
Contents
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Transient ischaemic attack and ischaemic stroke Transient ischaemic attack and ischaemic stroke
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Non-contrast CT Non-contrast CT
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Early ischaemic changes Early ischaemic changes
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Hyperdense arteries Hyperdense arteries
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Diagnosing mimics Diagnosing mimics
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Temporal evolution of ischaemia Temporal evolution of ischaemia
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Diffusion MRI Diffusion MRI
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Do diffusion lesions reverse? Do diffusion lesions reverse?
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FLAIR/T2-weighted MRI FLAIR/T2-weighted MRI
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Perfusion imaging Perfusion imaging
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Perfusion thresholds Perfusion thresholds
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Applications Applications
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TIA TIA
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Ischaemic stroke Ischaemic stroke
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Diagnosing stroke and excluding mimics Diagnosing stroke and excluding mimics
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Risk-stratifying ‘mild’ stroke Risk-stratifying ‘mild’ stroke
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Imaging selection for thrombolysis Imaging selection for thrombolysis
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Risk of haemorrhagic transformation Risk of haemorrhagic transformation
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Considering intra-arterial rescue Considering intra-arterial rescue
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Investigating the cause Investigating the cause
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Arterial imaging Arterial imaging
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Carotid duplex Doppler ultrasound Carotid duplex Doppler ultrasound
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Transcranial Doppler ultrasound Transcranial Doppler ultrasound
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CTA CTA
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MRA MRA
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Digital subtraction angiography Digital subtraction angiography
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Venous imaging Venous imaging
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Cardiac imaging Cardiac imaging
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Transthoracic and transoesophageal echocardiography Transthoracic and transoesophageal echocardiography
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Applications Applications
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Large artery disease Large artery disease
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Venous sinus thrombosis Venous sinus thrombosis
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Cardioembolism Cardioembolism
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Intracerebral haemorrhage Intracerebral haemorrhage
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Diagnosis and establishing aetiology Diagnosis and establishing aetiology
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Non-contrast CT brain Non-contrast CT brain
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CT angiography CT angiography
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MRI MRI
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Susceptibility-weighted imaging Susceptibility-weighted imaging
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Temporal evolution of haematoma Temporal evolution of haematoma
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Identifying underlying lesions Identifying underlying lesions
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Applications Applications
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Conclusion Conclusion
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References References
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9 Diagnosing transient ischaemic attack and stroke
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Published:March 2014
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Abstract
This chapter discusses the role of diagnostic imaging in stroke. Computed tomography (CT) and magnetic resonance imaging (MRI) have provided key insights into the mechanisms and dynamic nature of stroke. Irreversibly damaged infarct core can be differentiated from salvageable ‘ischaemic penumbra’. Arterial stenosis and occlusion are clearly visible. The increasing appreciation of pathophysiological heterogeneity has led to research into more selective and individualized approaches to therapy. Improved CT technology has allowed recognition of subtle early ischaemic signs and hyperdense arteries that help improve diagnostic confidence beyond simply identifying haemorrhage and established infarction. Diffusion MRI provides a highly sensitive indicator of ischaemic damage which is generally irreversible. Using CT, thresholded relative cerebral blood flow can provide similar information. Perfusion imaging with CT or MRI provides a useful estimate of ischaemic penumbra when appropriately thresholded to exclude ‘benign oligaemia’ (mildly hypoperfused tissue that will not infarct, even without reperfusion). Beyond diagnosing acute stroke, echocardiography and arterial imaging with ultrasound, CT, and MRI are central to the search for aetiology that determines the most appropriate secondary prevention strategy. The diagnosis of haemorrhage on CT is straightforward. However, CT angiography can add significantly to the diagnostic yield in uncovering aetiology and, with the ‘spot sign’ (active contrast extravasation), may allow estimation of the risk of haematoma expansion. More recent evolution in susceptibility-weighted imaging has enhanced detection of microbleeds. These are common in patients with haemorrhages due to both hypertension and amyloid angiopathy, but their distribution may indicate the likely aetiology and recurrence risk.
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