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Updated: Jun 8, 2026
Optimized Management of Endovascular Treatment for Acute Ischemic Stroke
Published on: January 18, 2018
Using advanced MRI techniques for patient selection before acute stroke therapy
Jean-Marc Olivot1, Gregory W Albers
1Department of Neurology and Neurological Sciences and the Stanford Stroke Center, Stanford University Medical Center, 701 Welch Road, Suite 325, Palo Alto, CA, 94304, USA.
Opinion Statement:
Results of acute MRI studies may help guide the management of acute stroke. Patients with a malignant MRI pattern may be poor candidates for reperfusion therapies yet may benefit from hemicraniectomy. Preliminary data suggest that patients with a carefully identified diffusion weighted imaging (DWI)/perfusion weighted imaging (PWI) mismatch may benefit from intravenous recombinant tissue plasminogen activator in a 3- to 6-hour time window; however, confirmatory studies with larger sample sizes are required before clinical use of this strategy can be generally recommended. Post hoc analyses of recent studies suggest that PWI techniques that use a threshold to exclude benign oligemia from penumbra and DWI techniques that use apparent diffusion coefficient thresholds to exclude reversible DWI lesions to distinguish the ischemic core from penumbra appear to provide more accurate determinations of the volume of salvageable tissue. New automated software programs are now implementing these techniques to generate quantitative PWI and DWI maps within minutes. Prospective trials are in progress to investigate these new techniques. The results of these studies will further refine the application of MRI to select patients for acute recanalization therapies.
Insights
Acute MRI studies, including diffusion weighted imaging (DWI) and perfusion weighted imaging (PWI), help guide acute stroke management. Advanced DWI/PWI mismatch analysis may identify patients who benefit from reperfusion therapies.
Area of Science:
- Neurology
- Radiology
- Medical Imaging
Background:
- Acute stroke management relies on timely and accurate patient selection for reperfusion therapies.
- Magnetic Resonance Imaging (MRI) offers advanced techniques to assess ischemic tissue.
Purpose of the Study:
- To review the role of acute MRI in guiding acute stroke management.
- To discuss the application of diffusion weighted imaging (DWI) and perfusion weighted imaging (PWI) in stroke assessment.
Main Methods:
- Analysis of preliminary data and post hoc studies on MRI techniques in acute stroke.
- Evaluation of diffusion weighted imaging (DWI) and perfusion weighted imaging (PWI) mismatch identification.
- Discussion of automated software for quantitative MRI map generation.
Main Results:
- Malignant MRI patterns may indicate poor candidacy for reperfusion but potential benefit from hemicraniectomy.
- Diffusion weighted imaging (DWI)/perfusion weighted imaging (PWI) mismatch may predict response to intravenous recombinant tissue plasminogen activator within 3-6 hours.
- Advanced DWI and PWI techniques improve the accuracy in determining salvageable brain tissue volume.
Conclusions:
- Acute MRI findings are crucial for optimizing acute stroke treatment strategies.
- Further large-scale prospective trials are needed to confirm the clinical utility of DWI/PWI mismatch for reperfusion therapy selection.
- Refined MRI applications will enhance patient selection for acute recanalization therapies.
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