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(Stroke. 2003;34:1892.)
© 2003 American Heart Association, Inc.

Original Contributions

Prediction of Malignant Middle Cerebral Artery Infarction by Early Perfusion- and Diffusion-Weighted Magnetic Resonance Imaging

Götz J. Thomalla, MD; Thomas Kucinski, MD; Volker Schoder, MSc; Jens Fiehler, MD; Rene Knab, MSc; Herrmann Zeumer, MD; Cornelius Weiller, MD Joachim Röther, MD

From the Klinik und Poliklinik für Neurologie (G.J.T., R.K., C.W., J.R.); Neuroradiologische Abteilung, Klinik und Poliklinik für Radiologie (T.K., J.F., H.Z.); and Institut für Mathematik und Datenverarbeitung in der Medizin (V.S.), Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany.

Correspondence to Götz Thomalla, MD, Klinik und Poliklinik für Neurologie, Universitätsklinikum Hamburg-Eppendorf, Martinistraße 52, D-20246 Hamburg, Germany. E-mail thomalla{at}uke.uni-hamburg.de

Background and Purpose— We tested the hypothesis that early diffusion- and perfusion-weighted MRI (DWI and PWI, respectively) allows the prediction of malignant middle cerebral artery (MCA) infarction (MMI).

Methods— Thirty-seven patients with acute MCA infarction and proximal vessel occlusion (carotid-T, MCA main stem) were studied by DWI, PWI, and MR angiography within 6 hours of symptom onset. Eleven patients developed MMI, defined by decline of consciousness and radiological signs of space-occupying brain edema. Lesion volumes were retrospectively defined as apparent diffusion coefficient <80% (ADC_<80%) and time to peak >+4 seconds (TTP_>+4s) compared with the unaffected hemisphere. ADC decrease within the infarct core (ADC_core) and relative ADC within the ADC_<80% lesion (rADC_lesion) were measured. Neurological deficit at admission was assessed with the National Institutes of Health Stroke Scale (NIHSS).

Results— Patients with MMI showed larger ADC_<80% (median, 157 versus 22 mL; P<0.001) and TTP_>+4s (208 versus 125 mL; P<0.001) lesion volumes, smaller TTP/ADC mismatch ratio (1.5 versus 5.5; P<0.001), lower ADC_core values (290 versus 411 mm²/s; P<0.001), lower rADC_lesion (0.60 versus 0.66; P=0.001), higher frequency of carotid-T occlusion (64% versus 15%; P=0.006), and higher NIHSS score at admission (20 versus 15; P=0.001). Predictors of MMI were as follows for sensitivity and specificity, respectively: ADC_<80% >82 mL, 87%, 91%; TTP_>+4s >162 mL, 83%, 75%; TTP/ADC mismatch ratio <2.4, 80%, 79%; ADC_core <300 mm²/s, 83%, 85%; rADC_lesion <0.62, 79%, 74%; and NIHSS score at admission 19, 96%, 72%.

Conclusions— Quantitative analysis of early DWI and PWI parameters allows the prediction of MMI and can help in the selection of patients for aggressive tissue-protective therapy.

Key Words: brain edema • magnetic resonance imaging, diffusion-weighted • magnetic resonance imaging, perfusion-weighted • stroke, acute

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