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Hyperacute Ischemic Stroke: Middle Cerebral Artery Susceptibility Sign at Echo-planar Gradient-Echo MR Imaging¹

¹ From the Department of Radiology, Magnetic Resonance Unit (A.R., P.O., X.A., E.G., A.R.G.) and Department of Neurology, Cerebrovascular Unit (J.A.S., J.F.A., C.M.), Hospital Universitari Vall d’Hebron, Passeig Vall d’Hebron 119–129, 08035 Barcelona, Spain. Received February 19, 2003; revision requested May 7; final revision received November 4; accepted January 5, 2004. Address correspondence to A.R. (e-mail: alex.rovira@idi-cat.org).

View larger version (146K): [in a new window]   Figure 1a. Images in a patient with acute right-sided hemiparesis. (a) Transverse echo-planar T2*-weighted MR image (0.8/29) shows the susceptibility sign (arrow), which indicates arterial occlusion within left MCA. Diameter of the affected vessel is larger than that of contralateral unaffected MCA. (b) Individual section of MR angiography (30/5.4) selected from the entire three-dimensional data set at the corresponding anatomic level shows absence of flow signal within left MCA. (c) Transverse maximum intensity projection displays acute proximal MCA occlusion (arrow).

View larger version (172K): [in a new window]   Figure 1b. Images in a patient with acute right-sided hemiparesis. (a) Transverse echo-planar T2*-weighted MR image (0.8/29) shows the susceptibility sign (arrow), which indicates arterial occlusion within left MCA. Diameter of the affected vessel is larger than that of contralateral unaffected MCA. (b) Individual section of MR angiography (30/5.4) selected from the entire three-dimensional data set at the corresponding anatomic level shows absence of flow signal within left MCA. (c) Transverse maximum intensity projection displays acute proximal MCA occlusion (arrow).

View larger version (132K): [in a new window]   Figure 1c. Images in a patient with acute right-sided hemiparesis. (a) Transverse echo-planar T2*-weighted MR image (0.8/29) shows the susceptibility sign (arrow), which indicates arterial occlusion within left MCA. Diameter of the affected vessel is larger than that of contralateral unaffected MCA. (b) Individual section of MR angiography (30/5.4) selected from the entire three-dimensional data set at the corresponding anatomic level shows absence of flow signal within left MCA. (c) Transverse maximum intensity projection displays acute proximal MCA occlusion (arrow).

View larger version (148K): [in a new window]   Figure 2a. Transverse echo-planar T2*-weighted MR images (0.8/29) obtained in three patients with acute right-sided hemispheric stroke. The susceptibility sign is (a) proximal (arrow) or (b) distal (arrowhead) to right MCA bifurcation. (c) The susceptibility sign is considered negative because no differences in diameters of the two MCAs (arrows) are observed.

View larger version (147K): [in a new window]   Figure 2b. Transverse echo-planar T2*-weighted MR images (0.8/29) obtained in three patients with acute right-sided hemispheric stroke. The susceptibility sign is (a) proximal (arrow) or (b) distal (arrowhead) to right MCA bifurcation. (c) The susceptibility sign is considered negative because no differences in diameters of the two MCAs (arrows) are observed.

View larger version (136K): [in a new window]   Figure 2c. Transverse echo-planar T2*-weighted MR images (0.8/29) obtained in three patients with acute right-sided hemispheric stroke. The susceptibility sign is (a) proximal (arrow) or (b) distal (arrowhead) to right MCA bifurcation. (c) The susceptibility sign is considered negative because no differences in diameters of the two MCAs (arrows) are observed.

View larger version (159K): [in a new window]   Figure 3a. MR images obtained in a patient 4 hours after onset of left-sided hemiparesis. (a) Transverse echo-planar T2*-weighted MR image (0.8/29) shows the susceptibility sign (arrow) within proximal right MCA. (b) Transverse MR angiogram confirms MCA occlusion (arrow) at the origin. (c) Transverse DW image (4,000/100; b = 1,000 sec/mm2) obtained at the level of basal ganglia shows acute infarct involving the lentiform nucleus (arrow). (d) Perfusion time-to-peak map obtained at the same level as c (2,000/60) shows a large perfusion abnormality (arrows) affecting almost the entire MCA territory.

View larger version (101K): [in a new window]   Figure 3b. MR images obtained in a patient 4 hours after onset of left-sided hemiparesis. (a) Transverse echo-planar T2*-weighted MR image (0.8/29) shows the susceptibility sign (arrow) within proximal right MCA. (b) Transverse MR angiogram confirms MCA occlusion (arrow) at the origin. (c) Transverse DW image (4,000/100; b = 1,000 sec/mm2) obtained at the level of basal ganglia shows acute infarct involving the lentiform nucleus (arrow). (d) Perfusion time-to-peak map obtained at the same level as c (2,000/60) shows a large perfusion abnormality (arrows) affecting almost the entire MCA territory.

View larger version (135K): [in a new window]   Figure 3c. MR images obtained in a patient 4 hours after onset of left-sided hemiparesis. (a) Transverse echo-planar T2*-weighted MR image (0.8/29) shows the susceptibility sign (arrow) within proximal right MCA. (b) Transverse MR angiogram confirms MCA occlusion (arrow) at the origin. (c) Transverse DW image (4,000/100; b = 1,000 sec/mm2) obtained at the level of basal ganglia shows acute infarct involving the lentiform nucleus (arrow). (d) Perfusion time-to-peak map obtained at the same level as c (2,000/60) shows a large perfusion abnormality (arrows) affecting almost the entire MCA territory.

View larger version (132K): [in a new window]   Figure 3d. MR images obtained in a patient 4 hours after onset of left-sided hemiparesis. (a) Transverse echo-planar T2*-weighted MR image (0.8/29) shows the susceptibility sign (arrow) within proximal right MCA. (b) Transverse MR angiogram confirms MCA occlusion (arrow) at the origin. (c) Transverse DW image (4,000/100; b = 1,000 sec/mm2) obtained at the level of basal ganglia shows acute infarct involving the lentiform nucleus (arrow). (d) Perfusion time-to-peak map obtained at the same level as c (2,000/60) shows a large perfusion abnormality (arrows) affecting almost the entire MCA territory.

View larger version (164K): [in a new window]   Figure 4a. False-negative susceptibility sign in a patient with acute distal occlusion of MCA. (a) Transverse echo-planar T2*-weighted MR image (0.8/29) shows no susceptibility sign. (b) Transverse MR angiogram shows MCA occlusion (arrow) distal to divisional bifurcation. (c) Transverse DW image (4,000/100; b = 1,000 sec/mm2) of the suprasylvian region shows a small acute right cortical infarct (arrow). (d) Perfusion time-to-peak map obtained at the same level as c (2,000/60) depicts perfusion abnormality (arrows) involving the posterior divisional trunk of MCA territory.

View larger version (116K): [in a new window]   Figure 4b. False-negative susceptibility sign in a patient with acute distal occlusion of MCA. (a) Transverse echo-planar T2*-weighted MR image (0.8/29) shows no susceptibility sign. (b) Transverse MR angiogram shows MCA occlusion (arrow) distal to divisional bifurcation. (c) Transverse DW image (4,000/100; b = 1,000 sec/mm2) of the suprasylvian region shows a small acute right cortical infarct (arrow). (d) Perfusion time-to-peak map obtained at the same level as c (2,000/60) depicts perfusion abnormality (arrows) involving the posterior divisional trunk of MCA territory.

View larger version (126K): [in a new window]   Figure 4c. False-negative susceptibility sign in a patient with acute distal occlusion of MCA. (a) Transverse echo-planar T2*-weighted MR image (0.8/29) shows no susceptibility sign. (b) Transverse MR angiogram shows MCA occlusion (arrow) distal to divisional bifurcation. (c) Transverse DW image (4,000/100; b = 1,000 sec/mm2) of the suprasylvian region shows a small acute right cortical infarct (arrow). (d) Perfusion time-to-peak map obtained at the same level as c (2,000/60) depicts perfusion abnormality (arrows) involving the posterior divisional trunk of MCA territory.

View larger version (132K): [in a new window]   Figure 4d. False-negative susceptibility sign in a patient with acute distal occlusion of MCA. (a) Transverse echo-planar T2*-weighted MR image (0.8/29) shows no susceptibility sign. (b) Transverse MR angiogram shows MCA occlusion (arrow) distal to divisional bifurcation. (c) Transverse DW image (4,000/100; b = 1,000 sec/mm2) of the suprasylvian region shows a small acute right cortical infarct (arrow). (d) Perfusion time-to-peak map obtained at the same level as c (2,000/60) depicts perfusion abnormality (arrows) involving the posterior divisional trunk of MCA territory.

View larger version (164K): [in a new window]   Figure 5a. False-negative susceptibility sign in a patient with acute proximal occlusion of MCA. (a) Transverse echo-planar T2*-weighted MR image (0.8/29) shows no susceptibility sign. (b) Coronal MR angiogram shows MCA occlusion (arrow) proximal to divisional bifurcation. (c) Transverse DW image (4,000/100; b = 1,000 sec/mm2) obtained at the frontoparietal region shows a large acute infarct (arrows) involving MCA territory. (d) Perfusion time-to-peak map obtained at the same level as c (2,000/60) shows a matched volume of abnormal perfusion (arrows).

View larger version (67K): [in a new window]   Figure 5b. False-negative susceptibility sign in a patient with acute proximal occlusion of MCA. (a) Transverse echo-planar T2*-weighted MR image (0.8/29) shows no susceptibility sign. (b) Coronal MR angiogram shows MCA occlusion (arrow) proximal to divisional bifurcation. (c) Transverse DW image (4,000/100; b = 1,000 sec/mm2) obtained at the frontoparietal region shows a large acute infarct (arrows) involving MCA territory. (d) Perfusion time-to-peak map obtained at the same level as c (2,000/60) shows a matched volume of abnormal perfusion (arrows).

View larger version (123K): [in a new window]   Figure 5c. False-negative susceptibility sign in a patient with acute proximal occlusion of MCA. (a) Transverse echo-planar T2*-weighted MR image (0.8/29) shows no susceptibility sign. (b) Coronal MR angiogram shows MCA occlusion (arrow) proximal to divisional bifurcation. (c) Transverse DW image (4,000/100; b = 1,000 sec/mm2) obtained at the frontoparietal region shows a large acute infarct (arrows) involving MCA territory. (d) Perfusion time-to-peak map obtained at the same level as c (2,000/60) shows a matched volume of abnormal perfusion (arrows).

View larger version (119K): [in a new window]   Figure 5d. False-negative susceptibility sign in a patient with acute proximal occlusion of MCA. (a) Transverse echo-planar T2*-weighted MR image (0.8/29) shows no susceptibility sign. (b) Coronal MR angiogram shows MCA occlusion (arrow) proximal to divisional bifurcation. (c) Transverse DW image (4,000/100; b = 1,000 sec/mm2) obtained at the frontoparietal region shows a large acute infarct (arrows) involving MCA territory. (d) Perfusion time-to-peak map obtained at the same level as c (2,000/60) shows a matched volume of abnormal perfusion (arrows).