Published Online
on July 14, 2005

A more recent version of this article appeared on August 1, 2005

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Submitted on April 11, 2005
Accepted on May 9, 2005

Clinical-Diffusion Mismatch Predicts the Putative Penumbra With High Specificity

Jane Prosser FRACP; Ken Butcher MD, PhD, FRCP(C); Louise Allport FRACP; Mark Parsons PhD, FRACP; Lachlan MacGregor MBBS, MMedSc; Patricia Desmond FRACR; Brian Tress FRACR; and Stephen Davis MD, FRCP, FRACP^*

From the Departments of Neurology (K.B., L.A., J.P., S.D.), Clinical Epidemiology (L.M.), and Radiology (P.D., B.T.), Royal Melbourne Hospital, University of Melbourne, Melbourne Australia.

^* To whom correspondence should be addressed. E-mail: stephen.davis{at}mh.org.au.

Background and Purpose--Perfusion-diffusion (PWI-DWI) mismatch may represent the ischemic penumbra. The complexities associated with perfusion-weighted imaging (PWI) have restricted its use. Mismatch between stroke severity, assessed with the National Institutes of Health Stroke Scale (NIHSS), and the volume of the diffusion-weighted imaging (DWI) lesion (clinical-diffusion mismatch; CDM) has been suggested as a surrogate for PWI-DWI mismatch. We compared CDM with PWI and DWI in acute stroke.

Methods--Seventy-nine hemispheric stroke patients were imaged within 24 hours of symptom onset and subacutely (3 to 5 days). CDM was defined as NIHSS 8 and DWI 25 mL. DWI lesion and PWI (Tmax+4s) volumes were measured by planimetric techniques. Acute PWI-DWI mismatch was examined as a continuous variable (mismatch volume=PWI_vol-DWI_vol) and a categorical variable (mismatch=PWI_vol-DWI_vol/DWI_volx100>20%). Early infarct expansion was calculated as DWI_{subacute vol}/DWI_{acute vol}.

Results--In the 54 sub-6-hour patients, CDM detected PWI-DWI mismatch with a specificity of 93% (95% confidence interval [CI], 62% to 99%), a positive predictive value of 95% (95% CI, 77% to 100%), but a sensitivity of only 53% (95% CI, 34% to 68%). Alternate DWI and NIHSS cutpoints did not improve test performance characteristics. In addition, subacute DWI expansion was significantly greater in patients with CDM (P=0.01) compared with those without.

Conclusions--CDM (NIH 8, DWI 25 mL) predicts the presence of PWI-DWI mismatch with high specificity and low sensitivity. CDM also predicts DWI expansion. CDM may be a useful selection tool in acute stroke therapies, including thrombolysis.

Key words: stroke, acute • magnetic resonance imaging, diffusion weighted • diagnostic imaging • magnetic resonance imaging, perfusion weighted

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