Limited Reliability of Computed Tomographic Perfusion Acute Infarct Volume Measurements Compared With Diffusion-Weighted Imaging in Anterior Circulation Stroke

AbstractIntraoperatively acquired diffusion-weighted imaging (DWI) sequences in cranial tumor surgery are used for early detection of ischemic brain injuries, which could result in impaired neurological outcome and their presence might thus influence the neurosurgeon’s decision on further resection. The phenomenon of false-negative DWI findings in intraoperative magnetic resonance imaging (ioMRI) has only been reported in single cases and therefore yet needs to be further analyzed. This retrospective single-center study’s objective was the identification and characterization of false-negative DWI findings in ioMRI with new or enlarged ischemic areas on postoperative MRI (poMRI). Out of 225 cranial tumor surgeries with intraoperative DWI sequences, 16 cases with no additional resection after ioMRI and available in-time poMRI (< 14 days) were identified. Of these, a total of 12 cases showed false-negative DWI in ioMRI (75%). The most frequent tumor types were oligodendrogliomas and glioblastomas (4 each). In 5/12 cases (41.7%), an ischemic area was already present in ioMRI, however, volumetrically increased in poMRI (mean infarct growth + 2.1 cm3; 0.48–3.6), whereas 7 cases (58.3%) harbored totally new infarcts on poMRI (mean infarct volume 0.77 cm3; 0.05–1.93). With this study we provide the most comprehensive series of false-negative DWI findings in ioMRI that were not followed by additional resection. Our study underlines the limitations of intraoperative DWI sequences for the detection and size-estimation of hyperacute infarction. The awareness of this phenomenon is crucial for any neurosurgeon utilizing ioMRI.

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Diffusion imaging of cerebral diaschisis in childhood arterial ischemic stroke

International Journal of Stroke ◽

10.1177/1747493016666089 ◽

2016 ◽

Vol 11 (9) ◽

pp. 1028-1035 ◽

Cited By ~ 10

Author(s):

Adam Kirton ◽

Elizabeth Williams ◽

Michael Dowling ◽

Sarah Mah ◽

Jacquie Hodge ◽

...

Keyword(s):

Magnetic Resonance Imaging ◽

Ischemic Stroke ◽

Magnetic Resonance ◽

Diffusion Weighted Imaging ◽

Infarct Volume ◽

Resonance Imaging ◽

Arterial Ischemic Stroke ◽

Diffusion Weighted ◽

Motor Outcome

Background Diffusion-weighted imaging magnetic resonance imaging may detect changes in brain structures remote but connected to stroke consistent with neuropathological descriptions of diaschisis. Early diffusion-weighted imaging demonstrates restriction in corticospinal pathways after arterial ischemic stroke of all ages that correlates with motor outcome. Aim/hypothesis We hypothesized that cerebral diaschisis is measurable in childhood arterial ischemic stroke and explored associations with outcome. Methods This sub-study of the validation of the Pediatric NIH Stroke Scale study prospectively enrolled children with acute arterial ischemic stroke and both acute and early follow-up (5–14 days) diffusion-weighted imaging. Inclusion criteria were (1) unilateral middle cerebral artery arterial ischemic stroke, (2) acute and subacute diffusion-weighted imaging ( b = 1000), and (3) 12 month neurological follow-up (Pediatric Stroke Outcome Measure). A validated method using ImageJ software quantified diffusion-weighted imaging diaschisis in anatomically connected structures. Diaschisis measures were corrected for infarct volume, compared to age, imaging timing, and outcomes (Chi square/Fisher, Mann–Whitney test). Results Nineteen children (53% male, median 8.1 years) had magnetic resonance imaging at medians of 21 and 168 h post-stroke onset. Diaschisis was common and evolved over time, observed in one (5%) on acute but eight (42%) by follow-up diffusion-weighted imaging. Thalamic and callosal diaschisis were most common (5, 26%). Estimates of perilesional diaschisis varied (54 ± 18% of infarct volume). Children with diaschisis tended to be younger (7.02 ± 5.4 vs. 11.82 ± 4.3 years, p = 0.08). Total diaschisis score was associated with poor cognitive outcomes ( p = 0.03). Corticospinal tract diaschisis was associated with motor outcome ( p = 0.004). Method reliability was excellent. Conclusions Diffusion-weighted imaging diaschisis occurs in childhood arterial ischemic stroke. Mistaking diaschisis for new areas of infarction carries important clinical implications. Improved recognition and study are required to establish clinical relevance.

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Abstract P362: A Volumetric Comparison of Computed Tomography Perfusion Rapid Core Volume in Different Time Frames With Diffusion-Weighted Imaging Infarct Volume in the Post-Thrombectomy Patients After Large Vessel Occlusion

Stroke ◽

10.1161/str.52.suppl_1.p362 ◽

2021 ◽

Vol 52 (Suppl_1) ◽

Author(s):

Riwaj Bhagat ◽

Krishna Madireddy ◽

Shivani Naik ◽

Gopika Kutty ◽

Wei Liu

Keyword(s):

Symptom Onset ◽

Diffusion Weighted Imaging ◽

Infarct Volume ◽

Time Frame ◽

Large Vessel Occlusion ◽

Anterior Circulation ◽

Vessel Occlusion ◽

Computed Tomography Perfusion ◽

Time Frames ◽

Core Volume

Introduction: The Computed Tomography Perfusion (CTP) RAPID software is widely used for the patient selection for mechanical thrombectomy (MT) after anterior circulation large vessel occlusion (LVO). There is a notion that it overestimates the core volume (CV) in an earlier time frame from symptom onset. We compared the accuracy of CTP RAPID estimated CV in different time frames with diffusion weighted imaging (DWI) infarct volume (IV). Method: A retrospective data review of patients who underwent MT for anterior circulation LVO with TICI 2b/3 reperfusion from 2017 to 2019 was done. Patients with baseline CTP and follow up 36-hour MRI was included. Patients with parenchymal hematoma, graded as per ECASS II classification were excluded. CTP time was dichotomized as 0-3 hours (hrs) and >3 hrs from symptom onset. DWI IV was calculated by ABC/2 formula. The volumetric difference (VD), defined as DWI IV minus CTP CV, core volume overestimation (CVO), defined as CTP CV minus DWI IV and CT ASPECTS was calculated. Large CV was defined as >50 ml CV. Standard descriptive statistics and independent sample T-test were used as statistical tools. Result: Total MT cases (n) were 61. Mean age (y.o) was 66 (SD 13.9) (male 57.4%). In < 3 hrs from symptom onset (n 27), mean CTP CV was 38.8 ml (SD 39.8), DWI IV was 39.6 ml (SD 51.4), VD was 0.9 ml (SD 55.2) (p 0.945) and CVO (n 11) was 39.6 ml (SD 35.7) (p 0.008). Mean large CV (n 8) was 78.3 ml (SD 25.4) with median CT ASPECTS of 8 (IQR 6.5-9) and median mRS at discharge 2 (IQR 0.8- 3.3). In >3 hrs from symptom onset (n 34), mean CTP CV was 28.81 ml (SD 47.4), DWI IV was 75.3 ml (SD 69.5), VD was 46.5 ml (SD 61.8) (p 0.002) and CVO (n 5) was 25.2 ml (SD 41.27) (p 0.60). Mean large CV (n 5) was 116.8 ml (SD 75.3) with median CT ASPECTS of 6 (IQR 5-7) and median mRS at discharge 5 (IQR 4- 6). Conclusion: Overestimated core volume on CTP was seen in more than one third cases within 3 hours from symptom onset. Large CV estimated within this time frame had higher CT ASPECTS and good functional outcome at discharge.

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Abstract T MP62: Acute Infarct Volume in Perinatal Stroke Can Be Accurately Estimated by Measuring Residual Uninfarcted Tissue on Follow-up MRI

Stroke ◽

10.1161/str.46.suppl_1.tmp62 ◽

2015 ◽

Vol 46 (suppl_1) ◽

Author(s):

Nicholas V Stence ◽

David M Mirsky ◽

David Weitzenkamp ◽

Sharon Poisson ◽

Paco S Herson ◽

...

Keyword(s):

Brain Tissue ◽

Direct Measurement ◽

Infarct Volume ◽

Arterial Ischemic Stroke ◽

Total Brain Volume ◽

Total Brain ◽

Acute Infarct ◽

Volume Measurements ◽

Perinatal Arterial Ischemic Stroke

Introduction: Developing accurate measurements of infarct volume is vital to studying outcomes in Perinatal Arterial Ischemic Stroke (PAS). Methods for measuring Acute Infarct Volumes (aIV) are well established in PAS. However, techniques for measuring chronic infarct volume (cIV) in order to estimate aIV have not been validated and must account for changes in Total Brain Volume (TBV) over time, as well as contraction of the infarct. We compared two methods of measuring cIV, hypothesizing that cIV extrapolated from residual uninfarcted brain tissue volume would better estimate aIV than direct measurement of cIV. Methods: Using modified manual segmentation techniques, two pediatric neuroradiologists independently measured the brain and infarct volumes of 10 PAS patients both on the acute (0-7 days old) and chronic (>3 months) MRIs. Volume measurements were averaged after high inter-rater reliability was established (ICC>0.9). We evaluated acute and chronic scans for changes in infarct anatomy, and excluded patients with bilateral infarctions. Method 1 for estimating cIV used a direct measurement of the infarct (figure). Method 2 extrapolated infarct volume from residual uninfarcted brain tissue (figure). The cIV for each method was then compared to the aIV. Results: 3 patients with bilateral infarcts were excluded. Infarct anatomy between acute and chronic scans did not change for the 7 unilateral infarcts evaluated. In these 7 cases, the ICC comparing aIV and cIV from Method 1 was 0.507 (CI -0.120, 0.891), while the ICC comparing aIV and cIV from Method 2 was 0.964 (CI 0.821, 0.994). cIV’s from Method 1 were smaller than the aIV’s in all cases, despite stability of infarct anatomy. Conclusions: In this pilot study measuring cIV in PAS, direct measurement of cIV likely underestimates volume because of contraction of infarcted tissue. In conclusion, extrapolation of cIV from measurement of residual uninfarcted tissue appears to accurately estimate aIV.

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Qualitative Posttreatment Diffusion-Weighted Imaging as a Predictor of 90-day Outcome in Stroke Intervention

Canadian Journal of Neurological Sciences / Journal Canadien des Sciences Neurologiques ◽

10.1017/cjn.2019.330 ◽

2019 ◽

Vol 47 (2) ◽

pp. 160-166

Author(s):

Adam A Dmytriw ◽

Abdullah Alrashed ◽

Alejandro Enriquez-Marulanda ◽

Shadi Daghighi ◽

Ghouth Waggas ◽

...

Keyword(s):

Diffusion Weighted Imaging ◽

Infarct Volume ◽

Multivariable Analysis ◽

Poor Performance ◽

Recombinant Tissue Plasminogen Activator ◽

National Institutes Of Health ◽

Infarct Core ◽

Vessel Occlusion ◽

Subjective Impression ◽

Diffusion Weighted

ABSTRACT:Purpose:The aim was to assess the ability of post-treatment diffusion-weighted imaging (DWI) to predict 90-day functional outcome in patients with endovascular therapy (EVT) for large vessel occlusion in acute ischemic stroke (AIS).Methods:We examined a retrospective cohort from March 2016 to January 2018, of consecutive patients with AIS who received EVT. Planimetric DWI was obtained and infarct volume calculated. Four blinded readers were asked to predict modified Rankin Score (mRS) at 90 days post-thrombectomy.Results:Fifty-one patients received endovascular treatment (mean age 65.1 years, median National Institutes of Health Stroke Scale (NIHSS) 18). Mean infarct volume was 43.7 mL. The baseline NIHSS, 24-hour NIHSS, and the DWI volume were lower for the mRS 0–2 group. Also, the thrombolysis in cerebral infarction (TICI) 2b/3 rate was higher in the mRS 0–2 group. No differences were found in terms of the occlusion level, reperfusion technique, or recombinant tissue plasminogen activator use. There was a significant association noted between average infarct volume and mRS at 90 days. On multivariable analysis, higher infarct volume was significantly associated with 90-day mRS 3–5 when adjusted to TICI scores and occlusion location (OR 1.01; CI 95% 1.001–1.03; p = 0.008). Area under curve analysis showed poor performance of DWI volume reader ability to qualitatively predict 90-day mRS.Conclusion:The subjective impression of DWI as a predictor of clinical outcome is poorly correlated when controlling for premorbid status and other confounders. Qualitative DWI by experienced readers both overestimated the severity of stroke for patients who achieved good recovery and underestimated the mRS for poor outcome patients. Infarct core quantitation was reliable.

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Comparison of computed tomographic urography, magnetic resonance urography and the combination of diffusion weighted imaging in diagnosis of upper urinary tract cancer

European Journal of Radiology ◽

10.1016/j.ejrad.2014.02.019 ◽

2014 ◽

Vol 83 (6) ◽

pp. 893-899 ◽

Cited By ~ 7

Author(s):

Guang-yu Wu ◽

Qing Lu ◽

Lian-ming Wu ◽

Jin Zhang ◽

Xiao-xi Chen ◽

...

Keyword(s):

Urinary Tract ◽

Magnetic Resonance ◽

Diffusion Weighted Imaging ◽

Upper Urinary Tract ◽

Magnetic Resonance Urography ◽

Tract Cancer ◽

Computed Tomographic ◽

Diffusion Weighted ◽

Urinary Tract Cancer ◽

Upper Urinary Tract Cancer

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Change in Diffusion-Weighted Imaging Infarct Volume Predicts Neurologic Outcome at 90 Days

Stroke ◽

10.1161/strokeaha.109.548933 ◽

2009 ◽

Vol 40 (7) ◽

pp. 2422-2427 ◽

Cited By ~ 46

Author(s):

Kevin M. Barrett ◽

Yong Hong Ding ◽

Douglas P. Wagner ◽

David F. Kallmes ◽

Karen C. Johnston

Keyword(s):

Diffusion Weighted Imaging ◽

Infarct Volume ◽

Neurologic Outcome ◽

Diffusion Weighted

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Susceptibility Weighted Imaging in Acute Stroke with Co-morbids: Magnetic Resonance Imaging Protocol Revisited

Journal of Advances in Medicine and Medical Research ◽

10.9734/jammr/2019/v29i1030134 ◽

2019 ◽

pp. 1-8 ◽

Cited By ~ 1

Author(s):

Fatima Mubarak ◽

Muhammad Danish Barakzai

Keyword(s):

Signal Intensity ◽

Diffusion Weighted Imaging ◽

Surrogate Marker ◽

Rank Correlation ◽

Acute Stage ◽

High Signal ◽

Susceptibility Weighted Imaging ◽

Imaging Protocol ◽

Diffusion Weighted ◽

Acute Infarct

Introduction: We aim to investigate ischemic penumbra using Diffusion weighted imaging- Susceptibility weighted imaging mismatch using DWI Alberta Stroke Program Early Computed tomography Stroke Score scoring in patients with multiple co morbid. Methods: From January 2011 to December, 2017; 70 consecutive patients (50 men, 20 women; mean age 64.5; range 45-82 years) with acute infarct on Diffusion weighted imaging (DWI) were selected for the study. Stroke protocol performed including DWI and susceptibility weighted imaging (SWI) on first day and repeat within three days. All initial MR images were interpreted by one Neuroradiologist with more than ten years blind to the clinical findings of each patient. The definition of an acute infarct area was high signal intensity on DWI with dark signal intensity on Apparent diffusion weighted imaging (ADC). The infarct extent was scored using the Alberta Stroke Program Early CT Score (ASPECTS) system. Infarct growth was defined as any new or larger lesion on the second DWI. For correlation with infarct growth, the same topographic system was used to record the extent of the Prominent vessel sign (PVS) on SWI. Spearman’s rank correlation test was used to examine the correlations between PVS score and infarct growth score. Regression was computed, with P<0.05 considered significant. Results: The study included 12 women and 10 men, (mean age 67.1 years). MRI images were initially acquired as stroke protocol (mean 12 hours) in acute stage and the next MRI was done within 3 days after the acute stage. 9 patients had right sided and 13 patients had left sided MCA territory infarct, the mean DWI-ASPECTS score was 4.3 (range 0–9). PVS was detected in 15 patients (mean score 4.1, range 0–10). Out of 22 patients 9 patients showed no evolution in infarct however in 13 patients evolution was from (ASPECTS mean score 3.95, range 0–9; mean infarct growth score 7.4, range 0–10). 7 patients devoid of PVS in initial MRI, did not exhibited evolution of infarction. Of 15 patients with PVS on initial MRI, 13 (87%) had infarct growth. Correlation between the evolution in infarct size and PVS score was observed (r = 0.86, P<0.001). Conclusion: PVS seen in infarcted territory is related to poor prognosis and this can be reliably used as a surrogate marker of oxygen extraction in penumbra. SWI can predict tissue at risk and can be a replacement for perfusion scan in clinical scenerio of acute ischaemic infarct.

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Automatic Assessment of ASPECTS Using Diffusion-Weighted Imaging in Acute Ischemic Stroke Using Recurrent Residual Convolutional Neural Network

Diagnostics ◽

10.3390/diagnostics10100803 ◽

2020 ◽

Vol 10 (10) ◽

pp. 803

Author(s):

Luu-Ngoc Do ◽

Byung Hyun Baek ◽

Seul Kee Kim ◽

Hyung-Jeong Yang ◽

Ilwoo Park ◽

...

Keyword(s):

Neural Network ◽

Deep Learning ◽

Convolutional Neural Network ◽

Diffusion Weighted Imaging ◽

Learning Algorithm ◽

Binary Classification ◽

Automatic Assessment ◽

Anterior Circulation ◽

Deep Learning Algorithm ◽

Diffusion Weighted

The early detection and rapid quantification of acute ischemic lesions play pivotal roles in stroke management. We developed a deep learning algorithm for the automatic binary classification of the Alberta Stroke Program Early Computed Tomographic Score (ASPECTS) using diffusion-weighted imaging (DWI) in acute stroke patients. Three hundred and ninety DWI datasets with acute anterior circulation stroke were included. A classifier algorithm utilizing a recurrent residual convolutional neural network (RRCNN) was developed for classification between low (1–6) and high (7–10) DWI-ASPECTS groups. The model performance was compared with a pre-trained VGG16, Inception V3, and a 3D convolutional neural network (3DCNN). The proposed RRCNN model demonstrated higher performance than the pre-trained models and 3DCNN with an accuracy of 87.3%, AUC of 0.941, and F1-score of 0.888 for classification between the low and high DWI-ASPECTS groups. These results suggest that the deep learning algorithm developed in this study can provide a rapid assessment of DWI-ASPECTS and may serve as an ancillary tool that can assist physicians in making urgent clinical decisions.

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