title: Viability thresholds of ischemic penumbra of hyperacute stroke defined by perfusion-weighted MRI and apparent diffusion coefficient.
abstract: OBJECTIVE
  The penumbra of ischemic stroke consists of hypoperfused, but not irreversibly damaged, tissue surrounding the ischemic core. The purpose of this study was to determine viability thresholds in the ischemic penumbra, defined as the perfusion/diffusion mismatch in hyperacute stroke, by the use of diffusion- and perfusion-weighted MRI (DWI and PWI, respectively).
  
  
  METHODS
  DWI and PWI were performed in 11 patients </=6 hours after the onset of symptoms of acute ischemic stroke. Regions of interest (ROIs) were placed covering the ischemic core (ROI 1), the penumbra that progressed to infarction on the basis of follow-up scans (ROI 2), and the penumbra that recovered (ROI 3). The ratios of relative cerebral blood flow (rCBF), relative cerebral blood volume (rCBV), mean transit time (MTT), and apparent diffusion coefficient were calculated as lesion ROIs relative to the contralateral mirror ROIS:
  
  
  RESULTS
  The post hoc analysis showed that the penumbra progressed to infarction at the following cutoff values: rCBF <0.59 and MTT >1.63. Higher sensitivity and accuracy in predicting outcome of the penumbra were obtained from the rCBF maps compared with the rCBV and MTT maps. The initial rCBV and apparent diffusion coefficient ratios did not differentiate between the part of the penumbra that recovered and the part that progressed to infarction. The mean rCBF ratio was optimal in distinguishing the parts of the penumbra recovering or progressing to infarction.
  
  
  CONCLUSIONS
  The thresholds found in this study by combined DWI/PWI might aid in the selection of patients suitable for therapeutic intervention within 6 hours. However, these hypothesized thresholds need to be prospectively tested at the voxel level on a larger patient sample before they can be applied clinically.
authors.affiliation: Department of Neuroradiology, Aarhus University Hospital, Aarhus, Denmark. Lisbeth@pet.auh.dk
authors.forename: L
authors.initials: L
authors.lastname: Røhl
authors.forename: L
authors.initials: L
authors.lastname: Ostergaard
authors.forename: C Z
authors.initials: CZ
authors.lastname: Simonsen
authors.forename: P
authors.initials: P
authors.lastname: Vestergaard-Poulsen
authors.forename: G
authors.initials: G
authors.lastname: Andersen
authors.forename: M
authors.initials: M
authors.lastname: Sakoh
authors.forename: D
authors.initials: D
authors.lastname: Le Bihan
authors.forename: C
authors.initials: C
authors.lastname: Gyldensted
mesh_terms: D000208:Acute Disease; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001783:Blood Flow Velocity; D001921:Brain / Q000098:blood supply / Q000473:pathology / Q000503:physiopathology; D002545:Brain Ischemia / Q000150:complications / Q000175:diagnosis* / Q000503:physiopathology*; D002470:Cell Survival; D002560:Cerebrovascular Circulation; D004058:Diffusion; D016002:Discriminant Analysis; D018450:Disease Progression; D005260:Female; D006801:Humans; D008279:Magnetic Resonance Imaging / Q000379:methods; D008297:Male; D008875:Middle Aged; D010477:Perfusion; D011237:Predictive Value of Tests; D012372:ROC Curve; D012680:Sensitivity and Specificity; D012720:Severity of Illness Index; D020521:Stroke / Q000150:complications / Q000175:diagnosis* / Q000503:physiopathology*; D014057:Tomography, X-Ray Computed