Magnetic resonance imaging in acute stroke: clinical perspective

The efficacy of intravenous (i.v.) and intra-arterial (i.a.) thrombolysis for hyperacute stroke has made "brain attack" a treatable emergency. The addition of ultrafast magnetic resonance imaging (MRI) to acute stroke investigation has both increased our knowledge of acute stroke pathophysiology and brought a tool to study how to best select patients for thrombolytic therapy. MR offers the three essential components: vascular lesion identification, delineation of injured brain tissue, and map of ischemic brain. MR angiography can demonstrate the site of major cerebral artery occlusion, providing a means to screen for i.a. thrombolysis. Diffusion-weighted imaging (DWI) is capable of showing acute ischemic injury within minutes of symptom onset. Perfusion-weighted imaging (PWI) shows the total area of acute ischemia, more accurately reflecting the extent of neurological dysfunction. Combining DWI and PWI immediately gives information that bears on how much tissue is injured (DWI) and how much tissue is functionally inactive but still viable (ischemic on PWI but still normal on DWI). A number of important questions remain, but current knowledge of natural history of stroke with MRI has provided a framework for comparing new therapeutic interventions. Ideally, patient treatment in the future will be tailored not to a fixed time window but to the physiological state of the ischemic tissue as defined by MRI.