Diffusion-weighted magnetic resonance imaging versus computed tomography in the diagnosis of acute ischemic stroke.

Current treatment protocols using reperfusion therapy for acute ischemic stroke rely on non-contrast computed tomography (NCCT), with most indications including the absence of acute hemorrhage or large volume of infarction in the presence of clinical signs and symptoms. This predictably results in a significant incidence of the administration of reperfusion therapy to patients with "stroke mimics," such as migraine headache or Todd's paralysis after a seizure. Diffusion-weighted imaging (DWI) is a technique based on magnetic resonance imaging (MRI) that may be more sensitive and specific for acute cerebral ischemia than NCCT. In addition, data for techniques such as perfusion-weighted imaging can be acquired with minimal additional time required. This may allow better risk assessment of a clinical response to reperfusion therapy vs. the possibility of hemorrhagic complications. This article describes a methodical review of studies comparing the sensitivity, specificity, positive predictive value, and negative predictive value of DWI vs. NCCT in the evaluation of acute ischemic stroke. Data from studies meeting our screening criteria are combined to produce overall values for each.

[1]  G. Albers,et al.  Diffusion and perfusion magnetic resonance imaging for the evaluation of acute stroke: potential use in guiding thrombolytic therapy. , 2000, Current opinion in neurology.

[2]  Cornelius Weiller,et al.  Sensitivity and interrater agreement of CT and diffusion-weighted MR imaging in hyperacute stroke. , 2003, AJNR. American journal of neuroradiology.

[3]  D L Schriger,et al.  Cranial computed tomography interpretation in acute stroke: physician accuracy in determining eligibility for thrombolytic therapy. , 1998, JAMA.

[4]  Comparison of diffusion-weighted MRI and CT in acute stroke , 2000 .

[5]  K. Welch,et al.  Total quality improvement method for reduction of delays between emergency department admission and treatment of acute ischemic stroke. The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. , 1997, Archives of neurology.

[6]  D. Le Bihan,et al.  Viability Thresholds of Ischemic Penumbra of Hyperacute Stroke Defined by Perfusion-Weighted MRI and Apparent Diffusion Coefficient , 2001, Stroke.

[7]  S. Warach,et al.  MRI features of intracerebral hemorrhage within 2 hours from symptom onset. , 1999, Stroke.

[8]  Chan Hong Moon,et al.  Multiphasic Perfusion Computed Tomography in Hyperacute Ischemic Stroke: Comparison with Diffusion and Perfusion Magnetic Resonance Imaging , 2003, Journal of computer assisted tomography.

[9]  R Stollberger,et al.  Diffusion-weighted imaging of patients with subacute cerebral ischemia: comparison with conventional and contrast-enhanced MR imaging. , 2000, AJNR. American journal of neuroradiology.

[10]  R. Silbergleit,et al.  Misdiagnosis of stroke in tissue plasminogen activator-treated patients: characteristics and outcomes. , 2003, Annals of emergency medicine.

[11]  M. Knauth,et al.  Comparison of CT with diffusion-weighted MRI in patients with hyperacute stroke , 2001, Neuroradiology.

[12]  A. Villringer,et al.  Stroke Magnetic Resonance Imaging Is Accurate in Hyperacute Intracerebral Hemorrhage: A Multicenter Study on the Validity of Stroke Imaging , 2004, Stroke.

[13]  D B Matchar,et al.  Incidence and occurrence of total (first-ever and recurrent) stroke. , 1999, Stroke.

[14]  J. Alvir,et al.  Conditions that mimic stroke in the emergency department. Implications for acute stroke trials. , 1995, Archives of neurology.

[15]  W. Hacke,et al.  CT and Diffusion-Weighted MR Imaging in Randomized Order: Diffusion-Weighted Imaging Results in Higher Accuracy and Lower Interrater Variability in the Diagnosis of Hyperacute Ischemic Stroke , 2002, Stroke.

[16]  R B Roemer,et al.  Thermal and circulatory response of tissue to localized pressure application: a mathematical model. , 1980, Archives of physical medicine and rehabilitation.

[17]  S W Atlas,et al.  MR detection of hyperacute parenchymal hemorrhage of the brain. , 1998, AJNR. American journal of neuroradiology.

[18]  P D Lyden,et al.  Guidelines for thrombolytic therapy for acute stroke: a supplement to the guidelines for the management of patients with acute ischemic stroke. A statement for healthcare professionals from a Special Writing Group of the Stroke Council, American Heart Association. , 1996, Circulation.

[19]  Diffusion and perfusion imaging techniques. , 1995, Magnetic resonance imaging clinics of North America.

[20]  J. Broderick,et al.  The Greater Cincinnati/Northern Kentucky Stroke Study: preliminary first-ever and total incidence rates of stroke among blacks. , 1998, Stroke.

[21]  M Fisher,et al.  New magnetic resonance techniques for acute ischemic stroke. , 1995, JAMA.

[22]  G. Teasdale,et al.  Effects of experimental intracerebral hemorrhage on blood flow, capillary permeability, and histochemistry. , 1987, Journal of neurosurgery.

[23]  H. Urbach,et al.  Detectability and detection rate of acute cerebral hemisphere infarcts on CT and diffusion-weighted MRI , 2000, Neuroradiology.

[24]  W. Barsan,et al.  Treatment of acute ischemic stroke. , 2001, Annals of emergency medicine.

[25]  Yueh Z. Lee,et al.  MR imaging enhancement patterns as predictors of hemorrhagic transformation in acute ischemic stroke. , 2003, AJNR. American journal of neuroradiology.

[26]  R. Higashida,et al.  Intra-arterial Prourokinase for Acute Ischemic Stroke: The PROACT II Study: A Randomized Controlled Trial , 1999 .

[27]  Sid Gilman,et al.  Imaging the brain. Second of two parts. , 1998, The New England journal of medicine.

[28]  J. Broderick,et al.  Emergency physicians. Accuracy in the diagnosis of stroke. , 1995, Stroke.

[29]  L Bozzao,et al.  Acute stroke: usefulness of early CT findings before thrombolytic therapy. , 1997, Radiology.

[30]  W Hacke,et al.  Sensitivity and prognostic value of early CT in occlusion of the middle cerebral artery trunk. , 1994, AJNR. American journal of neuroradiology.

[31]  W Hacke,et al.  A standardized MRI stroke protocol: comparison with CT in hyperacute intracerebral hemorrhage. , 1999, Stroke.

[32]  Jeffry R Alger,et al.  Perfusion-Weighted Magnetic Resonance Imaging Thresholds Identifying Core, Irreversibly Infarcted Tissue , 2003, Stroke.

[33]  J. Thiran,et al.  Comparison of Admission Perfusion Computed Tomography and Qualitative Diffusion- and Perfusion-Weighted Magnetic Resonance Imaging in Acute Stroke Patients , 2002, Stroke.

[34]  M. Hommel,et al.  Thrombolytic therapy with streptokinase in acute ischemic stroke. , 1996, The New England journal of medicine.

[35]  S M Davis,et al.  Prediction of stroke outcome with echoplanar perfusion- and diffusion-weighted MRI , 1998, Neurology.

[36]  R. Gonzalez,et al.  Magnetic Resonance Imaging Improves Detection of Intracerebral Hemorrhage Over Computed Tomography After Intra-Arterial Thrombolysis , 2004, Stroke.

[37]  P. Akins,et al.  Intra-arterial prourokinase for acute ischemic stroke. , 2000, JAMA.

[38]  J. Garcìa,et al.  Experimental ischemic stroke: a review. , 1984, Stroke.

[39]  L H Schwamm,et al.  Diffusion-weighted MR imaging: diagnostic accuracy in patients imaged within 6 hours of stroke symptom onset. , 1999, Radiology.

[40]  L. Munari,et al.  RANDOMIZED CONTROLLED TRIAL OF STREPTOKINASE, ASPIRIN, AND COMBINATION OF BOTH IN TREATMENT OF ACUTE ISCHEMIC STROKE , 1995 .

[41]  G. Albers,et al.  Expanding the window for thrombolytic therapy in acute stroke. The potential role of acute MRI for patient selection. , 1999, Stroke.

[42]  G. Hankey,et al.  Streptokinase for acute ischemic stroke with relationship to time of administration: Australian Streptokinase (ASK) Trial Study Group. , 1996, Journal of the American Medical Association (JAMA).

[43]  W Hacke,et al.  Feasibility and practicality of MR imaging of stroke in the management of hyperacute cerebral ischemia. , 2000, AJNR. American journal of neuroradiology.

[44]  J. Holmes,et al.  Lifetime cost of stroke in the United States. , 1996, Stroke.

[45]  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 .

[46]  M. Kaste,et al.  Randomised double-blind placebo-controlled trial of thrombolytic therapy with intravenous alteplase in acute ischaemic stroke (ECASS II) , 1998, The Lancet.

[47]  R. Ojemann,et al.  Thresholds of focal cerebral ischemia in awake monkeys. , 1981, Journal of neurosurgery.

[48]  G. Schlaug,et al.  Enlargement of human cerebral ischemic lesion volumes measured by diffusion‐weighted magnetic resonance imaging , 1997, Annals of neurology.

[49]  K. Wong,et al.  Multiple acute cerebral infarcts on diffusion-weighted imaging and risk of recurrent stroke , 2004, Neurology.

[50]  T. Rainer,et al.  B0 Images Obtained From Diffusion‐Weighted Echo Planar Sequences for the Detection of Intracerebral Bleeds , 2003, Journal of neuroimaging : official journal of the American Society of Neuroimaging.

[51]  R. Edelman,et al.  Detection of hyperacute primary intraparenchymal hemorrhage by magnetic resonance imaging. , 1996, Stroke.

[52]  J D Fenstermacher,et al.  Transient and permanent resolution of ischemic lesions on diffusion-weighted imaging after brief periods of focal ischemia in rats : correlation with histopathology. , 2000, Stroke.

[53]  Klaus Sartor,et al.  A Standardized MRI Stroke Protocol , 1999 .

[54]  L Bozzao,et al.  Early prediction of irreversible brain damage after ischemic stroke at CT. , 2001, Radiology.

[55]  W. Hacke,et al.  Comparison of CT and CT Angiography Source Images With Diffusion-Weighted Imaging in Patients With Acute Stroke Within 6 Hours After Onset , 2002, Stroke.

[56]  Gottfried Schlaug,et al.  Predictors of Hemorrhagic Transformation After Intravenous Recombinant Tissue Plasminogen Activator: Prognostic Value of the Initial Apparent Diffusion Coefficient and Diffusion-Weighted Lesion Volume , 2002, Stroke.

[57]  M. Kaste,et al.  Intravenous thrombolysis with recombinant tissue plasminogen activator for acute hemispheric stroke. The European Cooperative Acute Stroke Study (ECASS) , 1995, JAMA.

[58]  B. Siesjö,et al.  Thresholds in cerebral ischemia - the ischemic penumbra. , 1981, Stroke.

[59]  C. Warlow,et al.  Systematic review of evidence on thrombolytic therapy for acute ischaemic stroke , 1997, The Lancet.

[60]  Ting-Yim Lee,et al.  Correlation of early dynamic CT perfusion imaging with whole-brain MR diffusion and perfusion imaging in acute hemispheric stroke. , 2003, AJNR. American journal of neuroradiology.

[61]  J. Broderick,et al.  Frequency and accuracy of prehospital diagnosis of acute stroke. , 1995, Stroke.

[62]  A Gregory Sorensen,et al.  CT and conventional and diffusion-weighted MR imaging in acute stroke: study in 691 patients at presentation to the emergency department. , 2002, Radiology.

[63]  P D Lyden,et al.  Agreement and variability in the interpretation of early CT changes in stroke patients qualifying for intravenous rtPA therapy. , 1999, Stroke.

[64]  G. Hankey,et al.  Streptokinase for acute ischemic stroke with relationship to time of administration: Australian Streptokinase (ASK) Trial Study Group. , 1996, JAMA.

[65]  S M Davis,et al.  Identification of major ischemic change. Diffusion-weighted imaging versus computed tomography. , 1999, Stroke.

[66]  L. Wilkins.  Practice Advisory , 1996, Neurology.

[67]  W. Yuh,et al.  Magnetic resonance versus computed tomographic imaging in acute stroke. , 1995, Stroke.

[68]  C. Truwit,et al.  Loss of the insular ribbon: another early CT sign of acute middle cerebral artery infarction. , 1990, Radiology.

[69]  T. Tomsick.  Tick tock, doc: the rapid evaluation of acute stroke to direct therapy and improve patient outcome. , 2000, AJNR. American journal of neuroradiology.

[70]  B. Buckley,et al.  Audit of a policy of magnetic resonance imaging with diffusion-weighted imaging as first-line neuroimaging for in-patients with clinically suspected acute stroke. , 2003, Clinical radiology.

[71]  M. Gado,et al.  Water content and water structure in CT and MR signal changes: possible influence in detection of early stroke. , 1988, AJNR. American journal of neuroradiology.

[72]  R. Higashida,et al.  PROACT: a phase II randomized trial of recombinant pro-urokinase by direct arterial delivery in acute middle cerebral artery stroke. PROACT Investigators. Prolyse in Acute Cerebral Thromboembolism. , 1998, Stroke.

[73]  J. Kucharczyk,et al.  Early detection of regional cerebral ischemia in cats: Comparison of diffusion‐ and T2‐weighted MRI and spectroscopy , 1990, Magnetic resonance in medicine.

[74]  G. Albers,et al.  Recombinant tissue-type plasminogen activator (Alteplase) for ischemic stroke 3 to 5 hours after symptom onset. The ATLANTIS Study: a randomized controlled trial. Alteplase Thrombolysis for Acute Noninterventional Therapy in Ischemic Stroke. , 1999, JAMA.