Clinical review: Imaging in ischaemic stroke – implications for acute management

Imaging has become a cornerstone of stroke management, translating pathophysiological knowledge to everyday decision-making. Plain computed tomography is widely available and remains the standard for initial assessment: the technique rules out haemorrhage, visualizes the occluding thrombus and identifies early tissue hypodensity and swelling, which have different implications for thrombolysis. Based on evidence from positron emission tomography (PET), however, multimodal imaging is increasingly advocated. Computed tomography perfusion and angiography provide information on the occlusion site, on recanalization and on the extent of salvageable tissue. Magnetic resonance-based diffusion-weighted imaging (DWI) has exquisite sensitivity for acute ischaemia, however, and there is increasingly robust evidence that DWI combined with perfusion-weighted magnetic resonance imaging (PWI) and angiography improves functional outcome by selecting appropriate patients for thrombolysis (small DWI lesion but large PWI defect) and by ruling out those who would receive no benefit or might be harmed (very large DWI lesion, no PWI defect), especially beyond the 3-hour time window. Combined DWI-PWI also helps predict malignant oedema formation and therefore helps guide selection for early brain decompression. Finally, DWI-PWI is increasingly used for patient selection in therapeutic trials. Although further methodological developments are awaited, implementing the individual pathophysiologic diagnosis based on multimodal imaging is already refining indications for thrombolysis and offers new opportunities for management of acute stroke patients.