(Stroke. 2001;32:2460.)
© 2001 American Heart Association, Inc.
Editorials |
Tissue Viability Thresholds in Acute Stroke
The 4-Factor Model
From the National Institutes of Health, National Institute of Neurological Disorders and Stroke, Stroke Branch, Bethesda, Md.
Correspondence to Steven Warach, MD, PhD, National Institutes of Health, National Institute of Neurological Disorders and Stroke, Stroke Branch, 36 Convent Dr, MSC 4129, Room 4A03, Bethesda, MD 20892-4129.
And the LORD said, "Behold, they are one people, and they have all one language; and this is only the beginning of what they will do; and nothing that they propose to do will now be impossible for them." Genesis 11:6
Defining thresholds of tissue viability in ischemic stroke is not quite a problem of biblical proportions, but it has become a matter reminiscent of the story of Babel. From the earliest PET studies of altered tissue hemodynamics and metabolism 2 decades ago1 through the most sophisticated multiparametric models using MRI,2 investigators have worked to determine thresholds on imaging measures of stroke patients that would distinguish regions destined to recover spontaneously, from those irreversibly injured and destined to infarct, from those threatened but potentially viable—the ischemic penumbra. The answer has been given dozens of times by dozens of investigators, and it has been a different answer each time it has been given. This observation is not meant to be dismissive of the important work that has been done toward this goal, but to underscore the difficulty in studying the problem, a difficulty compounded by the fact that no two investigative groups have approached the problem in the exact same manner.
The articles of Oppenheim and colleagues in the current3 and recent4 issues of Stroke are excellent examples of MRI work investigating the value of single tissue parameters in predicting outcome. Their studies contained relatively large sample sizes for studies of this type. The patients were untreated and studied within 6
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