Carrera E, Jones PS, Alawneh JA, Klærke Mikkelsen I, Cho TH, Siemonsen S, Guadagno JV, Mouridsen K, Ribe L, Hjort N, Fryer TD, Carpenter TA, Aigbirhio FI, Fiehler J, Nighoghossian N, Warburton EA, Ostergaard L, Baron JC.BACKGROUND AND PURPOSE: There is ample evidence that in anterior circulation stroke, the diffusion-weighted imaging (DWI) lesion may escape infarction and thus is not a reliable infarct predictor. In this study, we assessed the predictive value of the mean transit time (MTT) for final infarction within the DWI lesion, first in patients scanned back-to-back with 15O-positron emission tomography and MR (DWI and perfusion-weighted imaging; „Cambridge sample“) within 7 to 21 hours of clinical onset, then in a large sample of patients with anterior circulation stroke receiving DWI and perfusion-weighted imaging within 12 hours (85% within 6 hours; „I-KNOW sample“). METHODS: Both samples underwent structural MRI at approximately 1 month to map final infarcts. For both imaging modalities, MTT was calculated as cerebral blood volume/cerebral blood flow. After image coregistration and matrix resampling, the MTT values between voxels of interest that later infarcted or not were compared separately within and outside DWI lesions (DWI+ and DWI-, respectively) both within and across patients. In the I-KNOW sample, receiver operating characteristic curves were calculated for these voxel of interest populations and areas under the curve and optimal thresholds calculated. RESULTS: In the Cambridge data set (n=4), there was good concordance between predictive values of MTT (positron emission tomography) and MTT (perfusion-weighted imaging) for both DWI+ and DWI- voxels of interest indicating adequate reliability of MTT (perfusion-weighted imaging) for this purpose. In the I-KNOW data set (N=42), the MTT significantly added to the DWI lesion to predict infarction in both DWI- and DWI+ voxels of interest with areas under the curve approximately 0.78 and 0.64 (both P<0.001) and optimal thresholds approximately 8 seconds and 11 seconds, respectively. CONCLUSIONS: Despite the relatively small samples, this study suggests that adding MTT (perfusion-weighted imaging) may improve infarct prediction not only as already known outside, but also within, DWI lesions.
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