Acute: Subtle low signal (hypointense) on T1, often difficult to see at this stage, and high signal (hyperintense) on spin density and/or T2-weighted and proton density-weighted images starting 8 h after onset; should follow vascular distribution. Mass effect maximal at 24 h, sometimes starting 2 h after onset, even in the absence of parenchymal signal changes. No parenchymal enhancement with paramagnetic contrast agent. Territorial intravascular paramagnetic contrast enhancement of "slow-flow" arteries in hyperacute infarcts; at 48 h, parenchymal and meningeal enhancement can be expected.

Subacute (1 wk or older): Low signal on T1, high signal on T2-weighted images. Follows vascular distribution. Revascularization and blood-brain barrier breakdown may cause parenchymal enhancement with contrast agents.

Old (several weeks to years): Low signal on T1, high signal on T2. Mass effect disappears after 1 mo. Loss of tissue with large infarcts. Parenchymal enhancement fades after several months.

References:

1. Culebras A, Kase CS, Masdeu JC, Fox AJ, Bryan RN, Grossman CB, Lee DH, Adams HP, Thies W. Practice guidelines for the use of imaging in transient ischemic attacks and acute stroke. A report of the Stroke Council, American Heart Association. Stroke. 1997 Jul;28(7):1480-97. [Medline]

Created: April 19, 2005