Evaluation of patients with stroke including vascular and cardiac imaging

Developments in brain and vascular imaging techniques and functional tests provide physicians with a plethora of tests to evaluate stroke patients. Unless ordering of procedures is based on thorough clinical evaluation, appropriate knowledge of the available imaging techniques, expected pathology, and normal variants, the results can be confusing. As an example, an early cerebral angiography study of “normal prisoners” by Faris et al. showed a high incidence of arterial occlusions and stenoses [1]. A more recent study using computed tomography (CT) angiography in young asymptomatic subjects found marked variation in the size of the vertebral artery relative to the transverse foramen, with the vertebral artery occupying 8–85% of the foramen. Such variability in normal vessel size may make it challenging to interpret vertebral artery pathology on CT angiograms [2]. Almost a quarter (22.7%) of the 629 patients without history of prior stroke enrolled in the Trial of Organon 10172 in Acute Stroke (TOAST) study had clinically silent lesions on baseline CT scans [3]. These observations belie the old adage dear to many neurosurgeons that an ounce of dye is worth all the neurologists in the room [4].