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From the Stanford Stroke Center, Department of Neurology and Neurological Sciences (Drs. Thijs, Adami, and Albers), and Department of Radiology, Section of Neuroradiology (Drs. Marks and Moseley), Stanford University Medical Center, Palo Alto, CA; Department of Neurology (Dr. Thijs), UZ Gasthuisberg, Katholieke Universiteit Leuven, Belgium; Clinica Neurologica (Dr. Adami), Universitá di Verona; and the Department of Neurology (Dr. Neumann–Haefelin), Johann-Wolfgang Goethe Universität, Frankfurt, Germany.
Address correspondence to Dr. Vincent N. Thijs, Department of Neurology, UZ Gasthuisberg, Katholieke Universiteit Leuven, Herestraat 49, B-3000 Leuven, Belgium; e-mail: vincent.thijs{at}uz.kuleuven.ac.be
Objective: To assess whether a quantitative analysis of the severity of the early perfusion deficit on MRI in acute ischemic stroke predicts the evolution of the perfusion/diffusion mismatch and to determine thresholds of hypoperfusion that can distinguish between critical and noncritical hypoperfusion. Methods: Patients with acute ischemic stroke were studied in whom perfusion-weighted imaging (PWI) and diffusion-weighted imaging (DWI MRI) were performed within 7 hours of symptom onset and again after 4 to 7 days. Patients with early important decreases in points on the NIH Stroke Scale were excluded. Maps of cerebral blood flow (CBF), cerebral blood volume (CBV), and mean transit time (MTT) were created. These hemodynamic parameters were correlated with the degree of recruitment of the baseline PWI lesion by the DWI lesion. Results: Twelve patients had an initial PWI > DWI mismatch of >20%. A linear relationship was observed between the initial MTT and the degree of recruitment of the baseline PWI lesion by the DWI lesion at follow-up (R2 = 0.9, p < 0.001). Higher CBV values were associated with higher degrees of recruitment (
= 0.732, p < 0.007). The volume of MTT of >4 (R2 = 0.86, p < 0.001) or >6 seconds (R2 = 0.85, p < 0.001) predicted final infarct size. Conclusion: Among patients who have had an acute stroke with PWI > DWI, who do not have dramatic early clinical improvement, the degree of expansion of the initial DWI lesion correlates with the severity of the initial perfusion deficit as measured by the mean transit time and the cerebral blood volume.
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