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Updated: Aug 25, 2026
A Magnetic Resonance Imaging Protocol for Stroke Onset Time Estimation in Permanent Cerebral Ischemia
Published on: September 16, 2017
More accurate identification of reversible ischemic injury in human stroke by cerebrospinal fluid suppressed
Julie L Bykowski1, Lawrence L Latour, Steven Warach
1Section on Stroke Diagnostics and Therapeutics, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Md, USA.
Background And Purpose:
The apparent diffusion coefficient (ADC) derived from diffusion-weighted (DWI) MRI has been used to differentiate reversible from irreversible ischemic injury. However, the ADC can be falsely elevated by partial volume averaging of cerebrospinal fluid (CSF) with parenchyma, limiting the accuracy of this approach. This study tested the hypothesis that the accuracy of differentiating reversible from irreversible ischemic injury could be improved by CSF suppression at image acquisition.
Methods:
Sixteen patients presenting within 6 hours from symptoms, and having partial reversal of the acute lesion on DWI were studied using conventional CSF-suppressed DWI. Lesions were segmented from coregistered acute DWI and follow-up fluid-attenuated inversion recovery (FLAIR) series. The segmented volumes were applied to conventional (ADC(C)) and CSF-suppressed ADC (ADC(FLIPD)) maps to classify each voxel as progressed to infarct or reversed. Individual voxel ADC values were pooled across all patients. Sensitivity to predict reversal, specificity, and accuracy were calculated for both methods.
Results:
A total of 25 313 voxels were classified as progressed and 31 952 voxels reversed. Across all lesion voxels, ADC(FLIPD) values more accurately depicted tissue fate compared with ADC(C) values (P<0.0001). The largest difference in the two methods was in voxels with <75% parenchyma, where the accuracy of ADC(C) was only 50% compared with 62% for ADC(FLIPD.)
Conclusions:
CSF-suppressed ADC measurements gave a more accurate identification of reversible ischemic injury in this sample. We predict that multimodal MRI models of tissue viability in ischemic stroke will be more accurate if CSF-suppressed ADC measurements are used.
Insights
Cerebrospinal fluid (CSF) suppression in diffusion-weighted MRI improves apparent diffusion coefficient (ADC) accuracy for distinguishing reversible from irreversible ischemic injury. This enhanced MRI technique offers more precise tissue viability assessment in stroke patients.
Area of Science:
- Neuroimaging
- Radiology
- Stroke Research
Background:
- Apparent diffusion coefficient (ADC) from diffusion-weighted MRI (DWI) is crucial for differentiating reversible from irreversible ischemic injury.
- Partial volume averaging of cerebrospinal fluid (CSF) with brain parenchyma can falsely elevate ADC values, reducing diagnostic accuracy.
- Existing MRI methods face limitations in accurately assessing tissue viability due to CSF contamination.
Purpose of the Study:
- To test the hypothesis that CSF suppression during image acquisition can improve the accuracy of differentiating reversible from irreversible ischemic injury.
- To evaluate the efficacy of CSF-suppressed DWI in stroke assessment.
- To enhance the reliability of MRI in predicting tissue fate after ischemic events.
Main Methods:
- Sixteen patients with acute ischemic stroke presenting within 6 hours were studied using conventional and CSF-suppressed DWI.
- Lesions were segmented from coregistered DWI and follow-up fluid-attenuated inversion recovery (FLAIR) images.
- Voxel-wise ADC values from conventional (ADC(C)) and CSF-suppressed (ADC(FLIPD)) maps were compared for accuracy in classifying tissue fate.
Main Results:
- CSF-suppressed ADC (ADC(FLIPD)) values demonstrated significantly higher accuracy in depicting tissue fate compared to conventional ADC (ADC(C)) (P<0.0001).
- The accuracy improvement was most pronounced in voxels with less than 75% parenchyma, where ADC(C) accuracy was 50% versus 62% for ADC(FLIPD).
- A total of 25,313 voxels were classified as progressed to infarct and 31,952 as reversed across all patients.
Conclusions:
- CSF-suppressed ADC measurements provide a more accurate identification of reversible ischemic injury.
- Integrating CSF-suppressed ADC measurements into multimodal MRI models is predicted to enhance tissue viability assessment in ischemic stroke.
- This technique offers a promising advancement for clinical decision-making in acute stroke management.
