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Clinical outcome in ischemic stroke predicted by early diffusion-weighted and perfusion magnetic resonance imaging: a
S Warach1, J F Dashe, R R Edelman
1Department of Neurology, Beth Israel Hospital, Harvard Medical School, Boston, Massachusetts 02215, USA.
Abstract:
Perfusion and diffusion-weighted magnetic resonance imaging (MRI) can demonstrate, respectively, cerebral ischemia and ischemic brain injury in the first several hours after onset of symptoms, when proton density and T2-weighted MRI may appear normal. It is hypothesized that these techniques could distinguish regions destined for infarction from those that will not progress to infarction. We provide preliminary evidence from an analysis of 19 patients with severely disabling clinical deficits attributable to ischemia in at least an entire division of the middle cerebral artery, that initial perfusion and diffusion MRI were more accurate than conventional MRI in predicting no, partial or complete improvement--17 of 19 cases (p < 0.0001) versus 10 of 19 cases, respectively. In the subset of patients studied within 6 h of onset, diffusion/perfusion MRI was an even better predictor than conventional MRI--11 of 12 versus four of 12, respectively. In this small sample of patients with severe clinical deficits, perfusion and diffusion MRI were highly accurate in distinguishing those who would improve from those who would not. These results need to be confirmed in a larger prospective study, which may support a future role in the initial screening, selection, and evaluation of patients with stroke for acute pharmacologic interventions.
Insights
Perfusion and diffusion MRI accurately predict stroke recovery. These advanced imaging techniques show better results than conventional MRI in identifying patients likely to improve after ischemic stroke.
Area of Science:
- Neurology
- Radiology
- Medical Imaging
Background:
- Conventional MRI may appear normal in early ischemic stroke.
- Perfusion and diffusion MRI can detect cerebral ischemia and injury within hours of symptom onset.
- These advanced MRI techniques may differentiate between infarct-destined tissue and salvageable tissue.
Purpose of the Study:
- To evaluate the accuracy of perfusion and diffusion MRI in predicting clinical improvement in patients with severe ischemic stroke.
- To compare the predictive accuracy of advanced MRI techniques with conventional MRI.
Main Methods:
- Analysis of 19 patients with severe middle cerebral artery (MCA) territory ischemia.
- Initial assessment using perfusion-weighted MRI, diffusion-weighted MRI, and conventional MRI.
- Correlation of imaging findings with clinical outcomes (no, partial, or complete improvement) at follow-up.
Main Results:
- Perfusion and diffusion MRI were significantly more accurate (17/19 cases) than conventional MRI (10/19 cases) in predicting clinical improvement (p < 0.0001).
- In patients studied within 6 hours of symptom onset, diffusion/perfusion MRI showed even higher accuracy (11/12) compared to conventional MRI (4/12).
- Advanced MRI techniques accurately distinguished patients with severe deficits who would improve from those who would not.
Conclusions:
- Perfusion and diffusion MRI are highly accurate in predicting clinical improvement in patients with severe ischemic stroke.
- These findings suggest a potential role for advanced MRI in the early evaluation of stroke patients for acute interventions.
- Further confirmation in larger prospective studies is warranted to support clinical implementation.