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Stroke. 2005;36:1700-1704
Published online before print July 14, 2005, doi: 10.1161/01.STR.0000173407.40773.17
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(Stroke. 2005;36:1700.)
© 2005 American Heart Association, Inc.

Original Contributions

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 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.

Reprint requests to Prof Stephen Davis, Department of Neurology, Royal Melbourne Hospital, Grattan Street, Parkville, Victoria 3050 Australia. 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=PWIvol–DWIvol) and a categorical variable (mismatch=PWIvol–DWIvol/DWIvolx100>20%). Early infarct expansion was calculated as DWIsubacute vol/DWIacute 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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