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Laila Ahmed: Stroke Imaging – A Practical Radiology Approach
Laila Ahmed/LinkedIn
Oct 6, 2026, 07:03

Laila Ahmed: Stroke Imaging – A Practical Radiology Approach

Laila Ahmed, Radiology Resident at Dar Al Fouad Hospital, shared a post on LinkedIn:

“Stroke Imaging: a practical radiology approach

A useful way to approach suspected acute stroke on imaging is to answer four questions – quickly and systematically:

1. Is there haemorrhage?

  • Start with non-contrast CT. Look for acute intracranial blood, early ischaemic change, mass effect, and important mimics.

2. Is there an arterial occlusion?

  • CTA identifies large-vessel occlusion, tandem lesions, carotid dissection, collateral status, and posterior-circulation occlusion.

3. Is there established infarct core?

  • Assess early CT changes and ASPECTS in MCA-territory stroke. On MRI, true acute infarction is DWI bright with low ADC.

4. Is there salvageable tissue?

  • CT or MR perfusion helps distinguish infarct core from penumbra:
  • Core: CBF decreased and CBV decreased
  • Penumbra: CBF decreased, delayed Tmax/MTT, but relatively preserved CBV

A key reminder: not every focal neurological deficit is an arterial infarct.

Important stroke mimics include:

  • Seizure/Todd paresis: often non-territorial cortical change and sometimes hyperperfusion
  • Cerebral venous thrombosis: haemorrhagic infarction crossing arterial territories
  • Migraine: usually normal structural imaging or multi-territorial perfusion change
  • PRES: bilateral posterior vasogenic oedema with high ADC
  • Tumour, subdural haematoma, encephalitis and metabolic causes such as hypoglycaemia

For intracranial haemorrhage, pattern recognition remains essential:

  • Deep basal ganglia, thalamic, pontine or cerebellar haemorrhage – think hypertensive arteriopathy
  • Lobar haemorrhage in an older patient – think cerebral amyloid angiopathy
  • Basal cisternal subarachnoid haemorrhage – investigate for aneurysm
  • Non-territorial haemorrhagic lesion – consider venous thrombosis or an underlying vascular lesion.

A concise rule I am trying to make automatic:

CT means blood. CTA means blocked artery. CTP means tissue at risk. DWI means acute infarct.

Excellent open-access case-based review from The Radiology Assistant:Imaging in Acute Stroke․”

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