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From the Departments of Neurology (Dr. Schlaug, A. Benfield, and Drs. Baird and Warach) and Radiology (Drs. Siewert, Lövblad, Edelman, and Warach) and Biometrics Center (R.A. Parker), Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA.
Address correspondence and reprint requests to Dr. Gottfried Schlaug, Department of Neurology, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02215; or Dr. Steven Warach, National Institute of Neurological Disorders and Stroke, Section on Stroke Diagnostics and Therapeutics, 10 Center Drive, Room 3B10A, MSC 1250, Bethesda, MD 20892.
BACKGROUND: Identifying tissue at risk for infarction is important in deciding which patients would benefit most from potentially harmful therapies and provides a way to evaluate newer therapies with regard to the amount of ischemic tissue salvaged.
OBJECTIVE: To operationally define and characterize cerebral tissue at risk for stroke progression.
METHODS: We retrospectively selected 25 patients with an acute onset of a hemispheric stroke from our database who had undergone a combination of two diffusion-weighted MRI studies and a perfusion-weighted MRI study. We applied a logistic regression model using maps of the relative mean transit time and relative cerebral blood flow (rCBF) as well as three different maps of the relative cerebral blood volume (rCBV) to predict an operationally defined penumbra (region of mismatch between the diffusion lesion on day 1 and its extension 24 to 72 hours later).
RESULTS: Maps of the rCBF and initial rCBV were significant predictors for identifying penumbral tissue. Our operationally defined penumbral region was characterized by a reduction in the initial rCBV (47% of contralateral control region [CCR]), an increase (163% of CCR) in the total rCBV, and a reduction (37% of CCR) in the rCBF, whereas the operationally defined ischemic core showed a more severe reduction in the rCBF (12% of CCR) and in the initial rCBV (19% of CCR).
CONCLUSION: These MR indexes may allow the identification and quantification of viable but ischemically threatened cerebral tissue amenable to therapeutic interventions in the hyperacute care of stroke patients.
Key words: Ischemic penumbra—Diffusion-weighted imaging—Cerebrovascular disease—MRI—Ischemic stroke.
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P.A. Ringleb, P.D. Schellinger, C. Schranz, and W. Hacke Thrombolytic Therapy Within 3 to 6 Hours After Onset of Ischemic Stroke: Useful or Harmful? Stroke, May 1, 2002; 33(5): 1437 - 1441. [Abstract] [Full Text] [PDF]
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J. N. Fink, M. H. Selim, S. Kumar, B. Silver, I. Linfante, L. R. Caplan, and G. Schlaug Is the Association of National Institutes of Health Stroke Scale Scores and Acute Magnetic Resonance Imaging Stroke Volume Equal for Patients With Right- and Left-Hemisphere Ischemic Stroke? Stroke, April 1, 2002; 33(4): 954 - 958. [Abstract] [Full Text] [PDF]
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F. Calamante, D.G. Gadian, and A. Connelly Quantification of Perfusion Using Bolus Tracking Magnetic Resonance Imaging in Stroke: Assumptions, Limitations, and Potential Implications for Clinical Use Stroke, April 1, 2002; 33(4): 1146 - 1151. [Abstract] [Full Text] [PDF]
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J. Fiehler, M. Foth, T. Kucinski, R. Knab, M. von Bezold, C. Weiller, H. Zeumer, and J. Rother Severe ADC Decreases Do Not Predict Irreversible Tissue Damage In Humans Stroke, January 1, 2002; 33(1): 79 - 86. [Abstract] [Full Text] [PDF]
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C. S. Kidwell, J. L. Saver, J. Mattiello, S. Warach, D. S. Liebeskind, S. Starkman, P. M. Vespa, J. P. Villablanca, N. A. Martin, J. Frazee, et al. Diffusion-perfusion MR evaluation of perihematomal injury in hyperacute intracerebral hemorrhage Neurology, November 13, 2001; 57(9): 1611 - 1617. [Abstract] [Full Text] [PDF]
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C. Oppenheim, C. Grandin, Y. Samson, A. Smith, T. Duprez, C. Marsault, and G. Cosnard Is There an Apparent Diffusion Coefficient Threshold in Predicting Tissue Viability in Hyperacute Stroke? Stroke, November 1, 2001; 32(11): 2486 - 2491. [Abstract] [Full Text] [PDF]
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V. N. Thijs, A. Adami, T. Neumann-Haefelin, M. E. Moseley, M. P. Marks, and G. W. Albers Relationship between severity of MR perfusion deficit and DWI lesion evolution Neurology, October 9, 2001; 57(7): 1205 - 1211. [Abstract] [Full Text] [PDF]
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A. J. Barkovich, K. D. Westmark, H. S. Bedi, J. C. Partridge, D. M. Ferriero, and D. B. Vigneron Proton Spectroscopy and Diffusion Imaging on the First Day of Life after Perinatal Asphyxia: Preliminary Report AJNR Am. J. Neuroradiol., October 1, 2001; 22(9): 1786 - 1794. [Abstract] [Full Text] [PDF]
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S. Warach New imaging strategies for patient selection for thrombolytic and neuroprotective therapies Neurology, September 1, 2001; 57(90002): S48 - 52. [Abstract] [Full Text]
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P. M. Desmond, A. C. Lovell, A. A. Rawlinson, M. W. Parsons, P. A. Barber, Q. Yang, T. Li, D. G. Darby, R. P. Gerraty, S. M. Davis, et al. The Value of Apparent Diffusion Coefficient Maps in Early Cerebral Ischemia AJNR Am. J. Neuroradiol., August 1, 2001; 22(7): 1260 - 1267. [Abstract] [Full Text] [PDF]
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I. A. Staroselskaya, C. Chaves, B. Silver, I. Linfante, R. R. Edelman, L. Caplan, S. Warach, and A. E. Baird Relationship Between Magnetic Resonance Arterial Patency and Perfusion-Diffusion Mismatch in Acute Ischemic Stroke and Its Potential Clinical Use Arch Neurol, July 1, 2001; 58(7): 1069 - 1074. [Abstract] [Full Text] [PDF]
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M. W. Parsons, Q. Yang, P. A. Barber, D. G. Darby, P. M. Desmond, R. P. Gerraty, B. M. Tress, and S. M. Davis Perfusion Magnetic Resonance Imaging Maps in Hyperacute Stroke : Relative Cerebral Blood Flow Most Accurately Identifies Tissue Destined to Infarct Stroke, July 1, 2001; 32(7): 1581 - 1587. [Abstract] [Full Text] [PDF]
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 C. P. Derdeyn Physiological Neuroimaging: Emerging Clinical Applications JAMA, June 27, 2001; 285(24): 3065 - 3068. [Full Text] [PDF]
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L. Rohl, L. Ostergaard, C. Z. Simonsen, P. Vestergaard-Poulsen, G. Andersen, M. Sakoh, D. Le Bihan, and C. Gyldensted Viability Thresholds of Ischemic Penumbra of Hyperacute Stroke Defined by Perfusion-Weighted MRI and Apparent Diffusion Coefficient Stroke, May 1, 2001; 32(5): 1140 - 1146. [Abstract] [Full Text] [PDF]
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C. B. Grandin, T. P. Duprez, A. M. Smith, F. Mataigne, A. Peeters, C. Oppenheim, and G. Cosnard Usefulness of Magnetic Resonance-Derived Quantitative Measurements of Cerebral Blood Flow and Volume in Prediction of Infarct Growth in Hyperacute Stroke Stroke, May 1, 2001; 32(5): 1147 - 1153. [Abstract] [Full Text] [PDF]
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P.J. Kelly, E.T. Hedley-Whyte, J. Primavera, J. He, and R.G. Gonzalez Diffusion MRI in ischemic stroke compared to pathologically verified infarction Neurology, April 10, 2001; 56(7): 914 - 920. [Abstract] [Full Text] [PDF]
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H. A. Rowley The Four Ps of Acute Stroke Imaging: Parenchyma, Pipes, Perfusion, and Penumbra AJNR Am. J. Neuroradiol., April 1, 2001; 22(4): 599 - 601. [Full Text]
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I. Linfante, R. H. Llinas, G. Schlaug, C. Chaves, S. Warach, and L. R. Caplan Diffusion-Weighted Imaging and National Institutes of Health Stroke Scale in the Acute Phase of Posterior-Circulation Stroke Arch Neurol, April 1, 2001; 58(4): 621 - 628. [Abstract] [Full Text] [PDF]
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O. Wu, W. J. Koroshetz, L. Ostergaard, F. S. Buonanno, W. A. Copen, R. G. Gonzalez, G. Rordorf, B. R. Rosen, L. H. Schwamm, R. M. Weisskoff, et al. Predicting Tissue Outcome in Acute Human Cerebral Ischemia Using Combined Diffusion- and Perfusion-Weighted MR Imaging Stroke, April 1, 2001; 32(4): 933 - 942. [Abstract] [Full Text] [PDF]
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A. Doerfler, T. Engelhorn, M. Forsting, C. Oppenheim, and Y. Samson Decompressive Craniectomy for Early Therapy and Secondary Prevention of Cerebral Infarction Response Stroke, March 1, 2001; 32(3): 813 - 815. [Full Text] [PDF]
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M. Koenig, M. Kraus, C. Theek, E. Klotz, W. Gehlen, and L. Heuser Quantitative Assessment of the Ischemic Brain by Means of Perfusion-Related Parameters Derived From Perfusion CT Stroke, February 1, 2001; 32(2): 431 - 437. [Abstract] [Full Text] [PDF]
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T. Back, J. G. Hirsch, K. Szabo, and A. Gass Failure to Demonstrate Peri-Infarct Depolarizations by Repetitive MR Diffusion Imaging in Acute Human Stroke Stroke, December 1, 2000; 31(12): 2901 - 2906. [Abstract] [Full Text] [PDF]
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