Workpackage 02 Illustrated imaging manual

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1 Workpackage 02 Illustrated imaging manual 05/05/2012 Slide no 1

2 Workpackage 02 Introduction to the main imaging concept 05/05/2012 Slide no 2

3 WP 02 main imaging concept of the study Main imaging question of the WAKE-UP study: Is a diffusion restriction (left) already visible in the image (right)? 05/05/2012 Slide no 3

4 WP 02 positive vs negative The diffusion restriction (left) is not already visible in the image (right), making the patient negative Suitable for randomization in WAKE-UP 05/05/2012 Slide no 4

5 WP 02 positive vs negative The diffusion restriction (left) is already visible in the image (right), making the patient positive Not suitable for randomization in WAKE-UP 05/05/2012 Slide no 5

6 WP 02 positive vs negative T2* The diffusion restriction (left) is not already visible in the image (right), making the patient negative Suitable for randomization in WAKE-UP 05/05/2012 Slide no 6

7 WP 02 positive vs negative The diffusion restriction (left) is already visible in the image (right), making the patient positive Not suitable for randomization in WAKE-UP 05/05/2012 Slide no 7

8 Workpackage 02 Further inclusion and exclusion criteria 05/05/2012 Slide no 8

Exclusion criterion for tpa and therefore not

9 WP 02- hemorrhage T2* Hemorrhagic stroke (primary bleed instead of an ischemic stroke) left frontal. Exclusion criterion for tpa and therefore not suitable for randomization in WAKE-UP 05/05/2012 Slide no 9

Suitable for randomization in WAKE-UP (if

10 WP 02- hemorrhage T2* Scattered left MCA-territory ischemic stroke multiple microbleeds seen on the T2* image are not necessarily an exclusion criterion for tpa Suitable for randomization in WAKE-UP (if the acute lesion isn t visible on ) 05/05/2012 Slide no 10

WP 02- large hemispheric stroke lesion is

criterion also applies to strokes covering

11 WP 02- large hemispheric stroke lesion is mainly cortical yet encompassing more than 1/3 of the MCA-territory* Not suitable for randomization in WAKE-UP * This exclusion criterion also applies to strokes covering more than 1/2 ACA or 1/2 PCA vessel territory 05/05/2012 Slide no 11

WP 02- large hemispheric stroke T2* Bad quality images due to patient movement, however lesion covering much more than 1/3 of the MCA-territory * Not

12 WP 02- large hemispheric stroke T2* Bad quality images due to patient movement, however lesion covering much more than 1/3 of the MCA-territory * Not suitable for randomization in WAKE-UP * This exclusion criterion also applies to strokes covering more than 1/2 ACA or 1/2 PCA vessel territory 05/05/2012 Slide no 12

13 WP 02- image quality Right-sided MCA-territory ischemic stroke Bad quality images (both and ) due to patient movement Not suitable for randomization in WAKE-UP 05/05/2012 Slide no 13

14 WP 02- motion artifacts Right-sided, basal ganglia and corona radiata (MCA-territory) ischemic stroke lesions appear in the area of extensive artifacts on the image, making visibility difficult to judge in a reliable fashion Not suitable for randomization in WAKE-UP 05/05/2012 Slide no 14

WP 02- motion artifacts Left-sided, MCA-territory ischemic stroke including the basal ganglia Although there are considerable motion artifacts in the area of the lesions, these are clearly visible on

15 WP 02- motion artifacts Left-sided, MCA-territory ischemic stroke including the basal ganglia Although there are considerable motion artifacts in the area of the lesions, these are clearly visible on the image. In addition, every second image doesn t suffer from motion artifacts due to the interleaved nature of the image acquisition (making lesion visibility reliable to judge). Not suitable for randomization in WAKE-UP (due to positivity, not motion artifacts) 05/05/2012 Slide no 15

WP 02- leukaraiosis Scattered right, mostly

visibility difficult to judge in a reliable

16 WP 02- leukaraiosis Scattered right, mostly subcortical MCA-territory ischemic stroke lesions appear in the area of extensive leukaraiosis and an old lacunar stroke, making visibility difficult to judge in a reliable fashion Not suitable for randomization in WAKE-UP 05/05/2012 Slide no 16

lesion are outside the white matter changes making visibility reliable

17 WP 02- leukaraiosis Right-sided MCA-territory ischemic stroke Although the lesion appears in the area of leukaraiosis, large portions of the lesion are outside the white matter changes making visibility reliable to judge Suitable for randomization in WAKE-UP 05/05/2012 Slide no 17

operculum and insula appears exactly the same as contralateral, no

18 WP 02- negative / positive Right-sided, mostly cortical MCA-territory ischemic stroke The tissue signal in the right operculum and insula appears exactly the same as contralateral, no lesion visibility on the Suitable for randomization in WAKE-UP 05/05/2012 Slide no 18

enough for inclusion into WAKE-UP, a purely subcortical stroke on imaging is

19 WP 02- negative / positive Right-sided, purely subcortical MCA-territory ischemic stroke, not visible in the If the clinical deficit is significant enough for inclusion into WAKE-UP, a purely subcortical stroke on imaging is _not_ an exclusion criterion Suitable for randomization in WAKE-UP 05/05/2012 Slide no 19

stroke With enough contrasting many lesions

Under the current contrast settings, there

20 WP 02- negative / positive Right-sided, mostly cortical MCA-territory ischemic stroke With enough contrasting many lesions can become subtly visible in the. WAKE-UP imaging criteria discourage aggressive contrasting. Under the current contrast settings, there is no lesion visibility on the Suitable for randomization in WAKE-UP 05/05/2012 Slide no 20

21 WP 02- negative / positive Right-sided MCA-territory ischemic stroke With enough contrasting the insular ribbon becomes subtly visible in the. However, without aggressive contrasting, there is no clear lesion visibility on the Suitable for randomization in WAKE-UP 05/05/2012 Slide no 21

22 WP 02- negative / positive Right-sided MCA-territory ischemic stroke Even with very mild contrasting the lesion is visible in the. Not suitable for randomization in WAKE-UP 05/05/2012 Slide no 22

a mostly cortical left-sided MCA-territory

signaling that this is a time distributed

visible in the, the patient is considered

23 WP 02- negative / positive Right PCA-territory stroke (visible in the ) and a mostly cortical left-sided MCA-territory stroke (clearly not visible in the ) signaling that this is a time distributed event If any acute ischemic lesion is visible in the, the patient is considered positive Not suitable for randomization in WAKE-UP 05/05/2012 Slide no 23

frontalis medius, postcentralis and angularis) whereas lower slices (insula and temporal lobe) are clearly not yet

24 WP 02- negative / positive Left-sided MCA-territory stroke. Higher cortical slices showing lesions which are visible in the (G. frontalis medius, postcentralis and angularis) whereas lower slices (insula and temporal lobe) are clearly not yet visible in the ) signaling that this is a time distributed event If any segment of the acute ischemic lesion is visible in the, the patient is considered positive Not suitable for randomization in WAKE-UP 05/05/2012 Slide no 24

25 Workpackage 02 Illustrated imaging manual Contacts: Priv. Doz. Dr. med. Jochen B. Fiebach Head of Academic Neuroradiology Center for Stroke Research Berlin (CSB) Charité - Universitätsmedizin Berlin Campus Benjamin Franklin Hindenburgdamm 30 D Berlin Tel. +49 (0) jochen.fiebach@charite.de Dr. med. MSc Ivana Galinovic Stroke MRI Group Center for Stroke Research Berlin (CSB) Charité Universitätsmedizin Berlin Campus Benjamin Franklin Hindenburgdamm 30 D Berlin Tel. +49 (0) ivana.galinovic@charite.de 05/05/2012 Slide no 25

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