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Published on: January 23, 2019
Prediction of malignant middle cerebral artery infarction by early perfusion- and diffusion-weighted magnetic
Götz J Thomalla1, Thomas Kucinski, Volker Schoder
1Klinik und Poliklinik für Neurologie, Universitätsklinikum Hamburg-Eppendorf, Martinistrabetae 52, D-20246 Hamburg, Germany. thomalla@uke.uni-hamburg.de
Background And Purpose:
We tested the hypothesis that early diffusion- and perfusion-weighted MRI (DWI and PWI, respectively) allows the prediction of malignant middle cerebral artery (MCA) infarction (MMI).
Methods:
Thirty-seven patients with acute MCA infarction and proximal vessel occlusion (carotid-T, MCA main stem) were studied by DWI, PWI, and MR angiography within 6 hours of symptom onset. Eleven patients developed MMI, defined by decline of consciousness and radiological signs of space-occupying brain edema. Lesion volumes were retrospectively defined as apparent diffusion coefficient <80% (ADC<80%) and time to peak >+4 seconds (TTP>+4s) compared with the unaffected hemisphere. ADC decrease within the infarct core (ADCcore) and relative ADC within the ADC<80% lesion (rADClesion) were measured. Neurological deficit at admission was assessed with the National Institutes of Health Stroke Scale (NIHSS).
Results:
Patients with MMI showed larger ADC<80% (median, 157 versus 22 mL; P<0.001) and TTP>+4s (208 versus 125 mL; P<0.001) lesion volumes, smaller TTP/ADC mismatch ratio (1.5 versus 5.5; P<0.001), lower ADCcore values (290 versus 411 mm2/s; P<0.001), lower rADClesion (0.60 versus 0.66; P=0.001), higher frequency of carotid-T occlusion (64% versus 15%; P=0.006), and higher NIHSS score at admission (20 versus 15; P=0.001). Predictors of MMI were as follows for sensitivity and specificity, respectively: ADC<80% >82 mL, 87%, 91%; TTP>+4s >162 mL, 83%, 75%; TTP/ADC mismatch ratio <2.4, 80%, 79%; ADCcore <300 mm2/s, 83%, 85%; rADClesion <0.62, 79%, 74%; and NIHSS score at admission > or =19, 96%, 72%.
Conclusions:
Quantitative analysis of early DWI and PWI parameters allows the prediction of MMI and can help in the selection of patients for aggressive tissue-protective therapy.
Insights
Early MRI scans, including diffusion-weighted imaging (DWI) and perfusion-weighted imaging (PWI), can predict malignant middle cerebral artery (MCA) infarction (MMI). This aids in selecting patients for urgent, tissue-protective treatments.
Area of Science:
- Neurology
- Radiology
- Medical Imaging
Background:
- Malignant middle cerebral artery (MCA) infarction (MMI) is a severe condition requiring timely intervention.
- Predicting MMI early is crucial for effective patient management and treatment selection.
Purpose of the Study:
- To evaluate the efficacy of early diffusion-weighted imaging (DWI) and perfusion-weighted imaging (PWI) in predicting MMI.
- To identify specific MRI parameters that correlate with MMI development.
Main Methods:
- 37 patients with acute MCA infarction and proximal vessel occlusion underwent DWI, PWI, and MR angiography within 6 hours of symptom onset.
- Lesion volumes (ADC<80%, TTP>+4s), ADCcore, rADClesion, TTP/ADC mismatch ratio, and NIHSS scores were analyzed.
- MMI was defined by clinical decline and radiological signs of space-occupying edema.
Main Results:
- Patients who developed MMI exhibited significantly larger DWI (ADC<80%) and PWI (TTP>+4s) lesion volumes.
- Lower ADCcore values, lower rADClesion, smaller TTP/ADC mismatch ratios, and higher NIHSS scores were associated with MMI.
- Specific thresholds for these parameters demonstrated high sensitivity and specificity in predicting MMI.
Conclusions:
- Quantitative analysis of early DWI and PWI parameters enables accurate prediction of MMI.
- These imaging findings can guide the selection of patients for aggressive, tissue-protective therapies.
