Abstract
There are few studies regarding functional outcome and lesion extent on diffusion-weighted MRI (DWI) in patients with posterior circulation (PC) infarction. The aim of our study was to assess whether a newly proposed posterior circulation Alberta Stroke Program Early CT Score (pc-ASPECTS) on DWI is useful for predicting functional outcome in PC patients. One hundred thirty-two patients with first-ever ischemic stroke in the posterior circulation within 24 h of onset who were admitted to our hospital were enrolled in the study. We compared background characteristics, vital signs, laboratory data, and MRI findings between favorable (F) and unfavorable (U) outcome groups at 3 months, according to the modified Rankin Scale (mRS). The F and U groups were defined as having a mRS of 0–2 and 3–6, respectively. pc-ASPECTS was scored by DWI obtained 12–36 h after onset. Ninety-eight patients (74.2%) were classified into the F group and 34 patients (25.8%) into the U group. On univariate analysis, F group patients were younger, had lower National Institutes of Health Stroke Scale (NIHSS) score at entry, and a lower rate of early neurological deterioration (END) and cardioembolic stroke than U group patients. On MRI, F group patients had lower leukoaraiosis and medial temporal atrophy score and higher pc-ASPECTS score on DWI compared to U group patients. Multiple logistic regression analysis revealed NIHSS (p < 0.001), END (p = 0.0057), pc-ASPECTS (p < 0.001), and leukoaraiosis (p = 0.0091) as independent predictors of functional outcome. pc-ASPECTS appears to be a powerful marker for predicting functional outcome, along with clinical severity and END. Leukoaraiosis may also be an independent predictor of functional outcome.
Similar content being viewed by others
Explore related subjects
Discover the latest articles, news and stories from top researchers in related subjects.References
Adams HP Jr, Davis PH, Leira EC, Chang K-C, Blendixen BH, Clarke WR, Woolson RF, Hansen MD (1999) Baseline NIH Stroke Scale score strongly predicts outcome after stroke. A report of the Trial of Org 10172 in Acute Stroke Treatment (TOAST). Neurology 53:126–131
Arsava EM, Rahman R, Rosand J, Lu J, Smith EE, Rost NS, Singhal AB, Lev MH, Furie KL, Koroshetz WJ, Sorensen AG, Ay H (2009) Severity of leukoaraiosis correlates with clinical outcome after ischemic stroke. Neurology 72:1403–1410
Ay H, Arsava M, Rosand J, Furie KL, Singhal AB, Schaefer PW, Wu O, Gonzalez G, Koroshetz WJ, Sorensen AG (2008) Severity of leukoaraisosis and susceptibility to infarct growth in acute stroke. Stroke 39:1409–1413
Baird AE, Dambrosia J, Janket SJ, Eichbaum Q, Chaves C, Silver B, Barber PA, Parsons M, Darby D, Davis S, Caplan LR, Edelman RE, Warach S (2001) A three-item scale for the early prediction of stroke recovery. Lancet 357:2095–2099
Barber PA, Demchuk AM, Zhang J, Buchan AM, for the ASPECTS Study Group (2000) Validity and reliability of a quantitative computed tomography score in predicting outcome of hyperacute stroke before thrombolytic therapy. Lancet 355:1670–1674
Barber PA, Hill MD, Eliasziw M, Demchuk AM, Pexman JHW, Hudon ME, Tamanek A, Frayne R, Buchan AM, for the ASPECTS Study Group (2005) Imaging of the brain in acute ischaemic stroke: comparison of computed tomography and magnetic resonance diffusion-weighted imaging. J Neurol Neurosurg Psychiatry 76:1528–1533
Castillo J, Leira R (2001) Predictors of deteriorating cerebral infarct: role of inflammatory mechanisms. Would its early treatment be useful? Cerebrovasc Dis 11(suppl 1):40–48
Cho T-H, Nighoghossian N, Tahon F, Némoz C, Hermier M, Salkine F, Derex L, Trouillas P, Froment J-C, Turjman F (2009) Brain stem diffusion-weighted imaging lesion score: a potential marker of outcome in acute basilar artery occlusion. AJNR Am J Neuroradiol 30:194–198
Engelter ST, Wetzel SG, Radue EW, Rausch M, Steck AJ, Lyrer PA (2004) The clinical significance of diffusion-weighted MR imaging in infratentorial strokes. Neurology 62:574–580
Engelter ST, Wetzel SG, Bonati LH, Fluri F, Lyrer PA (2008) The clinical significance of diffusion-weighted MR imaging in stroke and TIA patients. Swiss Med Wkly 138:729–740
Glass TA, Hennessey PM, Pazdera L, Chang H-M, Wityk RJ, Dewitt LD, Pessin MS, Caplan LR (2002) Outcome at 30 days in the New England Medical Center Posterior Circulation Registry. Arch Neurol 59:369–376
Grips E, Sedlaczek O, Bäzner H, Fritzinger M, Daffertshofer M, Hennerici M (2005) Supratentorial age-related white matter changes predict outcome in cerrebellar stroke. Stroke 36:1988–1993
Hand PJ, Wardlaw JM, Rivers CS, Armitage PA, Bastin ME, Lindley RI, Dennis MS (2006) MR diffusion-weighted imaging and outcome prediction after ischemic stroke. Neurology 66:1159–1163
Johnston KC, Wagner DP, Wang X-Q, Newman GC, Thijs V, Sen S, Warach S, for the GAIN, Citicoline, ASAP Investigators (2007) Validation of an acute ischemic stroke model. Does diffusion-weighted imaging lesion volume offer a clinically significant improvement in prediction of outcome? Stroke 38:1820–1825
Kimura K, Iguchi Y, Shibazaki K, Terasawa Y, Inoue T, Uemura J, Aoki J (2008) Large ischemic lesions on diffusion-weighted imaging done before intravenous tissue plasminogen activator thrombolysis predicts a poor outcome in patients with acute stroke. Stroke 39:2388–2391
Kissela B, Lindsell CJ, Kleindorfer D, Alwell K, Moomaw CJ, Woo D, Flaherty ML, Air E, Broderick J, Tsevat J (2009) Clinical prediction of functional outcome after ischemic stroke. The surprising importance of periventricular white matter disease and race. Stroke 40:530–536
Kolominsky-Rabas PL, Weber M, Gefeller O, Neundoerfer B, Heuschmann PU (2001) Epidemiology of ischemic stroke subtypes according to TOAST criteria. Incidence, recurrence, and long-term survival in ischemic stroke subtypes: a population-based study. Stroke 32:2735–2740
König IR, Ziegler A, Bluhmki E, Hacke W, Bath PMW, Sacco RL, Diener HC, Weimar C, on behalf of the Virtual International Stroke Trials Archive (VISTA) Investigators (2008) Predicting long-term outcome after acute ischemic stroke. Incidence, recurrence, and long-term survival in ischemic stroke subtypes: a population-based study. Stroke 39:1821–1826
Küker W, Weise J, Krapf H, Schmidt F, Friese S, Bähr M (2002) MRI characteristics of acute and subacute brainstem and thalamic infarctions: value of T2- and diffusion-weighted sequences. J Neurol 249:33–42
Li Y, Li J, Segal S, Wegiel J, De Santi S, Zhan J, de Leon MJ (2006) Hippocampal cerebrospinal fluid spaces on MR imaging: relation to aging and Alzheimer disease. AJNR Am J Neuroradiol 27:912–918
Lindsberg PJ, Mattle HP (2006) Therapy of basilar artery occlusion. A systematic analysis comparing intra-arterial and intravenous thrombolysis. Stroke 37:922–928
Linfante I, Llinas RH, Schlaug G, Chaves C, Warach S, Caplan LR (2001) Diffusion-weighted imaging and National Institutes of Health Stroke Scale in the acute phase of posterior-circulation stroke. Arch Neurol 58:621–628
Nuutinen J, Liu Y, Laakso MP, Karonen JO, Roivainen R, Vanninen RL, Partanen K, Østergaard L, Sivenius J, Arounen HJ (2006) Assessing the outcome of stroke: a comparison between MRI and clinical stroke scales. Acta Neurol Scand 113:100–107
Puetz V, Sylaja PN, Coutts SB, Hill MD, Dzialowski I, Mueller P, Becker U, Urban G, O’Reilly C, Barber PA, Sharma P, Goyal M, Gahn G, von Kummer R, Demchuk AM (2008) Extent of hypoattenuation on CT angiography source images predicts functional outcome in patients with basilar artery occlusion. Stroke 39:2485–2490
Renard D, Landragin N, Robinson A, Brunel H, Bonafe A, Heroum C, Milhaud C (2008) MRI-based score for acute basilar artery thrombosis. Cerebrovasc Dis 25:511–516
Schaefer PW, Yoo AJ, Bell D, Barak ER, Romero JM, Nogueira RG, Lev MH, Schwamm LH, Gonzalez RG, Hirsch JA (2008) CT angiography-source image hypoattenuation predicts clinical outcome in posterior circulation strokes treated with intra-arterial therapy. Stroke 39:3107–3109
Schonewille WJ, Wijman CAC, Michel P, Rueckert CM, Weimer C, Mattle HP, Engelter ST, Tanne D, Muir KW, Molina CA, Thijs V, Audebert H, Pfefferkorn T, Szabo K, Lindsberg PJ, de Freitas G, Kappelle LJ, Algra A, on behalf of the BASICS study group (2009) Treatment and outcomes of acute basilar artery occlusion in the Basilar Artery International Cooperation Study (BASICS): a prospective registry study. Lancet Neurol 8:724–730
Schwarz S, Egelhof T, Schwab S, Hacke W (1997) Basilar artery embolism. Clinical syndrome and neuroradiologic patterns in patients without permanent occlusion of the basilar artery. Neurology 49:1346–1352
Tei H, Uchiyama S, Ohara K, Kobayashi M, Uchiyama Y, Fukuzawa M (2000) Deteriorating ischemic stroke in 4 clinical categories classified by the Oxfordshire Community Stroke Project. Stroke 31:2049–2054
Tei H, Uchiyama S, Usui T (2006) Predictors of good prognosis in total anterior circulation infarction within 6 h after onset under conventional therapy. Acta Neurol Scand 113:301–306
Tei H, Uchiyama S, Usui T (2007) Clinical-diffusion mismatch defined by NIHSS and ASPECTS in non-lacunar anterior circulation infarction. J Neurol 254:340–346
The National Institute of Neurological Disorders, Stroke (NINDS) rt-PA Stroke Study Group (2000) Effects of intravenous recombinant tissue plasminogen activator on ischemic lesion size measured by computed tomography. Stroke 31:2912–2919
Thijs VN, Lansberg MG, Beaulieu C, Marks MP, Moseley ME, Albers GW (2000) Is early ischemic lesion volume on diffusion-weighted imaging an independent predictor of stroke outcome? A multivariable analysis. Stroke 31:2597–2602
Toyoda K, Fujii K, Kamouchi M, Nakane H, Arihiro S, Okada Y, Ibayashi S, Iida M (2004) Free radical scavenger, edaravone, in stroke with internal carotid artery occlusion. J Neurol Sci 221:11–17
van Swieten JC, Hijdra A, Koudstaal PJ, van Gijn J (1990) Grading white matter lesions on CT and MRI: a simple scale. J Neurol Neurosurg Psychiatry 53:1080–1083
Wardlaw JM, Keir SL, Bastin ME, Armitage PA, Rana AK (2002) Is diffusion imaging appearance an independent predictor of outcome after ischemic stroke? Neurology 59:1381–1387
Acknowledgments
We would like to thank Drs. Hiroshi Yoshizawa, Etsuko Nishizawa, Yumiko Uchiyama, Sono Toi, Hiroaki Nakahara, and Yoko Masuda for their clinical assistance.
Conflict of interest statement
None.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Tei, H., Uchiyama, S., Usui, T. et al. Posterior circulation ASPECTS on diffusion-weighted MRI can be a powerful marker for predicting functional outcome. J Neurol 257, 767–773 (2010). https://doi.org/10.1007/s00415-009-5406-x
Received:
Revised:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00415-009-5406-x