Abstract
Stroke is an emergent neurological condition where time is of the essence. Multimodal computed tomography (CT) and magnetic resonance imaging (MRI) techniques such as diffusion-weighed imaging (DWI) and perfusion-weighted imaging (PWI) represent powerful tools that offer unique insight into stroke pathophysiology. Information obtained from these imaging techniques allows further tissue-based management decisions and individualization of acute stroke reperfusion therapy. The prospect of extending the time window for acute stroke treatment beyond the current time-based treatment windows has been re-emphasized by the results of recent trials. This has led to re-emergence and increased performance of multimodal CT and MRI in emergent stroke settings. Multimodal imaging not only allows differentiation of hemorrhage and infarction but also areas of dead neural tissue or core, and viable tissue, or penumbra, which can benefit from reperfusion therapeutic options. This chapter reviews the use of diffusion-weighted imaging (DWI) and perfusion-weighted imaging (PWI) in the workup of acute stroke patients, their current clinical utility, as well as their advantages and disadvantages. The latest trials on stroke intervention are also reviewed.
Access this chapter
Tax calculation will be finalised at checkout
Purchases are for personal use only
References
Benjamin EJ, Blaha MJ, Chiuve SE, Cushman M, Das SR, Deo R, et al. Heart disease and stroke statistics–2017 update: a report from the American Heart Association. Circulation. 2017;135(10):146–603.
National Institute of Neurological Disorders and Stroke RT-PA Stroke Study Group. Tissue plasminogen activator for acute ischemic stroke. N Engl J Med. 1995;333(24):1581–7.
Hacke W, Kaste M, Fieschi C, von Kummer R, Davalos A, Meier D, et al. Randomised double-blind placebo-controlled trial of thrombolytic therapy with intravenous alteplase in acute ischaemic stroke (ECASS II). Second European-Australasian Acute Stroke Study Investigators. Lancet. 1998;352(9136):1245–51.
Røhl L, Ostergaard L, Simonsen CZ, Vestergaard-Poulsen P, Andersen G, Sakoh M, et al. Viability thresholds of ischemic penumbra of hyperacute stroke defined by perfusion-weighted MRI and apparent diffusion coefficient. Stroke. 2001;32(5):1140–6.
Schellinger PD, Fiebach JB, Mohr A, Ringleb PA, Jansen O, Hacke W. Thrombolytic therapy for ischemic stroke–a review. Part II–intra-arterial thrombolysis, vertebrobasilar stroke, phase IV trials, and stroke imaging. Crit Care Med. 2001;29(9):1819–25.
Warach S. New imaging strategies for patient selection for thrombolytic and neuroprotective therapies. Neurology. 2001;57(5):48–52.
Warach S. Thrombolysis in stroke beyond three hours: targeting patients with diffusion and perfusion MRI. Ann Neurol. 2002;51(1):11–3.
Song SS. Advanced imaging in acute ischemic stroke. Semin Neurol. 2013;33(5):436–40.
Warach S. Tissue viability thresholds in acute stroke: the 4-factor model. Stroke. 2001;32(11):2460–1.
Fransen PS, Beumer D, Berkhemer OA, van den Berg LA, Lingsma H, van der Lugt A, et al. MR CLEAN, a multicenter randomized clinical trial of endovascular treatment for acute ischemic stroke in the Netherlands: study protocol for a randomized controlled trial. Trials. 2014;15:343.
Demchuk AM, Goyal M, Menon BK, Eesa M, Ryckborst KJ, Kamal N, et al. Endovascular treatment for Small Core and Anterior circulation Proximal occlusion with Emphasis on minimizing CT to recanalization times (ESCAPE) trial: methodology. Int J Stroke. 2015;10(3):429–38.
Campbell BC, Mitchell PJ, Yan B, Parsons MW, Christensen S, Churilov L, et al. A multicenter, randomized, controlled study to investigate EXtending the time for Thrombolysis in Emergency Neurological Deficits with Intra-Arterial therapy (EXTEND-IA). Int J Stroke. 2014;9(1):126–32.
Saver JL, Goyal M, Bonafe A, Diener HC, Levy EI, Pereira VM, et al. Solitaire™ with the Intention for Thrombectomy as Primary Endovascular Treatment for Acute Ischemic Stroke (SWIFT PRIME) trial: protocol for a randomized, controlled, multicenter study comparing the Solitaire revascularization device with IV tPA with IV tPA alone in acute ischemic stroke. Int J Stroke. 2015;10(3):439–48.
Molina CA, Chamorro A, Rovira À, de Miquel A, Serena J, Roman LS, et al. REVASCAT: a randomized trial of revascularization with SOLITAIRE FR device vs. best medical therapy in the treatment of acute stroke due to anterior circulation large vessel occlusion presenting within eight-hours of symptom onset. Int J Stroke. 2015;10(4):619–26.
Nogueira RG, Jadhav AP, Haussen DC, Bonafe A, Budzik RF, Bhuva P, et al. Thrombectomy 6 to 24 hours after stroke with a mismatch between deficit and infarct. N Engl J Med. 2018;378(1):11–21.
Albers GW, Marks MP, Kemp S, Christensen S, Tsai JP, Ortega-Gutierrez S, et al. Thrombectomy for stroke at 6 to 16 hours with selection by perfusion imaging. N Engl J Med. 2018;378(8):708–18.
Crain MR, Yuh WT, Greene GM, Loes DJ, Ryals TJ, Sato Y, et al. Cerebral ischemia: evaluation with contrast-enhanced MR imaging. Am J Neuroradiol. 1991;12(4):631–9.
Lövblad KO, Baird AE, Schlaug G, Benfield A, Siewert B, Voetsch B, et al. Ischemic lesion volumes in acute stroke by diffusion-weighted magnetic resonance imaging correlate with clinical outcome. Ann Neurol. 1997;42(2):164–70.
Kamran S, Bates V, Bakshi R, Wright P, Kinkel W, Miletich R. Significance of hyperintense vessels on FLAIR MRI in acute stroke. Neurology. 2000;55(2):265–9.
Wycliffe ND, Choe J, Holshouser B, Oyoyo UE, Haacke EM, Kido DK. Reliability in detection of hemorrhage in acute stroke by a new three-dimensional gradient recalled echo susceptibility-weighted imaging technique compared to computed tomography: a retrospective study. J Magn Reson Imaging. 2004;20(3):372–7.
Kidwell CS, Chalela JA, Saver JL, Starkman S, Hill MD, Demchuk AM, et al. Comparison of MRI and CT for detection of acute intracerebral hemorrhage. JAMA. 2004;292(15):1823–30.
Kakuda W, Thijs VN, Lansberg MG, Bammer R, Wechsler L, Kemp S, et al. Clinical importance of microbleeds in patients receiving IV thrombolysis. Neurology. 2005;65(8):1175–8.
Moseley ME, Cohen Y, Mintorovitch J, Chileuitt L, Shimizu H, Kucharczyk J, et al. Early detection of regional cerebral ischemia in cats: comparison of diffusion- and T2-weighted MRI and spectroscopy. Magn Reson Med. 1990;14(2):330–46.
Chalela JA, Kidwell CS, Nentwich LM, Luby M, Butman JA, Demchuk AM, et al. Magnetic resonance imaging and computed tomography in emergency assessment of patients with suspected acute stroke: a prospective comparison. Lancet. 2007;369(9558):293–8.
Saur D, Kucinski T, Grzyska U, Eckert B, Eggers C, Niesen W, et al. Sensitivity and interrater agreement of CT and diffusion-weighted MR imaging in hyperacute stroke. Am J Neuroradiol. 2003;24(5):878–85.
Fiebach J, Jansen O, Schellinger P, Knauth M, Hartmann M, Heiland S, et al. Comparison of CT with diffusion-weighted MRI in patients with hyperacute stroke. Neuroradiology. 2001;43(8):628–32.
Ay H, Buonanno FS, Rordorf G, Schaefer PW, Schwamm LH, Wu O, et al. Normal diffusion-weighted MRI during stroke-like deficits. Neurology. 1999;52(9):1784–92.
Lefkowitz D, LaBenz M, Nudo SR, Steg RE, Bertoni JM. Hyperacute ischemic stroke missed by diffusion-weighted imaging. Am J Neuroradiol. 1999;20(10):1871–5.
Oppenheim C, Stanescu R, Dormont D, Crozier S, Marro B, Samson Y, et al. False-negative diffusion-weighted MR findings in acute ischemic stroke. Am J Neuroradiol. 2000;21(8):1434–40.
Scarabino T, Carriero A, Giannatempo GM, Marano R, De Matthaeis P, Bonomo L, et al. Contrast-enhanced MR angiography (CE MRA) in the study of the carotid stenosis: comparison with digital subtraction angiography (DSA). J Neuroradiol. 1999;26(2):87–91.
Nederkoorn PJ, van der Graaf Y, Hunink MG. Duplex ultrasound and magnetic resonance angiography compared with digital subtraction angiography in carotid artery stenosis: a systematic review. Stroke. 2003;34(5):1324–31.
Fellner C, Lang W, Janka R, Wutke R, Bautz W, Fellner FA. Magnetic resonance angiography of the carotid arteries using three different techniques: accuracy compared with intraarterial X-ray angiography and endarterectomy specimens. J Magn Reson Imaging. 2005;21(4):424–31.
Patel SG, Collie DA, Wardlaw JM, Lewis SC, Wright AR, Gibson RJ, et al. Outcome, observer reliability, and patient preferences if CTA, MRA, or Doppler ultrasound were used, individually or together, instead of digital subtraction angiography before carotid endarterectomy. J Neurol Neurosurg Psychiatry. 2002;73(1):21–8.
Binaghi S, Maeder P, Uské A, Meuwly JY, Devuyst G, Meuli RA. Three-dimensional computed tomography angiography and magnetic resonance angiography of carotid bifurcation stenosis. Eur Neurol. 2001;46(1):25–34.
Yang CW, Carr JC, Futterer SF, Morasch MD, Yang BP, Shors SM, et al. Contrast-enhanced MR angiography of the carotid and vertebrobasilar circulations. Am J Neuroradiol. 2005;26(8):2095–101.
Borisch I, Horn M, Butz B, Zorger N, Draganski B, Hoelscher T, et al. Preoperative evaluation of carotid artery stenosis: comparison of contrast-enhanced MR angiography and duplex sonography with digital subtraction angiography. Am J Neuroradiol. 2003;24(6):1117–22.
Kidwell CS, Alger JR, Saver JL. Beyond mismatch: evolving paradigms in imaging the ischemic penumbra with multimodal magnetic resonance imaging. Stroke. 2003;34(11):2729–35.
Alawneh JA, Jones PS, Mikkelsen IK, Cho TH, Siemonsen S, Mouridsen K, et al. Infarction of 'non-core-non-penumbral' tissue after stroke: multivariate modelling of clinical impact. Brain. 2011;134(6):1765–76.
Kanda T, Nakai Y, Oba H, Toyoda K, Kitajima K, Furui S. Gadolinium deposition in the brain. Magn Reson Imaging. 2016;34(10):1346–50.
Gevers S, van Osch MJ, Bokkers RP, Kies DA, Teeuwisse WM, Majoie CB, et al. Intra- and multicenter reproducibility of pulsed, continuous and pseudo-continuous arterial spin labeling methods for measuring cerebral perfusion. J Cereb Blood Flow Metab. 2011;31(8):1706–15.
Dehkharghani S, Andre J. Imaging approaches to stroke and neurovascular disease. Neurosurgery. 2017;80(5):681–700.
Wang DJ, Alger JR, Qiao JX, Hao Q, Hou S, Fiaz R, et al. The value of arterial spin-labeled perfusion imaging in acute ischemic stroke: comparison with dynamic susceptibility contrast-enhanced MRI. Stroke. 2012;43(4):1018–24.
Bivard A, Krishnamurthy V, Stanwell P, Levi C, Spratt NJ, Davis S, et al. Arterial spin labeling versus bolus-tracking perfusion in hyperacute stroke. Stroke. 2014;45(1):127–33.
Lyu J, Ma N, Liebeskind DS, Wang DJ, Ma L, Xu Y, et al. Arterial spin labeling magnetic resonance imaging estimation of antegrade and collateral flow in unilateral middle cerebral artery stenosis. Stroke. 2016;47(2):428–33.
McCunn M, Mirvis S, Reynolds N, Cottingham C. Physician utilization of a portable computed tomography scanner in the intensive care unit. Crit Care Med. 2000;28(12):3808–13.
Fassbender K, Walter S, Liu Y, Muehlhauser F, Ragoschke A, Kuehl S, et al. “Mobile stroke unit” for hyperacute stroke treatment. Stroke. 2003;34(6):44.
Walter S, Kostopoulos P, Haass A, Keller I, Lesmeister M, Schlechtriemen T, et al. Diagnosis and treatment of patients with stroke in a mobile stroke unit versus in hospital: a randomised controlled trial. Lancet Neurol. 2012;11(5):397–404.
Barber PA, Demchuk AM, Zhang J, Buchan AM. Validity and reliability of a quantitative computed tomography score in predicting outcome of hyperacute stroke before thrombolytic therapy. ASPECTS Study Group. Alberta Stroke Programme Early CT Score. Lancet. 2000;355(9216):1670–4.
Hirai T, Korogi Y, Ono K, Nagano M, Maruoka K, Uemura S, et al. Prospective evaluation of suspected stenoocclusive disease of the intracranial artery: combined MR angiography and CT angiography compared with digital subtraction angiography. Am J Neuroradiol. 2002;23(1):93–101.
Nguyen-Huynh MN, Wintermark M, English J, Lam J, Vittinghoff E, Smith WS, et al. How accurate is CT angiography in evaluating intracranial atherosclerotic disease? Stroke. 2008;39(4):1184–8.
Shrier DA, Tanaka H, Numaguchi Y, Konno S, Patel U, Shibata D. CT angiography in the evaluation of acute stroke. Am J Neuroradiol. 1997;18(6):1011–20.
Wintermark M, Jawadi SS, Rapp JH, Tihan T, Tong E, Glidden DV, et al. High-resolution CT imaging of carotid artery atherosclerotic plaques. Am J Neuroradiol. 2008;29(5):875–82.
Wintermark M, Flanders AE, Velthuis B, Meuli R, van Leeuwen M, Goldsher D, et al. Perfusion-CT assessment of infarct core and penumbra: receiver operating characteristic curve analysis in 130 patients suspected of acute hemispheric stroke. Stroke. 2006;37(4):979–85.
Wintermark M, Fischbein NJ, Smith WS, Ko NU, Quist M, Dillon WP. Accuracy of dynamic perfusion CT with deconvolution in detecting acute hemispheric stroke. Am J Neuroradiol. 2005;26(1):104–12.
Wintermark M, Reichhart M, Cuisenaire O, Maeder P, Thiran JP, Schnyder P, et al. Comparison of admission perfusion computed tomography and qualitative diffusion- and perfusion-weighted magnetic resonance imaging in acute stroke patients. Stroke. 2002;33(8):2025–31.
Wintermark M, Reichhart M, Thiran JP, Maeder P, Chalaron M, Schnyder P, et al. Prognostic accuracy of cerebral blood flow measurement by perfusion computed tomography, at the time of emergency room admission, in acute stroke patients. Ann Neurol. 2002;51(4):417–32.
Schramm P, Schellinger PD, Klotz E, Kallenberg K, Fiebach JB, Külkens S, et al. Comparison of perfusion computed tomography and computed tomography angiography source images with perfusion-weighted imaging and diffusion-weighted imaging in patients with acute stroke of less than 6 hours' duration. Stroke. 2004;35(7):1652–8.
Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K, et al. 2018 guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2018;49(3):46–110.
Hacke W, Albers G, Al-Rawi Y, Bogousslavsky J, Davalos A, Eliasziw M, et al. The desmoteplase in acute ischemic stroke trial (DIAS): a phase II MRI-based 9-hour window acute stroke thrombolysis trial with intravenous desmoteplase. Stroke. 2005;36(1):66–73.
Albers GW, Thijs VN, Wechsler L, Kemp S, Schlaug G, Skalabrin E, et al. Magnetic resonance imaging profiles predict clinical response to early reperfusion: the diffusion and perfusion imaging evaluation for understanding stroke evolution (DEFUSE) study. Ann Neurol. 2006;60(5):508–17.
Furlan AJ, Eyding D, Albers GW, Al-Rawi Y, Lees KR, Rowley HA, et al. Dose escalation of desmoteplase for acute ischemic stroke (DEDAS): evidence of safety and efficacy 3 to 9 hours after stroke onset. Stroke. 2006;37(5):1227–31.
Berkhemer OA, Fransen PS, Beumer D, van den Berg LA, Lingsma HF, Yoo AJ, et al. A randomized trial of intraarterial treatment for acute ischemic stroke. N Engl J Med. 2015;372(1):11–20.
Goyal M, Demchuk AM, Menon BK, Eesa M, Rempel JL, Thornton J, et al. Randomized assessment of rapid endovascular treatment of ischemic stroke. N Engl J Med. 2015;372(11):1019–30.
Campbell BC, Mitchell PJ, Kleinig TJ, Dewey HM, Churilov L, Yassi N, et al. Endovascular therapy for ischemic stroke with perfusion-imaging selection. N Engl J Med. 2015;372(11):1009–18.
Saver JL, Goyal M, Bonafe A, Diener HC, Levy EI, Pereira VM, et al. Stent-retriever thrombectomy after intravenous t-PA vs. t-PA alone in stroke. N Engl J Med. 2015;372(24):2285–95.
Jovin TG, Chamorro A, Cobo E, de Miquel MA, Molina CA, Rovira A, et al. Thrombectomy within 8 hours after symptom onset in ischemic stroke. N Engl J Med. 2015;372(24):2296–306.
Thomalla G, Simonsen CZ, Boutitie F, Andersen G, Berthezene Y, Cheng B, et al. MRI-guided thrombolysis for stroke with unknown time of onset. N Engl J Med. 2018;379(7):611–22.
Rosamond WD, Folsom AR, Chambless LE, Wang CH, McGovern PG, Howard G, et al. Stroke incidence and survival among middle-aged adults: 9-year follow-up of the Atherosclerosis Risk in Communities (ARIC) cohort. Stroke. 1999;30(4):736–43.
Fiebach JB, Schellinger PD, Gass A, Kucinski T, Siebler M, Villringer A, et al. Stroke magnetic resonance imaging is accurate in hyperacute intracerebral hemorrhage: a multicenter study on the validity of stroke imaging. Stroke. 2004;35(2):502–6.
Author information
Authors and Affiliations
Corresponding author
Editor information
Editors and Affiliations
Rights and permissions
Copyright information
© 2023 The Author(s), under exclusive license to Springer Nature Switzerland AG
About this chapter
Cite this chapter
Rizvi, T., Wintermark, M. (2023). Clinical Application of Perfusion and Diffusion in Stroke. In: Faro, S.H., Mohamed, F.B. (eds) Functional Neuroradiology. Springer, Cham. https://doi.org/10.1007/978-3-031-10909-6_6
Download citation
DOI: https://doi.org/10.1007/978-3-031-10909-6_6
Published:
Publisher Name: Springer, Cham
Print ISBN: 978-3-031-10908-9
Online ISBN: 978-3-031-10909-6
eBook Packages: MedicineMedicine (R0)