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Search for a map and threshold in perfusion MRI to accurately predict tissue fate: a protocol for assessing lesion
Ivana Galinovic1, Ann-Christin Ostwaldt, Carina Soemmer
1Center for Stroke Research Berlin (CSB), Charité-University Medicine Berlin, Campus Benjamin Franklin, Berlin, Germany. ivana.galinovic@charite.de
Background:
The MRI-based mismatch concept has been used to estimate the risk of infarction in ischemic stroke. Based on multiple studies on magnetic resonance perfusion imaging, it seems unlikely that any perfusion parameter threshold will provide a reliable prediction of radiological or clinical outcome for all patients. The goal of our study was to find a minimally biased yet maximally useful perfusion postprocessing protocol which would offer the treating physician a useful estimate of tissue fate.
Methods:
One hundred and forty-five acute ischemic stroke patients, admitted within 24 h after stroke to the Charité-University Medicine Hospital in Berlin between March 2008 and November 2009, were included in this study. Using three different software packages (Perfscape/Neuroscape, PMA and Stroketool), maps of mean transit time, cerebral blood flow (CBF) and T(max) were created. Three different thresholds were applied on each parameter map and subsequent volumes of hypoperfused tissue were calculated.
Results:
Overall, the maps and thresholds giving the least amount of overestimation of the final infarct volume were T(max) 8 s in Perfscape/Neuroscape, CBF 20 ml/100 g/min in PMA and CBF 15% (of the highest value on the scale for a given patient) in Stroketool. In patients with persistent vessel occlusion, a CBF map with a restrictive threshold showed volumes of tissue at definite risk of infarction in up to 100% of patients. The additional use of a CBF map with a high threshold enabled identification of patients without penumbras.
Conclusions:
No combination of software, map and threshold was able to give a reliable estimate of tissue fate for either all patients or any subgroup of patients. However, in patients with vessel occlusion, combination of a CBF map with a low and a high threshold can enable calculation of the minimum volume of brain tissue that will inevitably be lost if the occlusion persists.
Insights
Estimating ischemic stroke outcomes is challenging. This study found no single MRI perfusion method reliably predicts infarct volume, but specific protocols may help assess tissue fate in vessel occlusion cases.
Area of Science:
- Neurology
- Radiology
- Medical Imaging
Background:
- The mismatch concept using MRI aids in estimating ischemic stroke infarction risk.
- Previous studies suggest perfusion parameter thresholds may not reliably predict outcomes.
- A need exists for a robust perfusion postprocessing protocol to estimate tissue fate.
Purpose of the Study:
- To evaluate different MRI perfusion postprocessing protocols for predicting ischemic stroke outcomes.
- To identify a minimally biased and maximally useful protocol for estimating tissue fate.
Main Methods:
- 145 acute ischemic stroke patients were analyzed.
- Three software packages (Perfscape/Neuroscape, PMA, Stroketool) generated maps for mean transit time, cerebral blood flow (CBF), and Tmax.
- Three thresholds were applied to calculate hypoperfused tissue volumes.
Main Results:
- Tmax 8s (Perfscape/Neuroscape), CBF 20 ml/100 g/min (PMA), and CBF 15% (Stroketool) showed the least overestimation of infarct volume.
- CBF maps with restrictive thresholds identified tissue at definite risk in up to 100% of patients with persistent vessel occlusion.
- High-threshold CBF maps helped identify patients without penumbras.
Conclusions:
- No single software, map, or threshold combination reliably predicted tissue fate for all patients.
- In vessel occlusion cases, combining low and high threshold CBF maps can calculate the minimum inevitable brain tissue loss.
- This approach offers a more precise estimation of tissue fate in specific stroke scenarios.
