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(Stroke. 2005;36:1099.)
© 2005 American Heart Association, Inc.

Controversies in Stroke

Perfusion-Weighted Imaging/Diffusion-Weighted Imaging Mismatch on MRI Can Now Be Used to Select Patients for Recombinant Tissue Plasminogen Activator Beyond 3 Hours

Con

Justin A. Zivin, MD, PhD

From the Department of Neurosciences, University of California San Diego, La Jolla.

Correspondence to Justin A. Zivin, Professor of Neurosciences, University of California San Diego, 9500 Gilman Dr, La Jolla, CA 92093-0624. E-mail jzivin@ucsd.edu

Key Words: diffusion magnetic resonance imaging • magnetic resonance imaging

An extract of the first 250 words of the full text is provided, because this article has no abstract.

My German colleagues claim that MRI can now be used to select patients for tissue plasminogen activator (tPA) therapy beyond the 3-hour time window. I wish that were so. As a clinical investigator, it would make my life much easier. However, I still have important reservations.

The computed tomography (CT) criteria for excluding stroke victims within 3 hours were defined in the National Institutes of Health tPA trial³ as being the presence of an increased density on the image. This is associated with hemorrhage. However, as my colleagues note, "Although never formally assessed, CT is commonly considered the ‘gold standard’ to demonstrate (intracerebral hemorrhage)."² Nevertheless, the tPA trials showed that excluding patients with this abnormality leads to demonstrable efficacy of treatment for acute stroke patients. The reason we want to exclude patients with hemorrhage is that a thrombolytic will not be efficacious and may increase the hemorrhage rate.^1,3

Now the imagers want to substitute MRI for CT. We would like MRI to provide us with 2 types of information: (1) identification of salvageable tissue, and (2) exclusion of hemorrhage. Unfortunately, at present, we are not sure that MRI can do either. At least 3 clinical trials are currently in progress to find out whether perfusion/diffusion mismatch can be used to select patients with salvageable tissue. However, none of these trials have been published, so I cannot review the data. The claim is that the area in between the adequately perfused tissue and the DWI abnormality is the potential salvageable tissue. . . . [Full Text of this Article]

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