brain

swelling and small ventricles suggest the diagnosis of

CVT. CT venography has emerged as a good procedure

to detect CVT [51 – 53] (Class III, Level C).

Perfusion - CT (PCT) techniques, despite being less

sensitive than diffusion - weighted (DWI) MRI can show

the area of ischaemia [54, 55] . Also, may it help distin-

guish between reversible (ischaemic penumbra) and irre-

versible (infarction) areas of ischaemia with standardized

methodology [56 – 58] . Different preliminary studies

comparing PCT with MRI have shown comparable

results to depict penumbra tissue [59 – 62] . There is only

one study to date (in which the primary end point was

negative) demonstrating that perfusion CT may be used

for the selection of candidates to thrombolytic therapy

beyond the 3 - h window [63] . Pregnancy, diabetes, renal

failure, and allergy to contrast material are relative con-

traindications to performing a perfusion brain CT. Per-

fusion CT may be useful to characterize the presence of

marginally perfused tissue (Class II, Level B).

Magnetic r esonance i maging ( MRI ) Magnetic resonance imaging has a higher sensitivity than

conventional CT and results in lower inter - rater vari-

ability in the diagnosis of ischaemic stroke within the fi rst

hours of stroke onset [64 – 69] (Class I, Level A). MRI is

particularly useful to show lesions in the brain stem or

cerebellum, identify lacunar infarcts, and document

vessel occlusion and brain oedema [65, 66, 68] (Class I,

Level A).

In addition, MRI techniques can provide information

about tissue viability. DWI and perfusion (PI) MRI

studies may inform about the presence of reversibly

and irreversibly damaged ischaemic tissues in the hyper-

acute phase of stroke [70 – 78] (Class II, Level B). DWI

may demonstrate deeply ischaemic or infarcted brain

tissue within minutes of symptom onset [77] . However,

areas of abnormal DWI signal are not always infarcted

and the fi nding may disappear spontaneously or after


thrombolysis [79 – 81] . PI requires the intravenous

administration of gadolinium and provides information

about brain tissue perfusion at a given time. Different

perfusion parameters give different perfusion lesion

volumes in the same patient [82, 83] . The absolute

volume difference or ratio of the PI area and the DWI

area (diffusion – perfusion mismatch) is a useful method

to estimate the presence of ischaemic penumbra tissue

[84] . Not only the volume of abnormally perfused tissue

but also the degree of perfusion drop predict the extent

of ischaemic brain damage [85] . PI/DWI mismatch has

been evaluated in several studies as a selection tool for

thrombolytic therapy beyond 3 h [86 – 89] and in a phase

II trial it was used as a selection tool and surrogate

parameter for thrombolysis within 3 – 9 h [63] . A proposal

for the standardization of perfusion and penumbral

imaging techniques has been published [56]

Some neuroimaging fi ndings on MRI, such as the

presence of leukoaraiosis [90] and large DWI lesions

[91] , are associated with an increased risk for symptom-

atic intracerebral haemorrhage associated with thrombo-

lytic treatment.

MRI may be useful to predict which patients will

develop massive swelling with an MCA infarct. The mea-

surement of infarct volume on DWI allows the predic-

tion of malignant infarction [92, 93] , and may be helpful

for early management of these patients [94, 95] .

MRI can help identify occluded intracranial arteries

by the loss of the normal intravascular fl ow voids [65] .

Some sequences, such as T2 * - weighted MRI or fl uid -

attenuated inversion recovery (FLAIR; hyperintense

artery sign), may demonstrate acute MCA thromboem-

bolism with a higher sensitivity than CT, but the type of

arterial change on MRI does not predict recanalization,

clinical outcome, or ICH after intravenous thrombolysis

[96, 97] .

Intracranial haemorrhage is easily detectable on MRI

using T2 * - weighted images [98 – 100] . MRI can identify

intraparenchymal haemorrhage within the fi rst 6 h after

symptom onset as accurately as CT [100, 101] (Class I,

Level A). Susceptibility - weighted T2 * sequences (gradi-

ent echo) can also detect clinically silent parenchymal

microbleeds, not visible on CT, which may leave enough

local haemosiderin to remain detectable for months or

years after the bleeding. Microbleeds are associated with

a history of ICH and prospectively have been shown to

pose a 3% risk of ICH [102] . Although some retrospec-

tive studies reported an increased risk of symptomatic

haemorrhage after thrombolysis [103, 104] , this risk was

not found in more recent studies [82, 105, 106] . The risk

of bleeding after thrombolysis in patients with micro-

bleeds is small [106] and their presence is not a contra-

indication to the use of thrombolytic therapy in the fi rst

3 h after stroke (Class III, Level C).

MRI is also useful to date the haemorrhagic event

accurately and to detect lesions (as tumours, vascular

malformations, or aneurysms) that may underlie the

ICH [107] . To detect these lesions, repeated studies may

be needed after some of the swelling and vasospasm have

subsided.

Subarachnoid haemorrhage (SAH) can be detected

using T2 * [108] and FLAIR [109, 110] MR sequences, but

at present CT remains the imaging method of choice for

this diagnosis (Class I, Level A).

Arterial dissection is a leading cause of stroke in young

persons [47] . MRI is the initial procedure of choice [66,

68, 111, 112] , replacing conventional angiography as the

gold standard (Class II, Level B), because MRI can show

the mural haematoma of the dissected vessel on the axial

images [112] (high signal in the wall). Visualization of

these changes in the vertebral artery is more diffi cult than

for the larger carotid artery, making diagnosis of verte-

bral dissection less reliable. The study can be completed

with magnetic resonance angiography (MRA) to visual-

ize occlusion of the artery, pseudoaneurysms, or a long

stenotic segment with tapered ends [113, 114] . Other

techniques, including US [115 – 117] or CT angiography

[113, 114, 118, 119] , may be useful for the non - invasive

diagnosis of arterial dissection.

MRI combined with MRA is the method of choice for

the diagnosis and follow - up of CVT [49, 120 – 123] . MRI

is more sensitive than CT to show parechymal abnor-

malities and the presence of thrombosed veins.

In summary, MRI is very helpful in the clinical setting

for the management of acute stroke and to guide deci-

sions regarding thrombolysis (Class I, Level A). It is par-

ticularly helpful for the study of stroke patients for whom

perfusion CT may be dangerous, such as those with renal

failure or diabetes. However, MRI in the acute phase of

stroke is not widely available at European hospitals [124] .

Other limitations and contraindications for the use of

MRI are: claustrophobia, agitation, morbid obesity, the

presence of intracranial ferromagnetic elements, an

aneurysm recently clipped or coiled, otic or cochlear


implants, some old prosthetic heart valves, pacemakers,

and some, not all, neurostimulators.

SPECT and PET Single photon emission computed tomography (SPECT)

and positron emission tomography (PET) are functional

neuroimaging techniques based on the principles of

tracer technology using radiolabelled substances as sys-

temically administered tracers. In the setting of stroke,

SPECT has been used for the evaluation of cerebral perfu-

sion. Earlier perfusion SPECT studies failed to show any

advantage of SPECT over the structured clinical evalua-

tion (NIH, Canadian, Scandinavian stroke scales) in the

prediction of the evolution of acute stroke [125] .

However, using ethyl cysteinate dimer (ECD) SPECT in

the fi rst 6 h after stroke, Barthel et al. [126] were able to

determine which patients would develop massive MCA -

territory necrosis, with hemispheric herniation. These

patients have a high risk of haemorrhage following

thrombolysis and could potentially be helped by early

decompressive hemicraniectomy [127] . Complete MCA

infarctions were predicted with signifi cantly higher accu-

racy with early SPECT compared with early CT and clini-

cal parameters. The predictive value increased when the

fi ndings on CT, clinical examination, and SPECT were

considered [126] . Other studies have found SPECT to

add predictive value to the clinical score on admission

[128 – 130] . Those studies suggest that a patient with a

normal SPECT study performed within 3 h of stroke

onset will most likely recover spontaneously and there-

fore may not benefi t from thrombolysis. A patient with

a dense defi cit in the entire MCA distribution has a high

risk of haemorrhage with thrombolysis, and, depending

on age and other factors, should be considered for

decompressive hemicraniectomy. The patients most

likely to benefi t from thrombolysis are the ones with less

massive lesions [126, 128] . Thus, SPECT is helpful in the

evaluation of acute stroke (Class III, Level C). Unfortu-

nately, the need to perform either CT or MRI in acute

stroke renders the performance of SPECT diffi cult within

the time frame allotted for the evaluation of these patients.

SPECT is also helpful in the evaluation of cerebral perfu-

sion in non - acute cerebrovascular disease, for instance in

the days after a SAH [131] (Class III, Level C).

PET can be used to evaluate a large variety of physio-

logical variables including cerebral blood fl ow, cerebral

blood volume, and cerebral glucose metabolism, as well

as the density of neurotransmitters and neuroreceptors,

such as benzodiazepine receptors with fl umazenil, an

accurate marker of neuronal loss [132] . As PET has been

considered the gold standard for these kinds of measure-

ments in humans, it is also extremely well suited to help

identify the degree of ischaemic damage in the brain.

Heiss et al. compared 15 O - water PET and MRI in patients

with acute ischaemic stroke. They observed that DW/

PW – MRI mismatch overestimates the penumbra defi ned

by PET [133] . Although PET is the reference method for

quantitative perfusion imaging, it does not allow for the

reliable identifi cation of lesions in the vessels or non -

vascular lesions giving rise to the stroke syndrome. This,

coupled with the cost and current lack of availability of

this technique, renders it less useful than MRI and CT for

most practising neurologists.

Imaging of the e xtracranial v essels Imaging of the extracranial and intracranial vessels will

help identify the underlying mechanism of the stroke

(atherothrombotic, embolic, dissection, or other). Non -

invasive imaging methods are increasingly accepted as

replacements of digital substraction angiography (DSA)

in the evaluation of carotid stenosis prior to endarterec-

tomy [134] (Class IV, GCPP). US, comprising Doppler

sonography and colour - coded duplex sonography, is

probably the most common non - invasive imaging

examination performed to aid in the diagnosis of carotid

disease. The peak systolic velocity and the presence of

plaque on greyscale and/or colour Doppler/Duplex US

images are the main parameters that should be used

when diagnosing and grading internal carotid artery

(ICA) stenosis [135] . The examination may be limited

by the presence of extensive plaque calcifi cations, vessel

tortuosity and in patients with tandem lesions. In addi-

tion, Doppler US is both technician - and equipment -

dependent and all sonographers should be able to

demonstrate that they have validated their testing

procedures. Meta - analyses of published criteria for

US have demonstrated sensitivities of 98% and specifi ci-

ties of 88% for detecting > 50% ICA stenosis; and

94% and 90% respectively for detecting > 70% ICA

stenosis [136] .

Magnetic resonance angiography using time - of -

fl ight angiography (TOF) and contrast - enhanced MRA

(CEMRA) are powerful means to assess vascular pathol-

ogy. Either technique provides specifi c information:


while TOF visualizes changes of fl ow in the arteries or

veins depending on imaging parameters, CEMRA visual-

izes the vascular lumen. MRA and US have yielded com-

parable fi ndings. Two meta - analyses [137, 138] and

several reviews [139, 140] have compared the diagnostic

value of Doppler US, MRA, and conventional DSA for

the diagnosis of carotid artery stenosis. The meta - analysis

published by Blakeley et al. [137] in 1995 concluded

that Doppler US and MRA had similar diagnostic per-

formance in predicting carotid artery occlusion and

> 70% stenosis. In the systematic review performed by

Nederkoorn et al. [139] for the diagnosis of 70 – 99%

stenosis, MRA had a pooled sensitivity of 95% and a

pooled specifi city of 90%, and US 86% and 87% respec-

tively. For recognising occlusion, MRA had a sensitivity

of 98% and a specifi city of 100%, and DUS had a sensitiv-

ity of 96% and a specifi city of 100%. A meta - analysis

comparing the accuracy of TOF or CEMRA for the detec-

tion of ICA disease against intra - arterial angiography

showed that CEMRA is slightly more precise than TOF

for the detection of ICA high - grade ( ≥ 70 to 99%) stenosis

and occlusion, and appears to achieve a higher sensitivity

for the detection of moderate (50 – 69%) stenosis [141] .

Computed tomography angiography, a contrast - depen-

dent technique, has been compared with DSA for the

detection and quantifi cation of carotid stenosis and

occlusions [142 – 147] . A systematic review concludes that

this technique has demonstrated a good sensitivity and

specifi city for occlusion (97%), but the pooled sensitivity

and specifi city for detection of a 70 – 99% stenosis by CTA

were 85% and 93% respectively [146] (Class II, Level B).

In a systematic review, CEMRA is more accurate than

CTA to adequately evaluate 70 – 99% carotid stenosis

[148] , especially when there is an excess of calcium in the

plaque [149] . The difference among these modalities is

small, and other factors, such as availability and quality

of US performance, may render one procedure more

useful than the other (Class II, Level B).

Similarly to carotid stenosis, CEMRA and CTA may be

more sensitive in diagnosing vertebral artery stenosis

than DUS [150] .

Digital substraction angiography is the reference

method to determine the degree of carotid and vertebral

artery stenosis. Endarterectomy trials for symptomatic

[151 – 153] and asymptomatic [154] patients were per-

formed using this method. However, angiography carries

the risk of stroke and death [134, 155] , and many centres

are not using DSA prior to carotid endarterectomy

[135, 156 – 159] , particularly when non - invasive methods

are concordant (Class IV, GCPP). When non - invasive

methods are inconclusive or there is a discrepancy

between them, DSA is necessary.

Imaging of the i ntracranial v essels Transcranial Doppler (TCD) and transcranial colour -

coded duplex (TCCD) are non - invasive ultrasonographic

procedures that measure local blood fl ow velocity and

direction but also permit visualization of blood vessels

(TCCD) in the proximal portions of large intracranial

arteries [160, 161] . These methods are useful for the

screening of intracranial stenosis [162 – 164] and occlu-

sion [165, 166] in patients with cerebrovascular disease

(Class II, Level B). In children with sickle cell disease,

detection of asymptomatic intracerebral stenoses using

TCD allows selection of a group at high risk of future

stroke, who benefi t from exchange transfusion [167]

(Class II, Level B). It is also useful for the detection and

monitoring of intracranial artery vasospasm after SAH,

particularly in the MCA [168] (Class I, Level A). TCD

can be used to monitor recanalization during thromboly-

sis in acute MCA occlusions [169] (Class II, Level B).

There is increasing interest in its therapeutic use. In vitro

studies demonstrate it has an additive effect on clot lysis

when used with recombinant tissue plasminogen activa-

tor (rtPA), and clinical studies have suggested that con-

tinuous TCD monitoring in patients with acute MCA

occlusion treated with intravenous thrombolysis may

improve both early recanalization and clinical outcome

[170] . TCD allows for the documentation of a right - to -

left shunt in patients with ischaemic stroke (Class II,

Level A). TCD discloses a shower of air bubbles in the

MCA after the intravenous injection of saline mixed with

air bubbles [171 – 173] .

TCD is the only imaging technique that allows detec-

tion of circulating emboli, even in asymptomatic patients

(Class II, Level A). Emboli cause short - duration, high -

intensity signals, because they refl ect and backscatter

more ultrasound than the surrounding red blood cells.

Studies have shown that asymptomatic embolization is

common in acute stroke, particularly in patients with

carotid artery disease [174, 175] . In this group the pres-

ence of embolic signals has been shown to predict the risk

of stroke and transient ischaemic attack (TIA) [176 – 178]

(Class II, Level A). Embolic signals have also been used


as surrogate markers to evaluate antiplatelet agents in

both single - centre studies [179] and in the multicentre

international Clopidogrel and Aspirin for Reduction of

Emboli in Symptomatic Carotid Stenosis trial [180] .

Embolic signal monitoring is used to monitor emboliza-

tion following carotid endarterectomy; the presence of

frequent embolic signals in this setting predicts early

postoperative stroke [181] and can be reduced by more

aggressive antiplatelet treatment, including dextran [182]

and clopidogrel [183] . TCD can also be used to evaluate

cerebrovascular reserve by determining the extent to

which MCA fl ow velocity can increase in response to

the vasodilator carbon dioxide or acetazolamide. Reserve

is reduced in a proportion of patients with carotid

occlusion and tight stenosis, and impaired reserve

predicts recurrent TIA and stroke risk, particularly in

the group with carotid occlusion [184, 185] (Class III,

Level B).

Transcranial Doppler examination cannot be per-

formed in about 10 – 15% of patients, particularly older

women, because they lack a transtemporal window

due to the thickness of the skull [186] . The use of intra-

venous echo contrast agents may improve detection of

fl ow velocities in patients with limited transtemporal

window [187] . TCD velocities may be altered in patients

with cardiac pump failure (low velocities) or anaemia

(increased velocities).

Magnetic resonance angiography (MRA) can identify

intracranial steno - occlusive lesions mainly in the proxi-

mal segments. Both TCD ultrasound and MRA non -

invasively identify 50 – 99% of intracranial large vessel

stenoses with substantial negative predictive value (86%

and 91% respectively) [188] . Compared with DSA, MRA

has a higher sensitivity and specifi city (superior to 80%)

for the identifi cation of proximal intracranial arterial ste-

nosis [189, 190] (Class II, Level B).

CT angiography is another useful technique with high

sensitivity and specifi city (superior to 90%) for the diag-

nosis of occlusion and intracranial stenosis [191, 192] ,

with the exception of stenosis in the cavernous portion

of the internal carotid or in arteries with circumferential

wall calcifi cation [189, 193] (Class II, Level B).

Magnetic resonance and CT angiography can be used to

show large aneurysms (Class II, Level B), but these tech-

niques fail to identify aneurysm of less than 5 mm in diam-

eter, those located in the intracranial carotid artery, and

cannot clearly establish the critical relationship of the neck

of the aneurysm(s) with arterial branches [194 – 197] .

Therefore non – invasive techniques have not replaced

DSA for aneurysm identifi cation and localization. The

sensitivity of 3 - dimensional time - of - fl ight MRA for cere-

bral aneurysms ≥ 5 mm after SAH is between 85% and

100% [198 – 200] , with lower percentages for aneurysms

< 5 mm [45, 198, 200] . CT angiography has a sensitivity

for aneurysms ≥ 5 mm between 95% and 100% and a

specifi city between 79% and 100% [45, 201 – 203] . Some

authors suggest that CT angiography can be used as a reli-

able alternative to DSA after SAH, particularly in cases in

which the risk of delaying surgery does not justify the per-

formance of a catheter study [45, 204] (Class II, Level B).

MR and CT angiography have been used for screening

individuals with a history of intracranial aneurysm or

SAH in fi rst - degree relatives [205, 206] (Class II, Level

B). Overall reported sensitivity for both techniques was

76 – 98% and specifi city was 85 – 100% [207] .

DSA is needed to demonstrate small aneurysms and

before surgery or endovascular treatment (Class I,

Level A).

Recommendations

Imaging of the b rain • Either non - contrast computed tomography (CT) or magnetic

resonance imaging (MRI) should be used for the defi nition of stroke type and treatment of stroke (Class I, Level A).

• The presence of early CT infarct signs cannot be construed as an absolute contraindication to thrombolysis in the fi rst 3 h after stroke (Class IV, GCPP).

• MRI has a higher sensitivity than conventional CT for the documentation of infarction within the fi rst hours of stroke onset, lesions in the posterior fossa, identifi cation of small

lesions, and documentation of vessel occlusion and brain oedema (Class I, Level A).

• In conjunction with MRI and magnetic resonance angiography (MRA), perfusion and diffusion MR are very helpful for the evaluation of patients with acute ischaemic stroke (Class I, Level A).

• Single photon emission computed tomography (SPECT) is helpful to predict the malignant course of brain swelling with large hemispheric infarctions (Class III, Level C). SPECT is also helpful in the evaluation of cerebral perfusion in


non - acute cerebrovascular disease, for instance in the days after a subarachnoid haemorrhage (SAH) (Class III, Level C).

Detection of h aemorrhagic s troke • MRI can detect acute and chronic intracerebral haemorrhage

(Class I, Level A).

• Although the detection of SAH is possible with MRI, currently CT scan is the diagnostic procedure of choice (Class I, Level A). In case of doubt or negative CT scan, lumbar puncture and cerebrospinal fl uid (CSF) analysis is recommended (Class I, Level B)

Imaging of e xtracranial v essels • Although MRA has slightly higher sensitivity and specifi city

than ultrasonography (US) to determine carotid stenosis and occlusion, the usefulness of either procedure may be determined by other factors, such as availability (Class II, Level B).

• Computed tomography angiography (CTA) has a sensitivity and specifi city similar to MR for carotid occlusion and similar to US for the detection of severe stenosis (Class II, Level B).

• Digital substraction angiography (DSA) is generally recommended for grading carotid stenosis prior to endarterectomy (Class I, Level A), but when there is concordance of non - invasive methods cerebral arteriography may not be necessary (Class IV, GCPP).

Imaging of i ntracraneal v essels • Transcranial Doppler (TCD) is very useful for assessing

stroke risk of children aged 2 – 16 years with sickle cell

disease (Class II, Level B), detection and monitoring of vasospasm after SAH (Class I, Level A), diagnosis of intracranial steno - occlusive disease (Class II, Level B), diagnosis of right - to - left shunts (Class II, Level A), and for monitoring arterial recanalization after thrombolysis of acute middle cerebral artery (MCA) occlusions (Class II, Level B).

• TCD can detect cerebral emboli and impaired cerebral haemodynamics. The presence of embolic signals with carotid stenosis predicts early recurrent stroke risk (Class II, Level A). The detection of impaired cerebral haemodynamics in carotid occlusion may identify a group at high risk of recurrent stroke (Class III, Level B).

• MRA and CTA are very useful for the diagnosis of intracranial stenosis and cerebral aneurysms > 5 mm (Class II, Level B). MRA and CTA are the recommended techniques for screening cerebral aneurysms in individuals with a history of aneurysms or SAH in a fi rst - degree relative (Class II, Level B).

• DSA is the recommended technique for the diagnosis of cerebral aneurysm as the cause of SAH (Class I, Level A). CTA can be used as a reliable alternative to DSA in patients with SAH, particularly in cases in which the risk of delaying surgery for a catheter study is not justifi ed (Class II, Level B).

• MRI with MRA is recommended for the diagnosis and follow - up of cerebral venous thrombosis (Class II, Level B). Alternatively, CT venography is accurate and can be used for the same purpose (Class III, Level C).

Confl icts of i nterest J. Masdeu received an honorarium as Editor - in - Chief of

the Journal of Neuroimaging . With regard to this manu-

script there is no confl ict of interest.

P. D. Schellinger has received travel stipends, advisory

board and speakers honoraria from Boehringer Ingel-

heim, the manufacturers of Alteplase.

The rest of authors have reported no confl icts of inter-

est relevant to this manuscript.

References

1. World Health Organization . The Global Burden of Disease:

2004 Update . Geneva, Switzerland : World Health Organi-

zation , 2008 .

2. Truelsen T , Piechowski - Jozwiak B , Bonita R , Mathers C ,

Bogousslavsky J , Boysen G . Stroke incidence and preva-

lence in Europe: a review of available data . Eur J Neurol

2006 ; 13 ( 6 ): 581 – 98 .

3. Hacke W , Donnan G , Fieschi C , et al. Association of

outcome with early stroke treatment: pooled analysis of

ATLANTIS, ECASS, and NINDS rt - PA stroke trials . Lancet

2004 ; 363 ( 9411 ): 768 – 74 .

4. Hacke W , Kaste M , Bluhmki E , et al. Thrombolysis with

alteplase 3 to 4.5 hours after acute ischemic stroke . N Engl

J Med 2008 ; 359 ( 13 ): 1317 – 29 .

5. Furlan A , Higashida R , Wechsler L , et al. Intra - arterial

prourokinase for acute ischemic stroke: the PROACT II

Study: a randomized controlled trial . JAMA 1999 ; 282 ( 21 ):

2003 – 11 .

6. Schellinger PD , Fiebach JB , Hacke W . Imaging - based deci-

sion making in thrombolytic therapy for ischemic stroke:

present status . Stroke 2003 ; 34 ( 2 ): 575 – 83 .


7. Donnan GA , Baron JC , Ma H , Davis SM . Penumbral selec-

tion of patients for trials of acute stroke therapy . Lancet

Neurol 2009 ; 8 ( 3 ): 261 – 9 .

8. Wessels T , Wessels C , Ellsiepen A , et al. Contribution of

diffusion - weighted imaging in determination of stroke

etiology . AJNR Am J Neuroradiol 2006 ; 27 ( 1 ): 35 – 9 .

9. Caso V , Budak K , Georgiadis D , Schuknecht B , Baum-

gartner RW . Clinical signifi cance of detection of multiple

acute brain infarcts on diffusion weighted magnetic reso-

nance imaging . J Neurol Neurosurg Psychiatry 2005 ; 76 ( 4 ):

514 – 8 .

10. Lanczik O , Szabo K , Hennerici M , Gass A . Multiparamet-

ric MRI and ultrasound fi ndings in patients with internal

carotid artery dissection . Neurology 2005 ; 65 ( 3 ): 469 – 71 .

11. Brainin M , Barnes M , Baron JC , et al. Guidance for the

preparation of neurological management guidelines by

EFNS scientifi c task forces – revised recommendations

2004 . Eur J Neurol 2004 ; 11 ( 9 ): 577 – 81 .

12. Britton M , Hindmarsh T , Murray V , Tyden SA . Diagnostic

errors discovered by CT in patients with suspected stroke .

Neurology 1984 ; 34 ( 11 ): 1504 .

13. von Kummer R , Nolte PN , Schnittger H , Thron A ,

Ringelstein EB . Detectability of cerebral hemisphere isch-

aemic infarcts by CT within 6 h of stroke . Neuroradiology

1995 ; 38 ( 1 ): 31 – 3 .

14. Gacs G , Fox AJ , Barnett HJ , Vinuela F . CT visualization of

intracranial arterial thromboembolism . Stroke 1983 ; 14 ( 5 ):

756 – 62 .

15. Bastianello S , Pierallini A , Colonnese C , et al . Hyperdense

middle cerebral artery CT sign . Neuroradiology 1991 ; 33 ( 3 ):

207 – 11 .

16. Barber PA , Demchuk AM , Hudon ME , Pexman JH , Hill

MD , Buchan AM . Hyperdense sylvian fi ssure MCA “ Dot ”

sign: a CT marker of acute ischemia . Stroke 2001 ; 32 ( 1 ):

84 – 8 .

17. Leary MC , Kidwell CS , Villablanca JP , et al. Validation of

computed tomographic middle cerebral artery “ dot ” sign:

an angiographic correlation study . Stroke 2003 ; 34 ( 11 ):

2636 – 40 .

18. 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 .

19. Tomura N , Uemura K , Inugami A , Fujita H , Higano S ,

Shishido F . Early CT fi nding in cerebral infarction: obscu-

ration of the lentiform nucleus . Radiology 1988 ; 168 ( 2 ):

463 – 7 .

20. Moulin T , Cattin F , Crepin - Leblond T , et al. Early CT signs

in acute middle cerebral artery infarction: predictive value

for subsequent infarct locations and outcome . Neurology

1996 ; 47 ( 2 ): 366 – 75 .

21. Kharitonova T , Ahmed N , Thoren M , et al. Hyperdense

middle cerebral artery sign on admission CT scan – prog-

nostic signifi cance for ischaemic stroke patients treated

with intravenous thrombolysis in the safe implementation

of thrombolysis in Stroke International Stroke Throm-

bolysis Register . Cerebrovasc Dis 2009 ; 27 ( 1 ): 51 – 9 .

22. von Kummer R , Allen KL , Holle R , et al. Acute stroke:

usefulness of early CT fi ndings before thrombolytic

therapy . Radiology 1997 ; 205 ( 2 ): 327 – 33 .

23. Hacke W , Kaste M , Fieschi C , et al. Intravenous throm-

bolysis with recombinant tissue plasminogen activator for

acute hemispheric stroke. The European Cooperative

Acute Stroke Study (ECASS) . JAMA 1995 ; 274 ( 13 ): 1017 –

25 .

24. Larrue V , von Kummer RR , Muller A , Bluhmki E . Risk

factors for severe hemorrhagic transformation in ischemic

stroke patients treated with recombinant tissue plasmino-

gen activator: a secondary analysis of the European -

Australasian Acute Stroke Study (ECASS II) . Stroke

2001 ; 32 ( 2 ): 438 – 41 .

25. Jaillard A , Cornu C , Durieux A , et al. Hemorrhagic trans-

formation in acute ischemic stroke: the MAST - E study .

Stroke 1999 ; 30 ( 7 ): 1326 – 32 .

26. Tanne D , Kasner SE , Demchuk AM , et al. Markers of

increased risk of intracerebral hemorrhage after intrave-

nous recombinant tissue plasminogen activator therapy

for acute ischemic stroke in clinical practice: the multi-

center rt - PA acute stroke survey . Circulation 2002 ; 105 ( 14 ):

1679 – 85 .

27. Patel SC , Levine SR , Tilley BC , et al. Lack of clinical sig-

nifi cance of early ischemic changes on computed tomog-

raphy in acute stroke . JAMA 2001 ; 286 ( 22 ): 2830 – 8 .

28. Gilligan AK , Markus R , Read S , et al. Baseline blood pres-

sure but not early computed tomography changes predicts

major hemorrhage after streptokinase in acute ischemic

stroke . Stroke 2002 ; 33 ( 9 ): 2236 – 42 .

29. Grotta J . NIHSS/EIC mismatch explains the > 1/3 MCA

conundrum . Stroke 2003 ; 34 : e148 – 9 .

30. von Kummer R , Holle R , Gizyska U , et al. Interobserver

agreement in assessing early CT signs of middle cerebral

artery infarction . AJNR Am J Neuroradiol 1996 ; 17 ( 9 ):

1743 – 8 .

31. von Kummer R . Effect of training in reading CT scans on

patient selection for ECASS II . Neurology 1998 ; 51 ( 3 Suppl

3 ): S50 – 2 .

32. Hill MD , Rowley HA , Adler F , et al. Selection of acute

ischemic stroke patients for intra - arterial thrombolysis

with pro - urokinase by using ASPECTS . Stroke 2003 ; 34 ( 8 ):

1925 – 31 .

33. Barber PA , Demchuk AM , Zhang J , Buchan AM . Validity

and reliability of a quantitative computed tomography


score in predicting outcome of hyperacute stroke before

thrombolytic therapy . Lancet 2000 ; 355 ( 9216 ): 1670 – 4 .

34. Wing SD , Norman D , Pollock JA , Newton TH . Contrast

enhancement of cerebral infarcts in computed tomogra-

phy . Radiology 1976 ; 121 ( 1 ): 89 – 92 .

35. Becker H , Desch H , Hacker H , Pencz A . CT fogging

effect with ischemic cerebral infarcts . Neuroradiology

1979 ; 18 ( 4 ): 185 – 92 .

36. New PF , Aronow S . Attenuation measurements of whole

blood and blood fractions in computed tomography . Radi-

ology 1976 ; 121 ( 3 ): 635 – 40 .

37. Dennis M , Bamford JM , Molyneux AJ , Warlow CP . Rapid

resolution of signs of primary intracerebral haemorrhage

in computed tomograms of the brain . Br Med J (Clin Res

Ed) 1987 ; 295 : 379 – 81 .

38. Wardlaw J , Keir SL , Seymour J , et al. What is the best

imaging strategy for acute stroke? Health Technol Assess

2004 ; 8 ( iii, ix – iii ): 1 – 180 .

39. Sidman R , Connolly E , Lemke T . Subarachnoid hemor-

rhage diagnosis: lumbar puncture is still needed when the

computed tomography scan is normal . Acad Emerg Med

1996 ; 3 ( 9 ): 827 – 31 .

40. van der Wee N , Rinkel GJ , Hasan D , van Gijn J . Detection

of subarachnoid haemorrhage on early CT: is lumbar

puncture still needed after a negative scan? J Neurol Neu-

rosurg Psychiatry 1995 ; 58 ( 3 ): 357 – 9 .

41. Sames T , Storrow AB , Finkelstein JA , Magoon MR .

Sensitivity of new - generation computed tomography in

subarachnoid hemorrhage . Acad Emerg Med 1996 ; 3 ( 1 ):

16 – 20 .

42. Morgenstern L , Luna - Gonzales H , Huber JC Jr , et al.

Worst headache and subarachnoid hemorrhage: prospec-

tive, modern computed tomography and spinal fl uid anal-

ysis . Ann Emerg Med 1998 ; 32 ( 3Pt 1 ): 297 – 304 .

43. Edlow JA , Caplan LR . Avoiding pitfalls in the diagnosis of

subarachnoid hemorrhage . N Engl J Med 2000 ; 342 ( 1 ):

29 – 36 .

44. van Gijn J , van Dongen KJ . The time course of aneurysmal

haemorrhage on computed tomograms . Neuroradiology

1982 ; 23 ( 3 ): 153 – 6 .

45. Bederson JB , Connolly ES Jr , Batjer HH , et al.

Guidelines for the management of aneurysmal subarach-

noid hemorrhage: a statement for healthcare professionals

from a special writing group of the Stroke Council,

American Heart Association . Stroke 2009 ; 40 ( 3 ): 994 –

1025 .

46. Arboix A , Bechich S , Oliveres M , Garc í a - Eroles L , Massons

J , Targa C . Ischemic stroke of unusual cause: clinical

features, etiology and outcome . Eur J Neurol 2001 ; 8 ( 2 ):

133 – 9 .

47. Bogousslavsky J , Pierre P . Ischemic stroke in patients under

age 45 . Neurol Clin 1992 ; 10 ( 1 ): 113 – 24 .

48. Bousser MG , Chiras J , Bories J , Castaigne P . Cerebral

venous thrombosis – a review of 38 cases . Stroke

1985 ; 16 ( 2 ): 199 – 213 .

49. Renowden S . Cerebral venous sinus thrombosis . Eur

Radiol 2004 ; 14 ( 2 ): 215 – 26 .

50. Virapongse C , Cazenave C , Quisling R , Sarwar M , Hunter

S . The empty delta sign: frequency and signifi cance in 76

cases of dural sinus thrombosis . Radiology 1987 ; 162 ( 3 ):

779 – 85 .

51. Casey SO , Alberico RA , Patel M , et al. Cerebral CT venog-

raphy . Radiology 1996 ; 198 ( 1 ): 163 – 70 .

52. Gaikwad AB , Mudalgi BA , Patankar KB , Patil JK , Ghongade

DV . Diagnostic role of 64 - slice multidetector row CT scan

and CT venogram in cases of cerebral venous thrombosis .

Emerg Radiol 2008 ; 15 ( 5 ): 325 – 33 .

53. Linn J , Ertl - Wagner B , Seelos KC , et al. Diagnostic value

of multidetector - row CT angiography in the evaluation of

thrombosis of the cerebral venous sinuses . AJNR Am J

Neuroradiol 2007 ; 28 ( 5 ): 946 – 52 .

54. Kohrmann M , Schellinger PD . Acute stroke triage to intra-

venous thrombolysis and other therapies with advanced

CT or MR imaging: pro MR imaging . Radiology

2009 ; 251 ( 3 ): 627 – 33 .

55. Wintermark M , Rowley HA , Lev MH . Acute stroke triage

to intravenous thrombolysis and other therapies with

advanced CT or MR imaging: pro CT . Radiology

2009 ; 251 ( 3 ): 619 – 26 .

56. Wintermark M , Albers GW , Alexandrov AV , et al. Acute

stroke imaging research roadmap . AJNR Am J Neuroradiol

2008 ; 29 ( 5 ): e23 – 30 .

57. Schaefer PW , Roccatagliata L , Ledezma C , et al. First - pass

quantitative CT perfusion identifi es thresholds for salvage-

able penumbra in acute stroke patients treated with

intra - arterial therapy . AJNR Am J Neuroradiol 2006 ; 27 ( 1 ):

20 – 5 .

58. Wintermark M , Flanders AE , Velthuis B , et al. Perfusion -

CT assessment of infarct core and penumbra: receiver

operating characteristic curve analysis in 130 patients sus-

pected of acute hemispheric stroke . Stroke 2006 ; 37 ( 4 ):

979 – 85 .

59. Wintermark M , Reichhart M , Cuisenaire O , et al. Com-

parison of admission perfusion computed tomography

and qualitative diffusion - and perfusion - weighted mag-

netic resonance imaging in acute stroke patients . Stroke

2002 ; 33 ( 8 ): 2025 – 31 .

60. Eastwood JD , Lev MH , Wintermark M , et al. Correlation

of early dynamic CT perfusion imaging with whole - brain

MR diffusion and perfusion imaging in acute hemispheric

stroke . AJNR Am J Neuroradiol 2003 ; 24 ( 9 ): 1869 – 75 .

61. Schramm P , Schellinger PD , Klotz E , et al. Comparison

of perfusion computed tomography and computed

tomography angiography source images with perfusion -


weighted imaging and diffusion - weighted imaging in

patients with acute stroke of less than 6 hours ’ duration .

Stroke 2004 ; 35 ( 7 ): 1652 – 8 .

62. Schaefer PW , Barak ER , Kamalian S , et al. Quantitative

assessment of core/penumbra mismatch in acute stroke:

CT and MR perfusion imaging are strongly correlated

when suffi cient brain volume is imaged . Stroke 2008 ;

39 ( 11 ): 2986 – 92 .

63. Hacke W , Furlan AJ , Al - Rawi Y , et al. Intravenous

desmoteplase in patients with acute ischaemic stroke

selected by MRI perfusion - diffusion weighted imaging

or perfusion CT (DIAS - 2): a prospective, randomised,

double - blind, placebo - controlled study . Lancet Neurol

2009 ; 8 ( 2 ): 141 – 50 .

64. Fiebach JB , Schellinger PD , Jansen O , et al. CT and diffu-

sion - weighted MR imaging in randomized order: diffu-

sion - weighted imaging results in higher accuracy and

lower interrater variability in the diagnosis of hyperacute

ischemic stroke . Stroke 2002 ; 33 ( 9 ): 2206 – 10 .

65. Bryan RN , Levy LM , Whitlow WD , Killian JM , Preziosi TJ ,

Rosario JA . Diagnosis of acute cerebral infarction: com-

parison of CT and MR imaging . AJNR Am J Neuroradiol

1991 ; 12 ( 4 ): 611 – 20 .

66. Culebras A , Kase CS , Masdeu JC , et al. Practice guidelines

for the use of imaging in transient ischemic attacks and

acute stroke: a report of the stroke council, American

Heart Association . Stroke 1997 ; 28 ( 7 ): 1480 – 97 .

67. Shuaib A , Lee D , Pelz D , Fox A , Hachinski VC . The impact

of magnetic resonance imaging on the management of

acute ischemic stroke . Neurology 1992 ; 42 ( 4 ): 816 .

68. European Stroke Organization (ESO) Executive Commit-

tee . Guidelines for management of ischaemic stroke and

transient ischaemic attack 2008 . Cerebrovasc Dis 2008 ; 25 ( 5 ):

457 – 507 .

69. Chalela JA , Kidwell CS , Nentwich LM , et al. Magnetic reso-

nance imaging and computed tomography in emergency

assessment of patients with suspected acute stroke: a pro-

spective comparison . Lancet 2007 ; 369 ( 9558 ): 293 – 8 .

70. Rohl L , Ostergaard L , Simonsen CZ , et al. Viability thresh-

olds of ischemic penumbra of hyperacute stroke defi ned

by perfusion - weighted MRI and apparent diffusion coef-

fi cient . Stroke 2001 ; 32 ( 5 ): 1140 – 6 .

71. Warach S , Mosley M , Sorensen AG , Koroshetz W . Time

course of diffusion imaging abnormalities in human

stroke . Stroke 1996 ; 27 : 1254 – 6 .

72. Sorensen AG , Buonanno FS , Gonzalez RG , et al.

Hyperacute stroke: evaluation with combined multisection

diffusion - weighted and hemodynamically weighted

echo - planar MR imaging . Radiology 1996 ; 199 ( 2 ):

391 – 401 .

73. Barber PA , Darby DG , Desmond PM , et al.

Prediction of stroke outcome with echoplanar perfusion -

and diffusion - weighted MRI . Neurology 1998 ; 51 ( 2 ):

418 – 26 .

74. Warach S , Dashe JF , Edelman RR . Clinical outcome

in ischemic stroke predicted by early diffusion - weighted

and perfusion magnetic resonance imaging: a prelimi-

nary analysis . J Cereb Blood Flow Metab 1996 ; 16 ( 1 ):

53 – 9 .

75. Beaulieu C , de Crespigny A , Tong DC , Moseley ME , Albers

GW , Marks MP . Longitudinal magnetic resonance imaging

study of perfusion and diffusion in stroke: evolution of

lesion volume and correlation with clinical outcome . Ann

Neurol 1999 ; 46 ( 4 ): 568 – 78 .

76. Schlaug G , Benfi eld A , Baird AE , et al. The ischemic pen-

umbra: operationally defi ned by diffusion and perfusion

MRI . Neurology 1999 ; 53 ( 7 ): 1528 .

77. Warach S , Chien D , LiW , Ronthal M , Edelman RR . Fast

magnetic resonance diffusion - weighted imaging of acute

human stroke . Neurology 1992 ; 42 ( 9 ): 1717 .

78. Wittsack H - J , Ritzl A , Fink GR , et al. MR imaging in acute

stroke: diffusion - weighted and perfusion imaging param-

eters for predicting infarct size . Radiology 2002 ; 222 ( 2 ):

397 – 403 .

79. Fiehler J , Foth M , Kucinski T , et al. Severe ADC decreases

do not predict irreversible tissue damage in humans . Stroke

2002 ; 33 ( 1 ): 79 – 86 .

80. Fiehler J , Knudsen K , Kucinski T , et al. Predictors of appar-

ent diffusion coeffi cient normalization in stroke patients .

Stroke 2004 ; 35 ( 2 ): 514 – 9 .

81. Oppenheim C , Lamy C , Touze E , et al. Do transient

ischemic attacks with diffusion - weighted imaging abnor-

malities correspond to brain infarctions? AJNR Am J Neu-

roradiol 2006 ; 27 ( 8 ): 1782 – 7 .

82. Kane I , Carpenter T , Chappell F , et al. Comparison of 10

different magnetic resonance perfusion imaging process-

ing methods in acute ischemic stroke: effect on lesion

size, proportion of patients with diffusion/perfusion mis-

match, clinical scores, and radiologic outcomes . Stroke

2007 ; 38 ( 12 ): 3158 – 64 .

83. Kane I , Sandercock P , Wardlaw J . Magnetic resonance

perfusion diffusion mismatch and thrombolysis in acute

ischaemic stroke: a systematic review of the evidence to

date . J Neurol Neurosurg Psychiatry 2007 ; 78 ( 5 ): 485 – 91 .

84. Latchaw RE , Yonas H , Hunter GJ , et al. Guidelines and

recommendations for perfusion imaging in cerebral isch-

emia: a scientifi c statement for healthcare professionals by

the writing group on perfusion imaging, from the council

on cardiovascular radiology of the American Heart Asso-

ciation . Stroke 2003 ; 34 ( 4 ): 1084 – 104 .

85. Seitz RJ , Meisel S , Weller P , Junghans U , Wittsack HJ ,

Siebler M . Initial ischemic event: perfusion - weighted MR

imaging and apparent diffusion coeffi cient for stroke

evolution . Radiology 2005 ; 237 ( 3 ): 1020 – 8 .


86. Rother J , Schellinger PD , Gass A , et al. Effect of intrave-

nous thrombolysis on MRI parameters and functional

outcome in acute stroke < 6 hours . Stroke 2002 ; 33 ( 10 ):

2438 – 45 .

87. Davis SM , Donnan GA , Parsons MW , et al. Effects of

alteplase beyond 3 h after stroke in the Echoplanar Imaging

Thrombolytic Evaluation Trial (EPITHET): a placebo -

controlled randomised trial . Lancet Neurol 2008 ; 7 ( 4 ):

299 – 309 .

88. Albers GW , Thijs VN , Wechsler L , et al. Magnetic reso-

nance imaging profi les predict clinical response to early

reperfusion: the diffusion and perfusion imaging evalua-

tion for understanding stroke evolution (DEFUSE) study .

Ann Neurol 2006 ; 60 ( 5 ): 508 – 17 .

89. Schellinger PD , Thomalla G , Fiehler J , et al. MRI - based

and CT - based thrombolytic therapy in acute stroke within

and beyond established time windows: an analysis of 1210

patients . Stroke 2007 ; 38 ( 10 ): 2640 – 5 .

90. Neumann - Haefelin T , Hoelig S , Berkefeld J , et al. Leuko-

araiosis is a risk factor for symptomatic intracerebral hem-

orrhage after thrombolysis for acute stroke . Stroke

2006 ; 37 ( 10 ): 2463 – 6 .

91. Singer OC , Humpich MC , Fiehler J , et al. Risk for symp-

tomatic intracerebral hemorrhage after thrombolysis

assessed by diffusion - weighted magnetic resonance

imaging . Ann Neurol 2008 ; 63 ( 1 ): 52 – 60 .

92. Oppenheim C , Samson Y , Manai R , et al. Prediction of

malignant middle cerebral artery infarction by diffusion -

weighted imaging . Stroke 2000 ; 31 ( 9 ): 2175 – 81 .

93. Thomalla GJ , Kucinski T , Schoder V , et al. Prediction of

malignant middle cerebral artery infarction by early perfu-

sion - and diffusion - weighted magnetic resonance imaging .

Stroke 2003 ; 34 ( 8 ): 1892 – 9 .

94. Vahedi K , Vicaut E , Mateo J , et al. Sequential - design, mul-

ticenter, randomized, controlled trial of early decompres-

sive craniectomy in malignant middle cerebral artery

infarction (DECIMAL Trial) . Stroke 2007 ; 38 ( 9 ): 2506 – 17 .

95. Juttler E , Schwab S , Schmiedek P , et al. Decompressive

Surgery for the Treatment of Malignant Infarction of the

Middle Cerebral Artery (DESTINY): a randomized, con-

trolled trial . Stroke 2007 ; 38 ( 9 ): 2518 – 25 .

96. Schellinger PD , Chalela JA , KangDW , Latour LL , Warach

S . Diagnostic and prognostic value of early mr imaging

vessel signs in hyperacute stroke patients imaged < 3 hours

and treated with recombinant tissue plasminogen activa-

tor . AJNR Am J Neuroradiol 2005 ; 26 ( 3 ): 618 – 24 .

97. Flacke S , Urbach H , Keller E , et al. Middle Cerebral Artery

(MCA) susceptibility sign at susceptibility - based perfusion

MR imaging: clinical importance and comparison with

hyperdense MCA sign at CT . Radiology 2000 ; 215 ( 2 ):

476 – 82 .

98. Linfante I , Llinas RH , Caplan LR , Warach S . MRI features

of intracerebral hemorrhage within 2 hours from symptom

onset . Stroke 1999 ; 30 ( 11 ): 2263 – 7 .

99. Schellinger PD , Jansen O , Fiebach JB , Hacke W , Sartor K .

A standardized MRI stroke protocol: comparison with

CT in hyperacute intracerebral hemorrhage . Stroke

1999 ; 30 ( 4 ): 765 – 8 .

100. Fiebach JB , Schellinger PD , Gass A , et al. Stroke magnetic

resonance imaging is accurate in hyperacute intracerebral

hemorrhage: a multicenter study on the validity of stroke

imaging . Stroke 2004 ; 35 ( 2 ): 502 – 6 .

101. Kidwell CS , Chalela JA , Saver JL , et al. Comparison of MRI

and CT for detection of acute intracerebral hemorrhage .

JAMA 2004 ; 292 ( 15 ): 1823 – 30 .

102. Tsushima Y , Aoki J , Endo K . Brain microhemorrhages

detected on T2 * - weighted gradient - echo MR images .

AJNR Am J Neuroradiol 2003 ; 24 ( 1 ): 88 – 96 .

103. Kidwell CS , Saver JL , Villablanca JP , et al. Magnetic reso-

nance imaging detection of microbleeds before throm-

bolysis: an emerging application . Stroke 2002 ; 33 ( 1 ): 95 – 8 .

104. Nighoghossian N , Hermier M , Adeleine P , et al. Old

microbleeds are a potential risk factor for cerebral bleeding

after ischemic stroke: a gradient - echo T2 * - weighted brain

MRI study . Stroke 2002 ; 33 ( 3 ): 735 – 42 .

105. Derex L , Nighoghossian N , Hermier M , et al. Thromboly-

sis for ischemic stroke in patients with old microbleeds on

pretreatment MRI . Cerebrovasc Dis 2004 ; 17 ( 2 – 3 ): 238 – 41 .

106. Fiehler J , Albers GW , Boulanger JM , et al. Bleeding risk

analysis in stroke imaging before thromboLysis (BRASIL):

pooled analysis of T2 * - weighted magnetic resonance

imaging data from 570 patients . Stroke 2007 ; 38 ( 10 ):

2738 – 44 .

107. Dul K , Drayer B . CT and MRI imaging of intracerebral

hemorrhage . In: Kase CS , Caplan LR (eds) Intracerebral

Hemorrhage . Boston, MA : Butterworth - Heinemann , 1994 ;

pp. 73 – 93 .

108. Fiebach JB , Schellinger PD , Geletneky K , et al. MRI

in acute subarachnoid haemorrhage; fi ndings with a

standardised stroke protocol . Neuroradiology 2004 ; 46 ( 1 ):

44 – 8 .

109. Noguchi K , Ogawa T , Inugami A , et al. Acute subarach-

noid hemorrhage: MR imaging with fl uid - attenuated

inversion recovery pulse sequences . Radiology 1995 ; 196 ( 3 ):

773 – 7 .

110. Noguchi K , Ogawa T , Seto H , et al. Subacute and

chronic subarachnoid hemorrhage: diagnosis with fl uid -

attenuated inversion - recovery MR imaging . Radiology

1997 ; 203 ( 1 ): 257 – 62 .

111. Oelerich M , Stogbauer F , Kurlemann G , Schul C , Schuierer

G . Craniocervical artery dissection: MR imaging and MR

angiographic fi ndings . Eur Radiol 1999 ; 9 ( 7 ): 1385 – 91 .


112. Kirsch E , Kaim A , Engelter S , et al. MR angiography in

internal carotid artery dissection: improvement of diagno-

sis by selective demonstration of the intramural haema-

toma . Neuroradiology 1998 ; 40 ( 11 ): 704 – 9 .

113. Bousson V , Levy C , Brunereau L , Djouhri H , Tubiana

JM . Dissections of the internal carotid artery: three -

dimensional time - of - fl ight MR angiography and MR

imaging features . AJR Am J Roentgenol 1999 ; 173 ( 1 ): 139 –

43 .

114. Levy C , Laissy JP , Raveau V , et al. Carotid and vertebral

artery dissections: three - dimensional time - of - fl ight MR

angiography and MR imaging versus conventional angiog-

raphy . Radiology 1994 ; 190 ( 1 ): 97 – 103 .

115. de Bray JM , Lhoste P , Dubas F , Emile J , Saumet JL . Ultra-

sonic features of extracranial carotid dissections: 47 cases

studied by angiography . J Ultrasound Med 1994 ; 13 ( 9 ):

659 – 64 .

116. Bartels E , Flugel KA . Evaluation of extracranial vertebral

artery dissection with duplex color - fl ow imaging . Stroke

1996 ; 27 ( 2 ): 290 – 5 .

117. Benninger DH , Georgiadis D , Gandjour J , Baumgartner

RW . Accuracy of color duplex ultrasound diagnosis of

spontaneous carotid dissection causing ischemia . Stroke

2006 ; 37 ( 2 ): 377 – 81 .

118. Vertinsky AT , Schwartz NE , Fischbein NJ , Rosenberg J ,

Albers GW , Zaharchuk G . Comparison of multidetector

CT angiography and MR imaging of cervical artery dissec-

tion . AJNR Am J Neuroradiol 2008 ; 29 ( 9 ): 1753 – 60 .

119. Chen CJ , Tseng YC , Lee TH , Hsu HL , See LC . Multisection

CT angiography compared with catheter angiography in

diagnosing vertebral artery dissection . AJNR Am J Neuro-

radiol 2004 ; 25 ( 5 ): 769 – 74 .

120. Mattle HP , Wentz KU , Edelman RR , et al. Cerebral venog-

raphy with MR . Radiology 1991 ; 178 ( 2 ): 453 – 8 .

121. Ameri A , Bousser M . Cerebral venous thrombosis . Neurol

Clin 1992 ; 10 ( 1 ): 87 – 111 .

122. Bousser MG , Ferro JM . Cerebral venous thrombosis: an

update . Lancet Neurol 2007 ; 6 ( 2 ): 162 – 70 .

123. Idbaih A , Boukobza M , Crassard I , Porcher R , Bousser

MG , Chabriat H . MRI of clot in cerebral venous throm-

bosis: high diagnostic value of susceptibility - weighted

images . Stroke 2006 ; 37 ( 4 ): 991 – 5 .

124. Thomassen L , Brainin M , Demarin V , Grond M , Toni D ,

Venables GS . Acute stroke treatment in Europe: a ques-

tionnaire - based survey on behalf of the EFNS Task

Force on acute neurological stroke care . Eur J Neurol

2003 ; 10 ( 3 ): 199 – 204 .

125. Bowler JV , Wade JP , Jones BE , Nijran K , Steiner TJ . Single -

photon emission computed tomography using hexameth-

ylpropyleneamine oxime in the prognosis of acute cerebral

infarction . Stroke 1996 ; 27 ( 1 ): 82 – 6 .

126. Barthel H , Hesse S , Dannenberg C , et al. Prospective

value of perfusion and X - Ray attenuation imaging with

single - photon emission and transmission computed

tomography in acute cerebral ischemia . Stroke 2001 ; 32 ( 7 ):

1588 – 97 .

127. Berrouschot J , Barthel H , von Kummer R , Knapp WH ,

Hesse S , Schneider D . 99mTechnetium - ethyl - cysteinate -

dimer single - photon emission CT can predict fatal isch-

emic brain edema . Stroke 1998 ; 29 ( 12 ): 2556 – 62 .

128. Alexandrov AV , Masdeu JC , Devous M , Sr. , Black SE ,

Grotta JC . Brain single - photon emission CT with HMPAO

and safety of thrombolytic therapy in acute ischemic

stroke: proceedings of the meeting of the SPECT safe

thrombolysis study collaborators and the members of the

brain imaging council of the society of nuclear medicine .

Stroke 1997 ; 28 ( 9 ): 1830 – 4 .

129. Mahagne M , David O , Darcourt J , et al. Voxel - based

mapping of cortical ischemic damage using Tc 99 m L,L -

ethyl cysteinate dimer SPECT in acute stroke . J Neuroimag-

ing 2004 ; 14 ( 1 ): 23 – 32 .

130. Hirano T , Read SJ , Abbott DF , et al. Prediction of the fi nal

infarct volume within 6 h of stroke using single photon

emission computed tomography with technetium - 99m

hexamethylpropylene amine oxime . Cerebrovasc Dis

2001 ; 11 ( 2 ): 119 – 27 .

131. Sviri GE , Lewis DH , Correa R , Britz GW , Douville CM ,

Newell DW . Basilar artery vasospasm and delayed poste-

rior circulation ischemia after aneurysmal subarachnoid

hemorrhage . Stroke 2004 ; 35 ( 8 ): 1867 – 72 .

132. Heiss W - D , Sobesky J , Smekal V , et al. Probability of

cortical infarction predicted by fl umazenil binding and

diffusion - weighted imaging signal intensity: a compara-

tive positron emission tomography/magnetic resonance

imaging study in early ischemic stroke . Stroke 2004 ; 35 ( 8 ):

1892 – 8 .

133. Sobesky J , Zaro Weber O , Lehnhardt FG , et al. Does the

mismatch match the penumbra? Magnetic resonance

imaging and positron emission tomography in early isch-

emic stroke . Stroke 2005 ; 36 ( 5 ): 980 – 5 .

134. Hankey GJ , Warlow CP , Sellar RJ . Cerebral angiographic

risk in mild cerebrovascular disease . Stroke 1990 ; 21 ( 2 ):

209 – 22 .

135. Grant EG , Benson CB , Moneta GL , et al. Carotid artery

stenosis: gray - scale and doppler us diagnosis – society of

radiologists in ultrasound consensus conference . Radiology

2003 ; 229 ( 2 ): 340 – 6 .

136. Jahromi AS , Cina CS , Liu Y , Clase CM . Sensitivity and

specifi city of color duplex ultrasound measurement in

the estimation of internal carotid artery stenosis: a system-

atic review and meta - analysis . J Vasc Surg 2005 ; 41 ( 6 ):

962 – 72 .


137. Blakeley DD , Oddone EZ , Hasselblad V , Simel DL ,

Matchar DB . Noninvasive carotid artery testing: a meta -

analytic review . Ann Intern Med 1995 ; 122 ( 5 ): 360 – 7 .

138. Kallmes DF , Omary RA , Dix JE , Evans AJ , Hillman BJ .

Specifi city of MR angiography as a confi rmatory test

of carotid artery stenosis . AJNR Am J Neuroradiol

1996 ; 17 ( 8 ): 1501 – 6 .

139. Nederkoorn PJ , van der Graaf Y , Hunink MGM . Duplex

ultrasound and magnetic resonance. Angiography com-

pared with digital subtraction angiography in carotid

artery stenosis: a systematic review . Stroke 2003 ; 34 ( 5 ):

1324 – 31 .

140. Westwood ME , Kelly S , Berry E , et al. Use of magnetic

resonance angiography to select candidates with recently

symptomatic carotid stenosis for surgery: systematic

review . BMJ 2002 ; 324 ( 7331 ): 198 .

141. Debrey SM , Yu H , Lynch JK , et al. Diagnostic accuracy of

magnetic resonance angiography for internal carotid

artery disease: a systematic review and meta - analysis .

Stroke 2008 ; 39 ( 8 ): 2237 – 48 .

142. Marianne C , Christopher TL , Hanh P , Andrew L , Samuel

Eric W , Ian G . Helical CT angiography in the preoperative

evaluation of carotid artery stenosis . J Vasc Surg

1998 ; 28 ( 2 ): 290 – 300 .

143. Schwartz RB , Jones KM , Chernoff DM , et al. Common

carotid artery bifurcation: evaluation with spiral CT. Work

in progress . Radiology 1992 ; 185 ( 2 ): 513 – 9 .

144. Leclerc X , Godefroy O , Pruvo JP , Leys D . Computed tomo-

graphic angiography for the evaluation of carotid artery

stenosis . Stroke 1995 ; 26 ( 9 ): 1577 – 81 .

145. Cumming MJ , Morrow IM . Carotid artery stenosis: a pro-

spective comparison of CT angiography and conventional

angiography . Am J Roentgenol 1994 ; 163 ( 3 ): 517 – 23 .

146. Koelemay MJW , Nederkoorn PJ , Reitsma JB , Majoie

CB . Systematic review of computed tomographic angiog-

raphy for assessment of carotid artery disease . Stroke

2004 ; 35 ( 10 ): 2306 – 12 .

147. Sameshima T , Futami S , Morita Y , et al. Clinical usefulness

of and problems with three - dimensional CT angiography

for the evaluation of arteriosclerotic stenosis of the carotid

artery: comparison with conventional angiography, MRA,

and ultrasound sonography . Surg Neurol 1999 ; 51 ( 3 ): 301 – 8 .

148. Wardlaw JM , Chappell FM , Best JJ , Wartolowska K , Berry

E . Non - invasive imaging compared with intra - arterial

angiography in the diagnosis of symptomatic carotid ste-

nosis: a meta - analysis . Lancet 2006 ; 367 ( 9521 ): 1503 – 12 .

149. Alvarez - Linera J , Benito - Leon J , Escribano J , Campollo J ,

Gesto R . Prospective evaluation of carotid artery stenosis:

elliptic centric contrast - enhanced MR angiography and

spiral CT angiography compared with digital subtraction

angiography . AJNR Am J Neuroradiol 2003 ; 24 ( 5 ): 1012 – 9 .

150. Khan S , Cloud GC , Kerry S , Markus HS . Imaging of ver-

tebral artery stenosis: a systematic review . J Neurol Neuro-

surg Psychiatry 2007 ; 78 ( 11 ): 1218 – 25 .

151. North American Symptomatic Carotid Endarterectomy

Trial Collaborators . Benefi cial effect of carotid endarterec-

tomy in symptomatic patients with high - grade carotid

stenosis . N Engl J Med 1991 ; 325 ( 7 ): 445 – 53 .

152. ECST Collaborators . Randomised trial of endarterectomy

for recently symptomatic carotid stenosis: fi nal results of

the MRC European Carotid Surgery Trial (ECST) . Lancet

1998 ; 351 ( 9113 ): 1379 – 87 .

153. Barnett HJM , Taylor DW , Eliasziw M , et al. Benefi t of

carotid endarterectomy in patients with symptomatic

moderate or severe stenosis . N Engl J Med 1998 ; 339 ( 20 ):

1415 – 25 .

154. Executive Committee for the Asymptomatic Carotid Ath-

erosclerosis Study. Endarterectomy for asymptomatic

carotid artery stenosis. Executive Committee for the

Asymptomatic Carotid Atherosclerosis Study . JAMA

1995 ; 273 ( 18 ): 1421 – 8 .

155. Willinsky RA , Taylor SM , TerBrugge K , Farb RI ,

Tomlinson G , Montanera W . Neurologic complications of

cerebral angiography: prospective analysis of 2,899 proce-

dures and review of the literature . Radiology 2003 ; 227 ( 2 ):

522 – 8 .

156. Long A , Lepoutre A , Corbillon E , Branchereau A , Kretz

JG . Modalities of preoperative imaging of the internal

carotid artery used in France . Ann Vasc Surg 2002 ; 16 ( 3 ):

261 – 5 .

157. David LD , Christopher AR , Roy MF . Preoperative testing

before carotid endarterectomy: a survey of vascular sur-

geons ’ attitudes . Ann Vasc Surg 1997 ; 11 ( 3 ): 264 – 72 .

158. Barth A , Arnold M , Mattle HP , Schroth G , Remonda L .

Contrast - enhanced 3 - D MRA in decision making for

carotid endarterectomy: a 6 - year experience . Cerebrovasc

Dis 2006 ; 21 ( 5 - 6 ): 393 – 400 .

159. Osarumwense D , Pararajasingam R , Wilson P , Abraham J ,

Walker SR . Carotid artery imaging in the United Kingdom:

a postal questionnaire of current practice . Vascular

2005 ; 13 ( 3 ): 173 – 7 .

160. Babikian V , Feldmann E , Wechsler LR , et al. Transcranial

Doppler ultrasonography: year 2000 update . J Neuroimag-

ing 2000 ; 10 : 101 – 15 .

161. Sloan MA , Alexandrov AV , Tegeler CH , et al. Assessment:

transcranial doppler ultrasonography: report of the thera-

peutics and technology assessment subcommittee of the

American Academy of Neurology . Neurology 2004 ; 62 ( 9 ):

1468 – 81 .

162. Rorick MB , Nichols FT , Adams RJ . Transcranial Doppler

correlation with angiography in detection of intracranial

stenosis . Stroke 1994 ; 25 ( 10 ): 1931 – 4 .


163. Demchuk A , Christou I , Wein TH , et al. Accuracy and

criteria for localizing arterial occlusion with transcranial

Doppler . J Neuroimaging 2000 ; 10 ( 1 ): 1 – 12 .

164. Baumgartner RW , Mattle HP , Schroth G . Assessment of

> / = 50% and < 50% intracranial stenoses by transcranial

color - coded duplex sonography . Stroke 1999 ; 30 ( 1 ): 87 –

92 .

165. Zanette EM , Fieschi C , Bozzao L , et al. Comparison of

cerebral angiography and transcranial Doppler sonogra-

phy in acute stroke . Stroke 1989 ; 20 ( 7 ): 899 – 903 .

166. Gerriets T , Goertler M , Stolz E , et al. Feasibility and validity

of transcranial duplex sonography in patients with acute

stroke . J Neurol Neurosurg Psychiatry 2002 ; 73 ( 1 ): 17 – 20 .

167. Adams RJ , McKie VC , Hsu L , et al. Prevention of a fi rst

stroke by transfusions in children with sickle cell anemia

and abnormal results on transcranial doppler ultrasonog-

raphy . N Engl J Med 1998 ; 339 ( 1 ): 5 – 11 .

168. Lysakowski C , Walder B , Costanza MC , Tramer MR . Tran-

scranial Doppler versus angiography in patients with vaso-

spasm due to a ruptured cerebral aneurysm: a systematic

review . Stroke 2001 ; 32 ( 10 ): 2292 – 8 .

169. Burgin WS , Malkoff M , Felberg RA , et al. Transcranial

Doppler ultrasound criteria for recanalization after

thrombolysis for middle cerebral artery stroke . Stroke

2000 ; 31 ( 5 ): 1128 – 32 .

170. Alexandrov AV , Molina CA , Grotta JC , et al. Ultrasound -

enhanced systemic thrombolysis for acute ischemic stroke .

N Engl J Med 2004 ; 351 ( 21 ): 2170 – 8 .

171. Job F , Ringelstein EB , Grafen Y , et al. Comparison of tran-

scranial contrast Doppler sonography and transesophageal

contrast echocardiography for the detection of patent

foramen ovale in young stroke patients . Am J Cardiol

1994 ; 74 ( 4 ): 381 – 4 .

172. Klotzsch C , Janssen G , Berlit P . Transesophageal echocar-

diography and contrast - TCD in the detection of a patent

foramen ovale: experiences with 111 patients . Neurology

1994 ; 44 ( 9 ): 1603 .

173. Serena J , Segura T , Perez - Ayuso MJ , Bassaganyas J , Molins

A , Davalos A . The need to quantify right - to - left shunt

in acute ischemic stroke: a case - control study . Stroke

1998 ; 29 ( 7 ): 1322 – 8 .

174. Markus HS , Thomson ND , Brown MM . Asymptomatic

cerebral embolic signals in symptomatic and asymptom-

atic carotid artery disease . Brain 1995 ; 118 ( 4 ): 1005 – 11 .

175. Siebler M , Sitzer M , Rose G , Bendfeldt D , Steinmetz H .

Silent cerebral embolism caused by neurologically symp-

tomatic high - grade carotid stenosis: event rates before and

after carotid endarterectomy . Brain 1993 ; 116 ( 5 ): 1005 – 15 .

176. Molloy J , Markus HS . Asymptomatic embolization predicts

stroke and TIA risk in patients with carotid artery stenosis .

Stroke 1999 ; 30 ( 7 ): 1440 – 3 .

177. Siebler M , Nachtmann A , Sitzer M , et al. Cerebral micro-

embolism and the risk of ischemia in asymptomatic high -

grade internal carotid artery stenosis . Stroke 1995 ; 26 ( 11 ):

2184 – 6 .

178. Markus HS , MacKinnon A . Asymptomatic embolization

detected by doppler ultrasound predicts stroke risk in symp-

tomatic carotid artery stenosis . Stroke 2005 ; 36 ( 5 ): 971 – 5 .

179. Kaposzta Z , Martin JF , Markus HS . Switching off emboli-

zation from symptomatic carotid plaque using S - nitroso-

glutathione . Circulation 2002 ; 105 ( 12 ): 1480 – 4 .

180. Markus HS , Droste DW , Kaps M , et al. Dual antiplatelet

therapy with clopidogrel and aspirin in symptomatic

carotid stenosis evaluated using Doppler embolic signal

detection: the Clopidogrel and Aspirin for Reduction of

Emboli in Symptomatic Carotid Stenosis (CARESS) trial .

Circulation 2005 ; 111 ( 17 ): 2233 – 40 .

181. Levi CR , O ’ Malley HM , Fell G , et al. Transcranial Doppler

detected cerebral microembolism following carotid endar-

terectomy. High microembolic signal loads predict post-

operative cerebral ischaemia . Brain 1997 ; 120 ( 4 ): 621 – 9 .

182. Levi CR , Stork JL , Chambers BR , et al. Dextran reduces

embolic signals after carotid endarterectomy . Ann Neurol

2001 ; 50 ( 4 ): 544 – 7 .

183. Payne DA , Jones CI , Hayes PD , et al. Benefi cial effects of

clopidogrel combined with aspirin in reducing cerebral

emboli in patients undergoing carotid endarterectomy .

Circulation 2004 ; 109 ( 12 ): 1476 – 81 .

184. Markus H , Cullinane M . Severely impaired cerebrovascu-

lar reactivity predicts stroke and TIA risk in patients with

carotid artery stenosis and occlusion . Brain 2001 ; 124 ( 3 ):

457 – 67 .

185. Silvestrini M , Vernieri F , Pasqualetti P , et al. Impaired

cerebral vasoreactivity and risk of stroke in patients

with asymptomatic carotid artery stenosis . JAMA

2000 ; 283 ( 16 ): 2122 – 7 .

186. Jarquin - Valdivia A , McCartney J , Palestrant D , et al.

The thickness of the temporal squama and its implication

for transcranial sonography . J Neuroimaging 2004 ; 14 ( 2 ):

139 – 42 .

187. Hansberg T , Wong KS , Droste DW , Ringelstein EB , Kay R .

Effects of the ultrasound contrast - enhancing agent Levo-

vist on the detection of intracranial arteries and stenoses

in Chinese by transcranial Doppler ultrasound . Cerebro-

vasc Dis 2002 ; 14 ( 2 ): 105 – 8 .

188. Feldmann E , Wilterdink JL , Kosinski A , et al. The

stroke outcomes and neuroimaging of intracranial

atherosclerosis (SONIA) trial . Neurology 2007 ; 68 ( 24 ):

2099 – 106 .

189. Hirai T , Korogi Y , Ono K , et al. Prospective evaluation

of suspected stenoocclusive disease of the intracranial

artery: combined MR angiography and CT angiography


compared with digital subtraction angiography . AJNR Am

J Neuroradiol 2002 ; 23 ( 1 ): 93 – 101 .

190. Korogi Y , Terae S , Katoh C , et al. Intracranial vascular

stenosis and occlusion: MR angiographic fi ndings . AJNR

Am J Neuroradiol 1997 ; 18 ( 1 ): 135 – 43 .

191. Bash S , Villablanca JP , Jahan R , et al. Intracranial vascular

stenosis and occlusive disease: evaluation with CT angiog-

raphy, MR angiography, and digital subtraction angiogra-

phy . AJNR Am J Neuroradiol 2005 ; 26 ( 5 ): 1012 – 21 .

192. Nguyen - Huynh MN , Wintermark M , English J , et al. How

accurate is CT angiography in evaluating intracranial ath-

erosclerotic disease? Stroke 2008 ; 39 ( 4 ): 1184 – 8 .

193. Skutta B , Furst G , Eilers J , Ferbert A , Kuhn FP . Intracranial

stenoocclusive disease: double - detector helical CT angiog-

raphy versus digital subtraction angiography . AJNR Am J

Neuroradiol 1999 ; 20 ( 5 ): 791 – 9 .

194. Chung T - S , Joo JY , Lee SK , Chien D , Laub G . Evaluation

of cerebral aneurysms with high - resolution MR angiogra-

phy using a section - interpolation technique: correlation

with digital subtraction angiography . AJNR Am J Neuro-

radiol 1999 ; 20 ( 2 ): 229 – 35 .

195. White PM , Teasdale EM , Wardlaw JM , Easton V . Intracra-

nial aneurysms: CT angiography and MR angiography for

detection — prospective blinded comparison in a large

patient cohort . Radiology 2001 ; 219 ( 3 ): 739 – 49 .

196. Villablanca JP , Jahan R , Hooshi P , Detection and charac-

terization of very small cerebral aneurysms by using 2D

and 3D helical CT angiography . AJNR Am J Neuroradiol

2002 ; 23 ( 7 ): 1187 – 98 .

197. Kouskouras C , Charitanti A , Giavroglou C , et al. Intracra-

nial aneurysms: evaluation using CTA and MRA. Correla-

tion with DSA and intraoperative fi ndings . Neuroradiology

2004 ; 46 ( 10 ): 842 – 50 .

198. Huston J 3rd , Nichols DA , Luetmer PH , et al. Blinded

prospective evaluation of sensitivity of MR angiography to

known intracranial aneurysms: importance of aneurysm

size . AJNR Am J Neuroradiol 1994 ; 15 ( 9 ): 1607 – 14 .

199. Schuierer G , Huk WJ , Laub G . Magnetic resonance angi-

ography of intracranial aneurysms: comparison with intra -

arterial digital subtraction angiography . Neuroradiology

1992 ; 35 ( 1 ): 50 – 4 .

200. Anzalone N , Triulzi F , Scotti G . Acute subarachnoid haem-

orrhage: 3D time - of - fl ight MR angiography versus intra -

arterial digital angiography . Neuroradiology 1995 ; 37 ( 4 ):

257 – 61 .

201. Korogi Y , Takahashi M , Katada K , et al. Intracranial aneu-

rysms: detection with three - dimensional CT angiography

with volume rendering – comparison with conventional

angiographic and surgical fi ndings . Radiology 1999 ; 211 ( 2 ):

497 – 506 .

202. Alberico RA , Patel M , Casey S , Jacobs B , Maguire W ,

Decker R . Evaluation of the circle of Willis with

three - dimensional CT angiography in patients with sus-

pected intracranial aneurysms . AJNR Am J Neuroradiol

1995 ; 16 ( 8 ): 1571 – 8 .

203. Velthuis BK , Rinkel GJ , Ramos LM , et al. Subarachnoid

hemorrhage: aneurysm detection and preoperative evalu-

ation with CT angiography . Radiology 1998 ; 208 ( 2 ):

423 – 30 .

204. Hoh BL , Cheung AC , Rabinov JD , Pryor JC , Carter BS ,

Ogilvy CS . Results of a prospective protocol of computed

tomographic angiography in place of catheter angiography

as the only diagnostic and pretreatment planning study for

cerebral aneurysms by a combined neurovascular team .

Neurosurgery 2004 ; 54 ( 6 ): 1329 – 40 .

205. Masaryk T , Drayer BP , Anderson RE , et al. Cere-

brovascular disease. American College of Radiology.

ACR Appropriateness Criteria . Radiology 2000; 215 (Suppl):

415 – 35 .

206. The Magnetic Resonance Angiography in Relatives of

Patients with Subarachnoid Hemorrhage Study Group.

Risks and benefi ts of screening for intracranial aneurysms

in fi rst - degree relatives of patients with sporadic subarach-

noid hemorrhage . N Engl J Med 1999 ; 341 ( 18 ): 1344 – 50 .

207. Wardlaw JM , White PM . The detection and management

of unruptured intracranial aneurysms . Brain 2000 ; 123 ( Pt

2 ): 205 – 21 .

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