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Updated: Aug 16, 2025
Optimized Management of Endovascular Treatment for Acute Ischemic Stroke
Published on: January 18, 2018
Breaking with a dogma: persisting diffusion restrictions (pDWI) in follow-up after endovascular treatment for stroke
Moritz Roman Hernandez Petzsche1, Tobias Boeckh-Behrens1, Kathleen Bernkopf2
1Department of diagnostic and interventional Neuroradiology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany.
Background:
Post-stroke diffusion weighted imaging (DWI) signal transformation of the infarct core, which results in high apparent diffusion coefficient (ADC) values and variable DWI signal intensity, is completed no later than 1 month after onset of ischemia. We observed frequent exceptions to this timeline of change in DWI signal, which led to uncertainties in further clinical patient management.
Methods:
A prospective single-center study of patients treated with mechanical thrombectomy of a large vessel occlusion in the anterior circulation was conducted. Patients received high-resolution MRI at 3T, including DWI, in the acute post-stroke phase and in the follow-up after 3-12 months.
Results:
Overall, 78 patients (45 men) of mean age 63.6 years were evaluated. We identified persisting or new diffusion restriction in 29 of the 78 patients (37.2%) on follow-up imaging. Diffusion restrictions in a different location from the infarct core, representing new (sub-)acute ischemia, were observed in four patients (5.1%). Smaller areas of persisting diffusion restriction (pDWI lesions with high DWI signal and reduced ADC values) within the former infarct core were observed in 25 patients (32.1%) without clinical evidence of recurrent stroke, but with worse outcome scores at follow-up compared with patients without pDWI lesions. The presence of pDWI lesions is associated with a large primary infarct core (multivariate regression OR 1.03 (95% CI 1.01 to 1.05); p<0.01), mediating the relationship between pDWI lesions and clinical outcome.
Conclusion:
Smaller foci of persisting diffusion restriction (pDWI lesions) in the follow-up after endovascular treatment for stroke are frequent and likely represent a slowed ADC signal progression within a formerly large infarct core.
Insights
Persisting diffusion restriction on follow-up MRI after stroke treatment is common. These pDWI lesions, often within the original infarct core, correlate with worse patient outcomes.
Area of Science:
- Neurology
- Radiology
- Medical Imaging
Background:
- Diffusion-weighted imaging (DWI) signal changes in stroke infarct cores typically normalize within one month.
- Deviations from this timeline create uncertainty in clinical management.
- Mechanical thrombectomy is a key treatment for large vessel occlusion stroke.
Purpose of the Study:
- To investigate the frequency and implications of atypical DWI signal changes in patients treated with mechanical thrombectomy.
- To analyze the relationship between persisting diffusion restriction (pDWI) and clinical outcomes.
Main Methods:
- Prospective single-center study involving 78 patients undergoing mechanical thrombectomy for anterior circulation large vessel occlusion.
- High-resolution 3T MRI, including DWI, was performed in the acute phase and at 3-12 month follow-up.
- Analysis of diffusion restriction on follow-up imaging and correlation with clinical outcomes.
Main Results:
- Persisting or new diffusion restriction was observed in 37.2% of patients on follow-up.
- Smaller areas of persisting diffusion restriction (pDWI lesions) within the infarct core were found in 32.1% of patients.
- pDWI lesions were associated with larger initial infarct cores and worse clinical outcomes, despite no clinical evidence of recurrent stroke.
Conclusions:
- Smaller foci of persisting diffusion restriction (pDWI lesions) are frequent after endovascular stroke treatment.
- These pDWI lesions likely represent delayed apparent diffusion coefficient (ADC) signal normalization within a large infarct core.
- The presence of pDWI lesions is an independent predictor of worse clinical outcomes.
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