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Prediction of early neurological deterioration using diffusion- and perfusion-weighted imaging in hyperacute middle
Juan F Arenillas1, Alex Rovira, Carlos A Molina
1Cerebrovascular Unit, Vall d'Hebron Hospital, Barcelona, Spain. juanfarenillas@terra.es
Background And Purpose:
Early neurological deterioration (END) occurs in approximately one third of all ischemic stroke patients and is associated with a poor outcome. Our study sought to assess the value of ultra-early MRI in the prediction of END in stroke patients.
Methods:
Between August 1999 and November 2001, 38 stroke patients with a proven middle cerebral artery (MCA) or intracranial internal carotid artery (ICA) occlusion on MR angiography underwent perfusion-weighted imaging (PWI) and diffusion-weighted imaging (DWI) within 6 hours after onset, and 30 fulfilled all inclusion criteria. Control DWI and MR angiography were performed between days 3 and 5. Cranial CT was performed to rule out hemorrhagic transformation. Vascular risk factors, temperature, blood pressure, glycemia, and blood count were assessed on admission. National Institutes of Health Stroke Scale (NIHSS) scores were obtained at baseline and at 6, 12, 24, and 48 hours. At the same time points, transcranial Doppler (TCD) examinations were conducted to assess arterial recanalization. END was defined as an increase in the NIHSS score >4. A logistic regression model was applied to detect independent predictors of END. The Kruskal-Wallis test was used to evaluate the relationship between infarct growth and duration of vessel occlusion.
Results:
Initial MR angiography showed an occlusion of intracranial ICA in 7 patients (23.3%), of proximal MCA in 14 (46.6%), and of distal MCA in the remaining 9 (30%). A PWI-DWI mismatch >20% was observed in 28 patients (93.3%). END occurred in 7 patients (23.3%). Baseline NIHSS score (P=0.05), proximal site of occlusion (P=0.002), initial DWI (P=0.002) and PWI (P=0.003) volumes, and reduced PWI-DWI mismatch (P=0.038) were associated with END in the univariate analysis. Only hyperacute DWI volume remained as a predictor of END when a logistic regression model was applied (odds ratio, 11.5; 95% CI, 2.31 to 57.10; P=0.0028). A receiver operator characteristic curve identified a cutoff point of DWI >89 cm(3) (sensitivity, 85.7%; specificity, 95.7%) to predict END. A graded response was seen in DWI lesion expansion in relation to duration of arterial occlusion (P=0.017).
Conclusions:
Ultra-early DWI is a powerful predictor of END after MCA or intracranial ICA occlusion.
Insights
Ultra-early diffusion-weighted imaging (DWI) effectively predicts early neurological deterioration (END) in ischemic stroke patients with middle cerebral artery or intracranial internal carotid artery occlusion. A DWI volume greater than 89 cm³ is a key indicator for predicting END.
Area of Science:
- Neurology
- Radiology
- Medical Imaging
Background:
- Early neurological deterioration (END) affects about one-third of ischemic stroke patients, leading to poor outcomes.
- Predicting END is crucial for timely intervention and improved patient management.
Purpose of the Study:
- To evaluate the predictive value of ultra-early magnetic resonance imaging (MRI) for END in ischemic stroke patients.
- To identify specific MRI parameters that correlate with the risk of END.
Main Methods:
- 30 ischemic stroke patients with middle cerebral artery (MCA) or intracranial internal carotid artery (ICA) occlusion underwent perfusion-weighted imaging (PWI) and diffusion-weighted imaging (DWI) within 6 hours of symptom onset.
- NIH Stroke Scale (NIHSS) scores, vascular risk factors, and blood parameters were assessed. Logistic regression analysis was used to identify predictors of END.
Main Results:
- Ultra-early diffusion-weighted imaging (DWI) volume was a significant independent predictor of END (odds ratio, 11.5; P=0.0028).
- A DWI volume >89 cm³ predicted END with 85.7% sensitivity and 95.7% specificity.
- Infarct growth showed a graded response related to the duration of arterial occlusion.
Conclusions:
- Ultra-early DWI is a powerful tool for predicting END in patients with MCA or intracranial ICA occlusion.
- DWI-based volume assessment can guide clinical decisions for stroke management.