Does diffusion-weighted imaging represent the ischemic core? An evidence-based systematic review.
OBJECTIVE
Diffusion-weighted(DWI) hyperintensity is hypothesized to represent irreversibly infarcted tissue (ischemic core) in the setting of acute stroke [corrected]. Measurement of the ischemic core has implications for both prognosis and therapy. We wished to assess the level of evidence in the literature supporting this hypothesis.


METHODS
We performed a systematic review of the literature relating to tissue outcomes of DWI hyperintense stroke lesions in humans. The methodologic rigor of studies was evaluated by using criteria set out by the Oxford Centre for Evidence-Based Medicine. Data from individual studies were also analyzed to determine the prevalence of patients demonstrating lesion progression, no change, or lesion regression compared with follow-up imaging.


RESULTS
Limited numbers of highly methodologically rigorous studies (Oxford levels 1 and 2) were available. There was great variability in observed rates of DWI lesion reversal (0%-83%), with a surprisingly high mean rate of DWI lesion reversal (24% of pooled patients). Many studies did not include sufficient data to determine the precise prevalence of DWI lesion growth or reversal.


CONCLUSIONS
The available tissue-outcome evidence supporting the hypothesis that DWI is a surrogate marker for ischemic core in humans is troublingly inconsistent and merits an overall grade D based on the criteria set out by the Oxford Centre for Evidence-Based Medicine.
Department of Radiology, Duke University Medical Center, Durham, NC 27710, USA. peter.kranz@duke.edu
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Kranz
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Eastwood
D001921:Brain / Q000473:pathology*; D002545:Brain Ischemia / Q000175:diagnosis* / Q000453:epidemiology*; D002986:Clinical Trials as Topic; D015897:Comorbidity; D038524:Diffusion Magnetic Resonance Imaging / Q000379:methods* / Q000706:statistics & numerical data*; D019317:Evidence-Based Medicine; D006801:Humans; D015994:Incidence; D015203:Reproducibility of Results; D012680:Sensitivity and Specificity; D020521:Stroke / Q000175:diagnosis* / Q000453:epidemiology*