Added Value of Sodium MR Imaging and Proton MR Spectroscopy to Conventional MR Imaging for a Better Characterization of the Ischemic Stroke - A Narrative Review

Sep 29, 2026

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Ischemic stroke causes major disability and death worldwide, and conventional time-efficient MRI protocols help diagnose occlusion and estimate ischemic extent, but outcome prediction remains limited. This narrative review evaluates added value of sodium-23 (23Na) MRI and 1H MR spectroscopic imaging as complementary approaches. These methods provide new temporal and pathophysiological windows on ionic dyshomeostasis and metabolic alterations, and discuss cellular-event timelines that may support improved clinical outcome prediction.

LanguageEnglish

CategoryHealthcare

FormatPDF

Pages12

Reading Time30 min

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Introduction

Cellular mechanisms accompanying ischemic stroke

Ischemic cascade and ionic dyshomeostasis

Cytotoxic and vasogenic edema dynamics

Blood-brain barrier dysfunction and reperfusion timeline

Magn Reson Med Sci 2025; 24: 2025-0002 doi:10.2463/mrms. rev.2025-0002 Published Online: April 9, 2025 REVIEW Added Value of Sodium MR Imaging and Proton MR Spectroscopy to Conventional MR Imaging for a Better Characterization of the Ischemic Stroke: A Narrative Review Maëva Cotinat 1,2,3,4,5* , Emmanuelle Robinet6, Noëlle Messaoudi6, Laurent Suissa6,7, Emilie Doche6,7, Maxime Guye1,2,3, Laurent Bensoussan4,5,8,9, Wafaa Zaaraoui1,2,3, and Jean-Philippe Ranjeva1,2,3 Stroke is a major cause of disability and death in adults worldwide. In clinical setting, time efficient MRI protocols including diffusion weighted images, fluid attenuated inversion recovery, fast T2*-weighted images and MR angiography aim to establish ischemic stroke diagnosis, visualize vessel occlusion and determine the extent of ischemia damage distinguishing between the salvageable ischemic penumbra and the infarct core. Thus, MRI plays a pivotal role in diagnosis, treatment decision-making, and prognostic assessment, although prediction based on these elements remains limited and can be improved. Wereviewed the added-values of alternative MRI methods such as sodium(23Na) MRI and 1H MR spectroscopic imaging that open new temporal and pathophysiological windows on ionic dys-homeostasis and metabolism alteration in the context of ischemic stroke and reperfusion. Insights on the timeline of the cellular events accessible using these alternative methods and perspectives to improve clinical outcome prediction of ischemic stroke patients are discussed. Keywords: brain, 1H magnetic resonance spectroscopy, magnetic resonance imaging, 23Na magnetic resonance imaging, stroke Introduction Cellular mechanisms accompanying ischemic stroke Stroke is a major cause of disability and death in adults worldwide.1 Understanding and monitoring the spatialtemporal underpinnings of cellular mechanisms consecutive to ischemic stroke is a critical point to improve early diagnostic and therapeutic options including neuroprotection 1CRMBM, Aix Marseille University, Marseille, France 2CRMBM, CNRS, Marseille, France 3CEMEREM, Hôpital Universitaire Timone, APHM, Marseille, France 4Physical and Rehabilitation Medicine Department, Hôpitaux Sud, APHM, Marseille, France 5Physical and Rehabilitation Medicine Department, Hôpitaux Sud, Aix Marseille University, Marseille, France 6Stroke unit, APHM, Marseille, France 7C2VN, Aix Marseille University, Marseille, France 8INT, Aix Marseille University, Marseille, France 9UGECAM, Institut Universitaire de Réadaptation Valmante Sud, Marseille, France *Corresponding author: Physical and Rehabilitation Medicine Department, Hôpitaux Sud, APHM, 19, avenue Viton, 13274 Marseille cedex 9, France. [E-mail: maeva.cotinat@ap-hm.fr](E-mail: maeva.cotinat@ap-hm.fr) This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License. ©2025 Japanese Society for Magnetic Resonance in Medicine Received: January 7, 2025 | Accepted: February 27, 2025 targeting the biochemical consequences of the ischemic cascade. Ischemic stroke pathophysiology is resumed on the Fig. 1. Acute ischemic stroke is caused by an abrupt reduction in blood flow within specific brain areas, inducing a sequence of neurochemical processes known as the ischemic cascade.2–4 One key mechanism is the deficit of substrates for energy production, particularly oxygen and glucose, which is severely compromised, reducing the physiological production of adenosine triphosphate (ATP) . The rapid depletion of these substrates leads to lactate accumulation via anaerobic glycolysis and energy failure. One consequence is the dysfunction of the Na+/K+-ATPase and Ca2+/H+-ATPase pumps, which are responsible for ionic dyshomeostasis showing increases in intracellular levels of Na+, Ca2+, Cl − and extracellular levels ofK+ . As a result of energy depletion, neurons and glia depolarize through loss of membrane potential.5 The depolariza

FAQs

Why are conventional MRI protocols limited for ischemic stroke outcome prediction?

They can establish diagnosis, visualize vessel occlusion, and estimate ischemic extent, but prediction based on these elements remains limited.

What additional insights do 23Na MRI and 1H MR spectroscopic imaging aim to provide?

They open new temporal and pathophysiological windows on ionic dyshomeostasis and metabolism alterations during ischemic stroke and reperfusion.

How does the review connect ischemic cascade mechanisms to imaging-relevant cellular events?

It describes energy failure, ionic pump dysfunction, excitotoxic amino acid release, downstream edema formation, and blood-brain barrier dysfunction, including timing across early hours to days.

Sep 29, 2026

Uploaded by Elsa