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(Stroke. 1999;30:1591-1597.)
© 1999 American Heart Association, Inc.
Original Contributions |
Diffusion- and Perfusion-Weighted MRI
The DWI/PWI Mismatch Region in Acute Stroke
From the Department of Neurology (T.N.-H., H.-J.W., M.S., R.J.S., H.-J.F.) and Institute of Diagnostic Radiology (H.-J.W., F.W., U.M.), Heinrich-Heine University, Düsseldorf, Germany, and the Department of Radiology, Stanford University (T.N.-H.), Stanford, Calif.
Correspondence to Dr Tobias Neumann-Haefelin, Department of Radiology, Stanford University, Lucas MRS Center, MC: 5488, Stanford, CA 94305. E-mail tnh{at}s-word.stanford.edu
Background and Purpose—Diffusion-weighted imaging (DWI) and perfusion-weighted imaging (PWI) are relatively new MR techniques increasingly used in acute stroke. During the first hours of stroke evolution, the regions with abnormal perfusion are typically larger than the DWI lesions, and this mismatch region has been suggested to be "tissue at risk." The aim of this study was to evaluate the PWI/DWI mismatch region in acute stroke patients and find parameters indicative of both infarct progression and functional impairment.
Methods—Twenty patients with nonlacunar ischemic stroke
were imaged with DWI, PWI, and conventional MRI within 24 hours of
symptom onset and after 1 week; in addition, the European Stroke Scale
(ESS) score was recorded. With PWI, the volumes of regions with
"time-to-peak" (TTP) delays of 
2, 4, 6, 8, and 10 seconds were
measured; these volumes were compared with the acute DWI lesion
volumes, final infarct size, and ESS score.
Results—In 80% of patients the acute DWI lesion was surrounded
by regions with abnormal TTP delays (PWI>DWI lesion). A TTP delay of
6 s in the mismatch region was found to be associated with lesion
enlargement between the initial and follow-up MRI scans. Lesions
increased in 9 of 12 patients (75%) in whom the area with TTP delay
6 s was larger than the DWI lesion, but they increased in only 1 of 8
(12.5%) of the remaining patients, in whom the area with a TTP delay
6 s was smaller than the DWI lesion. The volume of the regions with
TTP delays of 4 s correlated better with ESS
(r=-0.88, P<0.001) than other PWI (or
DWI) volumes, which indicated that a TTP delay of 
4 s might be the
threshold for functional impairment of brain tissue.
Conclusions—Only patients with severe perfusion deficits in the
PWI/DWI mismatch (TTP delays of 6 s) are at high risk of lesion
enlargement. Functionally, more moderate perfusion deficits (TTP delays
4 and <6 s) appear to also contribute to the acute clinical deficit.
Key Words: diffusion • magnetic resonance imaging • penumbra • perfusion • stroke, acute
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A. E. Hillis, R. J. Wityk, P. B. Barker, N. J. Beauchamp, P. Gailloud, K. Murphy, O. Cooper, and E. J. Metter Subcortical aphasia and neglect in acute stroke: the role of cortical hypoperfusion Brain, May 1, 2002; 125(5): 1094 - 1104. [Abstract] [Full Text] [PDF]
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F. Calamante, D.G. Gadian, and A. Connelly Quantification of Perfusion Using Bolus Tracking Magnetic Resonance Imaging in Stroke: Assumptions, Limitations, and Potential Implications for Clinical Use Stroke, April 1, 2002; 33(4): 1146 - 1151. [Abstract] [Full Text] [PDF]
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 T. Baumann, R. Petsch, G. Fesl, and R. Niessner Flow and Diffusion Measurements in Natural Porous Media Using Magnetic Resonance Imaging J. Environ. Qual., March 1, 2002; 31(2): 470 - 476. [Abstract] [Full Text] [PDF]
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U. Junghans, R. J. Seitz, A. Ritzl, H.-J. Wittsack, G. R. Fink, H.-J. Freund, and M. Siebler Ischemic brain tissue salvaged from infarction by the GP IIb/IIIa platelet antagonist tirofiban Neurology, February 12, 2002; 58(3): 474 - 476. [Abstract] [Full Text] [PDF]
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J. Fiehler, M. Foth, T. Kucinski, R. Knab, M. von Bezold, C. Weiller, H. Zeumer, and J. Rother Severe ADC Decreases Do Not Predict Irreversible Tissue Damage In Humans Stroke, January 1, 2002; 33(1): 79 - 86. [Abstract] [Full Text] [PDF]
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K. Yamada, O. Wu, R. G. Gonzalez, D. Bakker, L. Ostergaard, W. A. Copen, R. M. Weisskoff, B. R. Rosen, K. Yagi, T. Nishimura, et al. Magnetic Resonance Perfusion-Weighted Imaging of Acute Cerebral Infarction: Effect of the Calculation Methods and Underlying Vasculopathy Stroke, January 1, 2002; 33(1): 87 - 94. [Abstract] [Full Text] [PDF]
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F. Calamante, V. Ganesan, F.J. Kirkham, W. Jan, W.K. Chong, D.G. Gadian, and A. Connelly MR Perfusion Imaging in Moyamoya Syndrome: Potential Implications for Clinical Evaluation of Occlusive Cerebrovascular Disease Stroke, December 1, 2001; 32(12): 2810 - 2816. [Abstract] [Full Text] [PDF]
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C. Oppenheim, C. Grandin, Y. Samson, A. Smith, T. Duprez, C. Marsault, and G. Cosnard Is There an Apparent Diffusion Coefficient Threshold in Predicting Tissue Viability in Hyperacute Stroke? Stroke, November 1, 2001; 32(11): 2486 - 2491. [Abstract] [Full Text] [PDF]
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V. N. Thijs, A. Adami, T. Neumann-Haefelin, M. E. Moseley, M. P. Marks, and G. W. Albers Relationship between severity of MR perfusion deficit and DWI lesion evolution Neurology, October 9, 2001; 57(7): 1205 - 1211. [Abstract] [Full Text] [PDF]
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F. Caramia, A. Santoro, P. Pantano, E. Passacantilli, G. Guidetti, A. Pierallini, L. M. Fantozzi, G. P. Cantore, and L. Bozzao Cerebral Hemodynamics on MR Perfusion Images before and after Bypass Surgery in Patients with Giant Intracranial Aneurysms AJNR Am. J. Neuroradiol., October 1, 2001; 22(9): 1704 - 1710. [Abstract] [Full Text] [PDF]
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R. Bruening, M. Dichgans, C. Berchtenbreiter, T. Yousry, K. C. Seelos, R. H. Wu, M. Mayer, G. Brix, and M. Reiser Cerebral Autosomal Dominant Arteriopathy with Subcortical Infarcts and Leukoencephalopathy: Decrease in Regional Cerebral Blood Volume in Hyperintense Subcortical Lesions Inversely Correlates with Disability and Cognitive Performance AJNR Am. J. Neuroradiol., August 1, 2001; 22(7): 1268 - 1274. [Abstract] [Full Text] [PDF]
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 I. A. Staroselskaya, C. Chaves, B. Silver, I. Linfante, R. R. Edelman, L. Caplan, S. Warach, and A. E. Baird Relationship Between Magnetic Resonance Arterial Patency and Perfusion-Diffusion Mismatch in Acute Ischemic Stroke and Its Potential Clinical Use Arch Neurol, July 1, 2001; 58(7): 1069 - 1074. [Abstract] [Full Text] [PDF]
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M. W. Parsons, Q. Yang, P. A. Barber, D. G. Darby, P. M. Desmond, R. P. Gerraty, B. M. Tress, and S. M. Davis Perfusion Magnetic Resonance Imaging Maps in Hyperacute Stroke : Relative Cerebral Blood Flow Most Accurately Identifies Tissue Destined to Infarct Stroke, July 1, 2001; 32(7): 1581 - 1587. [Abstract] [Full Text] [PDF]
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C. Nasel, A. Azizi, A. Wilfort, R. Mallek, and E. Schindler Measurement of Time-to-peak Parameter by Use of a New Standardization Method in Patients with Stenotic or Occlusive Disease of the Carotid Artery AJNR Am. J. Neuroradiol., June 1, 2001; 22(6): 1056 - 1061. [Abstract] [Full Text] [PDF]
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K. Szabo, R. Kern, A. Gass, J. Hirsch, and M. Hennerici Acute Stroke Patterns in Patients With Internal Carotid Artery Disease : A Diffusion-Weighted Magnetic Resonance Imaging Study Stroke, June 1, 2001; 32(6): 1323 - 1329. [Abstract] [Full Text] [PDF]
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C. B. Grandin, T. P. Duprez, A. M. Smith, F. Mataigne, A. Peeters, C. Oppenheim, and G. Cosnard Usefulness of Magnetic Resonance-Derived Quantitative Measurements of Cerebral Blood Flow and Volume in Prediction of Infarct Growth in Hyperacute Stroke Stroke, May 1, 2001; 32(5): 1147 - 1153. [Abstract] [Full Text] [PDF]
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D. C. Tong, A. Adami, M. E. Moseley, and M. P. Marks Prediction of Hemorrhagic Transformation Following Acute Stroke: Role of Diffusion- and Perfusion-Weighted Magnetic Resonance Imaging Arch Neurol, April 1, 2001; 58(4): 587 - 593. [Abstract] [Full Text] [PDF]
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O. Wu, W. J. Koroshetz, L. Ostergaard, F. S. Buonanno, W. A. Copen, R. G. Gonzalez, G. Rordorf, B. R. Rosen, L. H. Schwamm, R. M. Weisskoff, et al. Predicting Tissue Outcome in Acute Human Cerebral Ischemia Using Combined Diffusion- and Perfusion-Weighted MR Imaging Stroke, April 1, 2001; 32(4): 933 - 942. [Abstract] [Full Text] [PDF]
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P. Pantano, D. Toni, F. Caramia, A. Falcou, M. Fiorelli, C. Argentino, L. M. Fantozzi, and L. Bozzao Relationship between Vascular Enhancement, Cerebral Hemodynamics, and MR Angiography in Cases of Acute Stroke AJNR Am. J. Neuroradiol., February 1, 2001; 22(2): 255 - 260. [Abstract] [Full Text] [PDF]
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M. Koenig, M. Kraus, C. Theek, E. Klotz, W. Gehlen, and L. Heuser Quantitative Assessment of the Ischemic Brain by Means of Perfusion-Related Parameters Derived From Perfusion CT Stroke, February 1, 2001; 32(2): 431 - 437. [Abstract] [Full Text] [PDF]
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E. COMMITTEE OF THE ASITN Intraarterial Thrombolysis: Ready for Prime Time? AJNR Am. J. Neuroradiol., January 1, 2001; 22(1): 55 - 58. [Full Text] [PDF]
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J. O. Karonen, Y. Liu, R. L. Vanninen, L. Østergaard, P. L. Kaarina Partanen, P. A. Vainio, E. J. Vanninen, J. Nuutinen, R. Roivainen, S. Soimakallio, et al. Combined Perfusion- and Diffusion-weighted MR Imaging in Acute Ischemic Stroke during the 1st Week: A Longitudinal Study Radiology, December 1, 2000; 217(3): 886 - 894. [Abstract] [Full Text]
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T. Back, J. G. Hirsch, K. Szabo, and A. Gass Failure to Demonstrate Peri-Infarct Depolarizations by Repetitive MR Diffusion Imaging in Acute Human Stroke Stroke, December 1, 2000; 31(12): 2901 - 2906. [Abstract] [Full Text] [PDF]
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V. N. Thijs, M. G. Lansberg, C. Beaulieu, M. P. Marks, M. E. Moseley, and G. W. Albers Is Early Ischemic Lesion Volume on Diffusion-Weighted Imaging an Independent Predictor of Stroke Outcome? : A Multivariable Analysis Stroke, November 1, 2000; 31(11): 2597 - 2602. [Abstract] [Full Text] [PDF]
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K. Krueger, H. Kugel, M. Grond, A. Thiel, D. Maintz, and K. Lackner Late Resolution of Diffusion-Weighted MRI Changes in a Patient With Prolonged Reversible Ischemic Neurological Deficit After Thrombolytic Therapy Stroke, November 1, 2000; 31(11): 2715 - 2718. [Abstract] [Full Text] [PDF]
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S. L. Keir and J. M. Wardlaw Systematic Review of Diffusion and Perfusion Imaging in Acute Ischemic Stroke Stroke, November 1, 2000; 31(11): 2723 - 2731. [Abstract] [Full Text] [PDF]
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C. Nasel, A. Azizi, A. Veintimilla, R. Mallek, and E. Schindler A Standardized Method of Generating Time-to-peak Perfusion Maps in Dynamic-susceptibility Contrast-enhanced MR Imaging AJNR Am. J. Neuroradiol., July 1, 2000; 21(7): 1195 - 1198. [Abstract] [Full Text] [PDF]
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T. Neumann-Haefelin, H.-J. Wittsack, G. R. Fink, F. Wenserski, T.-Q. Li, R. J. Seitz, M. Siebler, U. Modder, and H.-J. Freund Diffusion- and Perfusion-Weighted MRI : Influence of Severe Carotid Artery Stenosis on the DWI/PWI Mismatch in Acute Stroke Stroke, June 1, 2000; 31(6): 1311 - 1317. [Abstract] [Full Text] [PDF]
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H.-J. Wittsack, A. Ritzl, G. R. Fink, F. Wenserski, M. Siebler, R. J. Seitz, U. Modder, and H.-J. Freund MR Imaging in Acute Stroke: Diffusion-weighted and Perfusion Imaging Parameters for Predicting Infarct Size Radiology, February 1, 2002; 222(2): 397 - 403. [Abstract] [Full Text] [PDF]
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