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An 84-year-old female slumped over in her chair at a senior citizen center. She was unable to move her right side.

She arrived in the ED twenty minutes after the stroke onset. She had a “dense” right hemiparesis with no motor strength of her arm and face. Her speech was slurred but fluent and she had normal language comprehension.

The “stroke team” was notified and a “stroke CT” was performed shortly after her arrival: noncontrast CT (Figure 1), perfusion CT (Figure 2), and CT angiogram.

Figure 2

Perfusion CT (same level as CT slice in upper right corner of Figure 1).

(A) Time-to-peak. (B) Cerebral blood volume

Recombinant tissue plasminogen activator (rt-PA) was administered within 30 minutes of her arrival in the ED.

  • What does the noncontrast CT show?
  • What does the perfusion CT suggest about the potential benefit of thrombolytic therapy?

Several new CT and MR imaging modalities have been developed that could potentially improve acute stroke management (Table 1). The role of these tests include: (1) accurate early identification of an acute ischemic stroke; (2) distinguishing potentially salvageable ischemic brain tissue from irreversible ischemia (the ischemic penumbra); and (3) visualization of the vascular lesion responsible for the ischemic event. The benefits of these imaging modalities have yet to be proven in large clinical trials and their use remains experimental.

Table 1 Advanced Imaging in Ischemic Stroke

Early diagnosis of stroke can be made using diffusion-weighted MRI, perfusion CT and CT angiographic source images. Distinguishing potentially salvageable from irreversibly ischemic brain tissue can be accomplished using perfusion CT or perfusion-weighted MRI (Figure 2). Vascular lesions are demonstrated using CT angiography or MR angiography.

These imaging techniques may, in the future, help select patients for thrombolytic therapy. For example, early imaging confirmation of stroke would positively identify patients having an acute ischemic ...

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