The Role of Neuroimaging in Acute Stroke

The Role of Neuroimaging in Acute Stroke

1. The Role of Neuroimaging in Acute Stroke: Guiding Interventi
ons and Improving Prognosis
SUNSHINE 2025
Dr. dr. Rachmi Fauziah Rahayu, Sp.Rad, Subsp. N-KL (K)
KSM Radiologi RSUD Dr. MoewardiSunshine 2025

2. OVERVIEW
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IMAGING OF ACUTE STROKE
ASPECT SCORE
CASES
TAKE HOME POINTSunshine 2025

3. IMAGING OF ACUTE STROKESunshine 2025

4. RACHMI FAUZIAH R
AHAYU
NEURORADIOLOGIS
T
Educational Background:
•Medical Faculty of Universitas Sebelas Maret, 1996
•Radiology Specialist of Airlangga University- Dr Soetomo
Hospital Surabaya , 2011
•Neuroradiology Attachment Program at Neuroradiology
Science Institute – Tan Tock Seng Hospital Singapore
2014
•Neuroradiology Head and Neck Concultant 2019
•Postgraduate Doctoral Studies 2025
Employment
•Head of Medical Staff Radiology Group RSUD dr Moewardi 2
017-2023
•Head of Radiology Instalation RSUD dr Moewardi 2021-2023
•Head of Radiology Residenct Program Universitas Sebelas
Maret 2022 - Present
Scientific Publication :
•Combination of Metformin and Magnesium Citrate Reduces
TNF-α, NF-κB p65, IL-6, CD4, and MMP-9 Expressions in
Diabetic Model Rats (2024)
•Bibliometric analysis of research in Moringa oleifera Lam. a
nd atherosclerosis (2024)
•Bibliometric Analysis: Research Trends In Vitamin D And M
agnesium as A Diabetes Mellitus Therapy Model (2024)
•Exploring the therapeutic potential of functional foods for di
abetes: A Bibliometric Analysis and Scientific mapping (202
4)Sunshine 2025

5. Manifestasi klinis akut akibat disfungsi neurologis pada otak,
medulla spinalis, dan retina baik sebagian atau menyeluruh
yang menetap selama ≥24 jam atau menimbulkan kematian
akibat gangguan pembuluh darah.
STROKE
Trombosis
•Aterosklerosis atau white
thrombus  Obstruksi
Lokal
•Hipertensi kronis
menyebabkan deposisi
fibrinoid dan hipertorfi
tunika media  Lumen
menyempit.
Emboli
•Obstruksi karena materi
yang berjalan ke arah
distal
•Sumber berasal dari
cardiac, artery to artery,
Emboli paradoxical,
sumber lain.
Hipoperfusi
•Gangguan pompa jantung
(ACS atau artimia jantung)
•Hipotensi sistemik
(Hipovolemia atau Blood
Loss)
•Area yang tedampak adalah pada Regio
Watershed.
Coupland, A. P., Thapar , A., Qureshi, M. I., Jenkins, H., Davies, A. H. The definition of stroke. Journal of the Royal Society of Medicine. 2017. 110(1): pp. 9–12.
doi: 10.1177/0141076816680121.Sunshine 2025

6. PATOFISIOLOGI
Sumbatan pembuluh darah
otak oleh embolus
Embolus yang terbawa aliran darah menyumbat di
pembuluh darah kecil
Pembuluh darah tersumbat  sel
otak kekurangan suplai oksigen da
n nutrisi
Iskemik  sintesis ATP terhenti  disfungsi pompa ion Na+/K+-ATPase  eksitotoksisitas yang
merusak neuron  edem sitotoksis dan vasogenic yang akan meningkatkan teknan intrakranial
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Salaudeen, M.A.; Bello, N.; Danraka , R.N.; Ammani , M.L. Understanding the Pathophysiology of Ischemic Stroke: The Basis of Current Therapies and Opportunity for
New Ones. Biomolecules 2024, 14, 305. https://doi.org/10.3390/biom14030305Sunshine 2025

7. ANATOMY RADIOLOGY
PDQ Adult Treatment Editorial Board. Adult Central Nervous System Tumors Treatment (PDQ®): Patient Version. 2024 Jan 5. In: PDQ Cancer Information Summaries
[Internet]. Bethesda (MD): National Cancer Institute (US)Sunshine 2025

8. PDQ Adult Treatment Editorial Board. Adult Central Nervous System Tumors Treatment (PDQ®): Patient Version. 2024 Jan 5. In: PDQ Cancer Information Summaries
[Internet]. Bethesda (MD): National Cancer Institute (US)Sunshine 2025

9. Sunshine 2025

10. RADIOLOGY IMAGING
KRONIK
SUBAKUT
AKUT
•MCA dense sign
•Hiperatenuasi
•Edema lokal ringan di
area Infark
•3-24 jam
•Atrofi kortikal lokal
•Loss of brain substance in the infarcted area
•> 3 minggu
•Area hipodensitas mulai
terlihat
•Edema sitotoksik
•24-72 jam
Abdalkader M, Siegler JE, Lee JS, Yaghi S, Qiu Z, Huo X, Miao Z, Campbell BCV, Nguyen TN. Neuroimaging of Acute Ischemic Stroke: Multimodal Imaging Approach for
Acute Endovascular Therapy. J Stroke. 2023 Jan;25(1):55-71. doi : 10.5853/jos.2022.03286. Epub 2023 Jan 31. PMID: 36746380; PMCID: PMC9911849.
HIPERAKUT
•MCA dense sign
•Hiperatenuasi
•Edema lokal ringan di
area Infark
•0-3 jamSunshine 2025

11. Sunshine 2025

12. MCA dense sign in CT Basilar dot sign in CTSunshine 2025

13. Sylvii dot sign in CTSunshine 2025

14. Obscuring Fissura sylvii in CTSunshine 2025

15. Hypoattenuation on CT is highly specific for irreversible
ischemic brain damage if it is detected within first 6 hours
Hypo attenuating brain tissue in CTSunshine 2025

16. Focal hypoattenuation in CTSunshine 2025

17. Obscuration of the lentiform nucleus in CTSunshine 2025

18. Dissapear basal gangglia sign in CTSunshine 2025

19. Sulcal effacement in CTSunshine 2025

20. Insular Ribbon Sign in CTSunshine 2025

21. Loss of cortical ribbon sign in CTSunshine 2025

22. Hyperacute Stroke in MRI
Gambar Gradient-echo T2* menunjukkan tak tampak perdarahan intracranial (A) dan tak tampak kelainan
pada T2-FLAIR images (B). Tampak restricted diffusion area (C) Sunshine 2025

23. Hyperacute Stroke in MRISunshine 2025

24. Hyperacute Stroke in MRISunshine 2025

25. Sunshine 2025

26. ASPECTS SCORESunshine 2025

27. Penilaian yang digunakan untuk menilai tingkat kerusakan
parenkim otak akibat stroke infark emboli pada imaging
CT-scan kepala
M1, M2, M3
M4, M5, M6
KORTIKAL
Nucleus lentiformis
Capsula Interna
Nucleus caudatus
SUBKORTIKAL
Insula
GANGLIA BASAL
ASPECTS
SCORESunshine 2025

28. MCA ALBERTA STROKE PROGRAM EARLY
CT STROKE (ASPECTS)Sunshine 2025

29. MCA ALBERTA STROKE PROGRAM EARLY
CT STROKE (ASPECTS)Sunshine 2025

30. ASPECT SCORE
Skor ASPECTS > 7 dapat menjadi prediktor yang baik untuk outcome fungsional dan
prediktor transformasi perdarahan kasus stroke iskemik yang mendapat terapi alteplase.
Rekomendasi AHA/ASA 2018 menyatakan bahwa temuan gambaran iskemik akut pada
CT Scan non-kontras sebaiknya tidak menjadi halangan untuk memberikan alteplase.
Skor ASPECT ≥6 merupakan salah satu poin yang menjadi kriteria tindakan trombektomi
mekanik. Penelitian meta-analisis HERMES (2016) menunjukkan bahwa nilai ASPECTS
lebih rendah berhubungan dengan outcome terapi yang buruk
Michael, Lie. "Sistem Skoring Alberta Stroke Program Early CT Score untuk Evaluasi Kasus Stroke Iskemik." 
Cermin Dunia Kedokteran , vol. 47, no. 9, 2020, doi:10.55175/cdk.v47i9.919 .Sunshine 2025

31. Algoritma triase untuk Acute
Ischemic Stroke dengan
Large Vessel Occlusion
Xu Guo, Zhongrong Miao - Advances in mechanical thrombectomy for acute ischaemic stroke from large vessel occlusions: Stroke and Vascular Neurology 2021;6:.Sunshine 2025

32. TROMBOLISIS IV, IA, TH
ROMBECTOMYSunshine 2025

33. Trombolisis Intravena (IV tPA) dapat diberikan hingg
a 3 jam setelah onset gejala stroke iskemik akut. Dala
m beberapa kasus tertentu,
bisa diperpanjang hingga 4.5 jam setelah onset gejala.
WINDOW
PERIOD I
V tPASunshine 2025

34. Indikasi dan Kontraindikasi
Trombolisis
Tawil SE, Muir KW. Thrombolysis and thrombectomy for acute ischaemic stroke. Clin Med (Lond). 2017 Apr;17(2):161-165. doi: 10.7861/clinmedicine.17-2-161. PMID: 28365630; PMCID: PMC629
7620.Sunshine 2025

35. WINDOW
PERIOD
IAT
Skor ASPECT >7 dikaitkan dengan hasil neurologi yang
baik paska trombolisis. Trombolisis intraarterial (IAT) biasa
nya direkomendasikan dalam rentang waktu 6 jam setelah
onset stroke, terutama untuk oklusi pada arteri serebri
media (MCA) atau karotis interna (ICA).Sunshine 2025

36. Powers WJ. et al. 2018 Guidelines for the Early Management of Patients With Acute Ischemic Stroke. AHA/ASA Guidelines. 2018
Nguyen TN et al. Mechanical Thrombectomy in the Late Presentation of Anterior Circulation Large Vessel Occlusion Stroke: A Guideline From the Society of Vascular and Interventional Neurology
Guidelines and Practice Standards Committee. Published online 2022.Sunshine 2025

37. CASESSunshine 2025

38. CASE 1Sunshine 2025

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40. Chronic Tromboemboli Infark di lobus temporoparietal kanan sesuai territory A. Cerebri Media Kanan Segmen M1
-6, nucleus caudatus kanan, corona radiata kanan, insula kanan dengan gambaran kalsifikasi di dalamnya
Chronic Tromboemboli infark di lobus parietalis kiri sesuai territory A.Cerebri Media kiri segmen M6Sunshine 2025

41. CASE 2Sunshine 2025

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43. Tromboemboli infarct lobus frontotemporoparietalis kanan sesuai dengan teritori MCA kanan
segmen M1,M2 ,M4, M5 dan nukleus lentiformis kanan, insular kanan, crus anterior et posteri
or capsula interna kanan disertai transformasi perdarahan (Parenchymal hemorrhage type 2)Sunshine 2025

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45. CASE 3Sunshine 2025

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48. Tromboemboli infark dengan transformasi perdarahan di lobus frontalis kiri sesuai dengan teritory ACA dan
parietotemporalis kiri sesuai dengan teritory MCA segmen M1-M2, M4, M5 kiri, insular kiri dan nucleus lentiformis kiri
(ASPECT Score : 4)Sunshine 2025

49. CASE 4Sunshine 2025

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51. Hyperacute thromboemboli infark pada lobus temporoparietalis kiri sesuai teritori MCA kiri segmen
M2, M5, insula kiri, dan nucleus lentiformis kiri (ASPECT score 6) disertai gambaran insular ribbon
signSunshine 2025

52. CASE 5Sunshine 2025

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55. Chronic tromboemboli infark di lobus temporoparietalis kiri sesuai dengan teritory MCA kiri segmen
M1-M6, capsula interna kiri, nucleus lentiformis kiri, capsula eksterna kiri
Watershed tromboemboli infark di lobus temporoparietalis kanan sesuai dengan teritory MCA kanan
segmen M3,M4,M5,M6, dan lobus occipitalis kiri sesuai teritory PCA kanan (ASPECT score 6,
Pc-ASPECT score 9)Sunshine 2025

56. CASE 6Sunshine 2025

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58. Acute tromboemboli infark di lobus occipitalis bilateral, mesencephalon sisi kiri dan ponsSunshine 2025

59. CASE 7Sunshine 2025

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63. Hyperacute tromboemboli infark di lobus frontotemporooccipitalis kiri sesuai dengan territory
MCA segmen M1,2,3,4,5,6, nucleus caudatus kiri , nucleus lentiformis kiri , crus anterior et post
erior capsula interna kiri (ASPECT SCORE 0)Sunshine 2025

64. CASE 8Sunshine 2025

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67. Chronic watershed infark di parietooccipitalis kanan sesuai dengan teritori MCA
kanan, segmen M3 dan M6 serta teritori PCA kananSunshine 2025

68. TAKE HOME POINTSunshine 2025

69. Time is brain
Imaging dan diagnostic yang tepat dan cepat akan membantu
keberhasilan tindakan
§CT scan merupakan imaging pilihan untuk acute stroke , MRI
diperlukan untuk kasus- kasus borderline, CTA datau MRA, CTP dan
MRP juga diperlukan untu kasus kasus tertentuSunshine 2025

70. DAFTAR PUSTAKA
●Aninditha, T., Harris, S. dan Wiratman, W. Buku Ajar Neurologi. 2022. 2nd ed. Jakarta: Yayasan Otak Sehat Indonesia.
●Boehme, A. K., Esenwa, C. dan Elkind, M. S. V. Stroke Risk Factors, Genetics, and Prevention. Circulation Research. 2017. 120 (3): 472–495.
doi: 10.1161/CIRCRESAHA.116.308398.
●Coupland, A. P., Thapar, A., Qureshi, M. I., Jenkins, H., Davies, A. H. The definition of stroke. Journal of the Royal Society of Medicine. 201
7. 110(1): pp. 9–12. doi: 10.1177/0141076816680121.
●Demel, S. L. Kittner, S., Ley S. H., McDermott, M., Rexrode, K.M. Stroke risk factors unique to women. Stroke. 2018. 49(3): 518–523. doi:
10.1161/STROKEAHA.117.018415.
●Hacking, C. (2024) Alberta stroke programme early CT score (ASPECTS), Radiopedia. Available at: https://radiopaedia.org/articles/alberta
-stroke-programme-early-ct-score-aspects. Di akses 10 Januari 2025
●Hooi, T. (2024) Hyperdense MCA sign (brain), Radiopedia. Tersedia di: https://radiopaedia.org/articles/hyperdense-mca-sign-brain-1.
●Kementerian Kesehatan RI. Pedoman Nasional Pelayanan Kedokteran Tatalaksana Stroke. 2019. Jakarta.
●Miller, S. E. dan Warach, S. J. Evolving Thrombolytics: from Alteplase to Tenecteplase. Neurotherapeutics. 2023. 20(3): 664–678. doi: http
s://doi.org/10.1007/s13311-023-01391-3.
●Zhu, A., Rajendram, P., Tseng, E., Coutts, S. B., Yu, A. Y. X. Alteplase or tenecteplase for thrombolysis in ischemic stroke: An illustrated revi
ew. Research and Practice in Thrombosis and Haemostasis. 2022. 6(6). doi: https://doi.org/10.1002/rth2.12795.
●Powers WJ. et al. 2018 Guidelines for the Early Management of Patients With Acute Ischemic Stroke. AHA/ASA Guidelines. 2018
●Nguyen TN et al. Mechanical Thrombectomy in the Late Presentation of Anterior Circulation Large Vessel Occlusion Stroke: A Guideline From the Society of Vascular and Interventional Neurology Guidelines and Practice Standards Committee. Published online 2022.Sunshine 2025

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