Clinical-diffusion mismatch defined by NIHSS and ASPECTS in non-lacunar anterior circulation infarction

Objectives Instead of the mismatch in MRI between the perfusion-weighted imaging (PWI) lesion and the smaller diffusion-weighted imaging (DWI) lesion (PWI-DWI mismatch), clinical-DWI mismatch (CDM) has been proposed as a new diagnostic marker of brain tissue at risk of infarction in acute ischemic stroke. The Alberta Stroke Program Early CT Score (ASPECTS) has recently been applied to detect early ischemic change of acute ischemic stroke. The present study applies the CDM concept to DWI data and investigated the utility of the CDM defined by the NIH Stroke Scale (NIHSS) and ASPECTS in patients with non-lacunar anterior circulation infarction. Methods Eighty-seven patients with first ever ischemic stroke within 24 hours of onset with symptoms of non-lacunar anterior circulation infarction with the NIHSS score ≥ 8 were enrolled. Initial lesion extent was measured by the ASPECTS on DWI within 24 hours, and initial neurological score was measured by the NIHSS. As NIHSS ≥ 8 has been suggested as a clinical indicator of a large volume of ischemic brain tissue, and the majority of patients with non-lacunar anterior infarction with score of NIHSS < 8 had lesions with ASPECTS ≥ 8 on DWI, so CDM was defined as NIHSS ≥ 8 and DWI-ASPECTS 8 ≥ . We divided patients into matched and mismatched patient groups, and compared them with respect to background characteristics, neurological findings, laboratory data, radiological findings and outcome. Results There were 35 CDM-positive patients (P group, 40.2%) and 52 CDM-negative patients (N group , 59.8%). P group patients had a higher risk of early neurological deterioration (END) than N group patients (37.1% vs 13.5%, p < 0.05), which were always accompanied by lesion growth defined by 2 or more points decrease on ASPECTS (36 to 72 hours after onset on CT). The NIHSS at entry were significantly lower in the P group, but there was no difference in the outcome at three months measured by the modified Rankin Scale. However, CDM was not an independent predictor of END by multiple logistic regression analysis. Conclusions Patients with CDM had high rate of early neurological deterioration and lesion growth. CDM defined as NIHSS ≥ 8 and DWI-ASPECTS ≥ 8 can be another marker for detecting patients with tissue at risk of infarction, but more work is needed to clarify whether this CDM method is useful in acute stroke management.

[1]  S. Warach,et al.  The Desmoteplase in Acute Ischemic Stroke Trial (DIAS): A Phase II MRI-Based 9-Hour Window Acute Stroke Thrombolysis Trial With Intravenous Desmoteplase , 2005, Stroke.

[2]  Jeffrey L. Saver,et al.  Extending Reperfusion Therapy for Acute Ischemic Stroke: Emerging Pharmacological, Mechanical, and Imaging Strategies , 2005, Stroke.

[3]  S. Uchiyama,et al.  Predictors of good prognosis in total anterior circulation infarction within 6 h after onset under conventional therapy , 2006, Acta neurologica Scandinavica.

[4]  Olaf Gefeller,et al.  Epidemiology of Ischemic Stroke Subtypes According to TOAST Criteria: Incidence, Recurrence, and Long-Term Survival in Ischemic Stroke Subtypes: A Population-Based Study , 2001, Stroke.

[5]  Brian Silver,et al.  Importance of Early Ischemic Computed Tomography Changes Using ASPECTS in NINDS rtPA Stroke Study , 2005, Stroke.

[6]  S. Uchiyama,et al.  Deteriorating Ischemic Stroke in 4 Clinical Categories Classified by the Oxfordshire Community Stroke Project , 2000, Stroke.

[7]  Patricia Desmond,et al.  Clinical-Diffusion Mismatch Predicts the Putative Penumbra With High Specificity , 2005, Stroke.

[8]  Joseph P. Broderick,et al.  Tissue plasminogen activator for acute ischemic stroke. The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. , 1995 .

[9]  M. E. Moseley,et al.  Correlation of perfusion- and diffusion-weighted MRI with NIHSS score in acute (<6.5 hour) ischemic stroke , 1998, Neurology.

[10]  R Frayne,et al.  Imaging of the brain in acute ischaemic stroke: comparison of computed tomography and magnetic resonance diffusion-weighted imaging , 2005, Journal of Neurology, Neurosurgery & Psychiatry.

[11]  S M Davis,et al.  Pathophysiological topography of acute ischemia by combined diffusion-weighted and perfusion MRI. , 1999, Stroke.

[12]  Ninds,et al.  Effect of Intravenous Recombinant Tissue Plasminogen Activator on Ischemic Stroke Lesion Size Measured by Computed Tomography , 2000, Stroke.

[13]  W. Heiss,et al.  Does the Mismatch Match the Penumbra?: Magnetic Resonance Imaging and Positron Emission Tomography in Early Ischemic Stroke , 2005, Stroke.

[14]  K. Pettigrew,et al.  Progression in acute stroke: value of the initial NIH stroke scale score on patient stratification in future trials. , 1999, Stroke.

[15]  A. Demchuk,et al.  Validity and reliability of a quantitative computed tomography score in predicting outcome of hyperacute stroke before thrombolytic therapy , 2000, The Lancet.

[16]  A. Demchuk,et al.  “Clinical-CT Mismatch” and the Response to Systemic Thrombolytic Therapy in Acute Ischemic Stroke , 2005, Stroke.

[17]  S. Pedraza,et al.  The clinical–DWI mismatch , 2004, Neurology.

[18]  A. Hillis,et al.  “Diffusion-clinical mismatch” is associated with potential for early recovery of aphasia , 2005, Neurology.

[19]  P. S. Jones,et al.  The Diffusion-Weighted Lesion in Acute Stroke: Heterogeneous Patterns of Flow/Metabolism Uncoupling as Assessed by Quantitative Positron Emission Tomography , 2005, Cerebrovascular Diseases.

[20]  R. Olshen,et al.  Who is most likely to benefit from tPA? The perfusion-diffusion and clinical-diffusion mismatch models disagree , 2005 .

[21]  Peter B Barker,et al.  Change in Perfusion in Acute Nondominant Hemisphere Stroke May Be Better Estimated by Tests of Hemispatial Neglect Than by the National Institutes of Health Stroke Scale , 2003, Stroke.

[22]  A. Buchan,et al.  Selection of Acute Ischemic Stroke Patients for Intra-Arterial Thrombolysis With Pro-Urokinase by Using ASPECTS , 2003, Stroke.

[23]  S. Ibayashi,et al.  Free radical scavenger, edaravone, in stroke with internal carotid artery occlusion , 2004, Journal of the Neurological Sciences.