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Updated: Aug 13, 2026
Integrated Photoacoustic, Ultrasound, and Angiographic Tomography (PAUSAT) for NonInvasive Whole-Brain Imaging of Ischemic Stroke
Published on: June 2, 2023
ASFNR Clinical State-of-Practice: Neuroimaging in Posterior Circulation Large Vessel Occlusion Stroke
Aakanksha Sriwastwa1, Dhairya A Lakhani2, Hamza A Salim2
1From the Department of Radiology (A.S., A.S.V.), College of Medicine, University of Cincinnati, Cincinnati, Ohio, USA; Department of Radiology (D.A.L.), Division of Neuroradiology,West Virginia University, Morgantown,West Virginia, USA; Department of Neuroradiology (H.A.S.), The University of Texas MD Anderson Center, Houston, Texas, USA; Department of Radiology (D.W.), Rhode Island Hospital, Brown University Health, Providence, Rhode Island, USA; Department of Radiology (M.G., V.S.Y.), Division of Neuroradiology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA; Department of Neurology (S.M.), University of Maryland Medical Center, Baltimore, Maryland, USA; Stanford Stroke Center (A.G.), Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford, California, USA; Neuroendovascular Program (A.A.D.), Massachusetts General Hospital & Brigham and Women's Hospital, Harvard University, Boston, Massachusetts, USA; Department of Radiology, Neuroendovascular Program (T.D.F.), University Medical Center Münster, Münster, Germany; Department of Interventional Neuroradiology (G.W.A., J.J.H.), Stanford Medical Center, Palo Alto, California; Department of Radiology (G.V.S.), University of Michigan, Ann Arbor, USA; Department of Radiology (M.M.-B.), University of Alabama at Birmingham, Birmingham, USA; Department of Radiology (J.W.A.), Indiana University School of Medicine, Indianapolis, USA and Department of Radiology (R.J.), New York University Grossman School of Medicine, New York, USA. sriwasaa@ucmail.uc.edu.
Diagnosing posterior circulation large vessel occlusions (PC-LVO) is challenging. Multimodal imaging, including CT angiography and MRI, is crucial for detection, triage, and outcome prediction in PC-LVO stroke patients.
Area of Science:
- Neuroradiology
- Stroke Imaging
- Cerebrovascular Diseases
Background:
- Posterior circulation (PC) large vessel occlusions (PC-LVO) represent a significant cause of PC stroke, often presenting with nonspecific symptoms.
- Diagnosis is challenging due to limited CT sensitivity for posterior fossa ischemia, yet PC-LVO, especially basilar artery occlusion, carries high mortality and disability.
- Endovascular thrombectomy (EVT) shows clear benefits for basilar artery occlusion up to 24 hours in selected patients, emphasizing the need for precise imaging.
Purpose of the Study:
- To develop a practical, evidence-based neuroimaging framework for acute PC-LVO stroke.
- To guide diagnosis, triage, and prognostication in routine neuroradiology practice.
- To provide a State-of-Practice document for the American Society of Functional Neuroradiology.
Main Methods:
- A working group of the American Society of Functional Neuroradiology convened to develop the clinical document.
- The focus was on creating a concise and practical imaging framework.
- Evidence-informed guidelines were synthesized for everyday neuroradiology.
Main Results:
- Multimodal imaging is essential for PC-LVO stroke detection.
- CT angiography (CTA) is the cornerstone for identifying PC-LVO, while non-contrast CT (NCCT) rules out hemorrhage.
- DWI-MRI is the reference standard, though early false negatives can occur; CT perfusion has limited posterior fossa sensitivity.
Conclusions:
- A multimodal imaging approach is necessary for accurate PC-LVO stroke diagnosis.
- Imaging biomarkers like PC-ASPECTS and brainstem infarct scores aid patient selection and outcome prediction.
- CTA is key for LVO identification, while DWI-MRI remains the gold standard despite limitations.
