Combined Perfusion and Permeability Imaging Reveals Different Pathophysiologic Tissue Responses After Successful Thrombectomy.

Despite successful recanalization of large-vessel occlusions in acute ischemic stroke, individual patients profit to a varying degree. Dynamic susceptibility-weighted perfusion and dynamic T1-weighted contrast-enhanced blood-brain barrier permeability imaging may help to determine secondary stroke injury and predict clinical outcome. We prospectively performed perfusion and permeability imaging in 38 patients within 24 h after successful mechanical thrombectomy of an occlusion of the middle cerebral artery M1 segment. Perfusion alterations were evaluated on cerebral blood flow maps, blood-brain barrier disruption (BBBD) visually and quantitatively on ktrans maps and hemorrhagic transformation on susceptibility-weighted images. Visual BBBD within the DWI lesion corresponded to a median ktrans elevation (IQR) of 0.77 (0.41-1.4) min-1 and was found in all 7 cases of hypoperfusion (100%), in 10 of 16 cases of hyperperfusion (63%), and in only three of 13 cases with unaffected perfusion (23%). BBBD was significantly associated with hemorrhagic transformation (p < 0.001). While BBBD alone was not a predictor of clinical outcome at 3 months (positive predictive value (PPV) = 0.8 [0.56-0.94]), hypoperfusion occurred more often in patients with unfavorable clinical outcome (PPV = 0.43 [0.10-0.82]) compared to hyperperfusion (PPV = 0.93 [0.68-1.0]) or unaffected perfusion (PPV = 1.0 [0.75-1.0]). We show that combined perfusion and permeability imaging reveals distinct infarct signatures after recanalization, indicating the severity of prior ischemic damage. It assists in predicting clinical outcome and may identify patients at risk of stroke progression

Comparing Poor and Favorable Outcome Prediction With Machine Learning After Mechanical Thrombectomy in Acute Ischemic Stroke

Outcome prediction after mechanical thrombectomy (MT) in patients with acute ischemic stroke (AIS) and large vessel occlusion (LVO) is commonly performed by focusing on favorable outcome (modified Rankin Scale, mRS 0–2) after 3 months but poor outcome representing severe disability and mortality (mRS 5 and 6) might be of equal importance for clinical decision-making

Ultrahigh-Field MRI in Human Ischemic Stroke – a 7 Tesla Study

INTRODUCTION: Magnetic resonance imaging (MRI) using field strengths up to 3 Tesla (T) has proven to be a powerful tool for stroke diagnosis. Recently, ultrahigh-field (UHF) MRI at 7 T has shown relevant diagnostic benefits in imaging of neurological diseases, but its value for stroke imaging has not been investigated yet. We present the first evaluation of a clinically feasible stroke imaging protocol at 7 T. For comparison an established stroke imaging protocol was applied at 3 T. METHODS: In a prospective imaging study seven patients with subacute and chronic stroke were included. Imaging at 3 T was immediately followed by 7 T imaging. Both protocols included T1-weighted 3D Magnetization-Prepared Rapid-Acquired Gradient-Echo (3D-MPRAGE), T2-weighted 2D Fluid Attenuated Inversion Recovery (2D-FLAIR), T2-weighted 2D Fluid Attenuated Inversion Recovery (2D-T2-TSE), T2* weighted 2D Fast Low Angle Shot Gradient Echo (2D-HemoFLASH) and 3D Time-of-Flight angiography (3D-TOF). RESULTS: The diagnostic information relevant for clinical stroke imaging obtained at 3 T was equally available at 7 T. Higher spatial resolution at 7 T revealed more anatomical details precisely depicting ischemic lesions and periinfarct alterations. A clear benefit in anatomical resolution was also demonstrated for vessel imaging at 7 T. RF power deposition constraints induced scan time prolongation and reduced brain coverage for 2D-FLAIR, 2D-T2-TSE and 3D-TOF at 7 T versus 3 T. CONCLUSIONS: The potential of 7 T MRI for human stroke imaging is shown. Our pilot study encourages a further evaluation of the diagnostic benefit of stroke imaging at 7 T in a larger study

Diagnostic and prognostic benefit of arterial spin labeling in subacute stroke

Background and Purpose: Brain perfusion measurement in the subacute phase of stroke may support therapeutic decisions. We evaluated whether arterial spin labeling (ASL), a noninvasive perfusion imaging technique based on magnetic resonance imaging (MRI), adds diagnostic and prognostic benefit to diffusion-weighted imaging (DWI) in subacute stroke. Methods: In a single-center imaging study, patients with DWI lesion(s) in the middle cerebral artery (MCA) territory were included. Onset to imaging time was ≤ 7 days and imaging included ASL and DWI sequences. Qualitative (standardized visual analysis) and quantitative perfusion analyses (region of interest analysis) were performed. Dichotomized early outcome (modified Rankin Scale [mRS] 0-2 vs. 3-6) was analyzed in two logistic regression models. Model 1 included DWI lesion volume, age, vascular pathology, admission NIHSS, and acute stroke treatment as covariates. Model 2 added the ASL-based perfusion pattern to Model 1. Receiver-operating-characteristic (ROC) and area-under-the-curve (AUC) were calculated for both models to assess their predictive power. The likelihood-ratio-test compared both models. Results: Thirty-eight patients were included (median age 70 years, admission NIHSS 4, onset to imaging time 67 hr, discharge mRS 2). Qualitative perfusion analysis yielded additional diagnostic information in 84% of the patients. In the quantitative analysis, AUC for outcome prediction was 0.88 (95% CI 0.77-0.99) for Model 1 and 0.97 (95% CI 0.91-1.00) for Model 2. Inclusion of perfusion data significantly improved performance and outcome prediction (p = 0.002) of stroke imaging. Conclusions: In patients with subacute stroke, our study showed that adding perfusion imaging to structural imaging and clinical data significantly improved outcome prediction. This highlights the usefulness of ASL and noninvasive perfusion biomarkers in stroke diagnosis and management

Synopsis of the parameters of the imaging techniques used.

<p> <i>TR: repetition time; TE: echo time; BW: Bandwidth; FA: flip angle; t = time.</i></p

Comparison of T2-weighted imaging performed at 3 T and 7 T.

<p>Boxed areas are shown at higher magnification. A) In patient No. 3, artifacts were present (red arrowheads). Contrast and detail level of the lesion (white arrowhead) and of Virchow-Robin spaces were not higher at 7 T. B) In contrast, in patient No. 1 no artifacts were present. Virchow Robin spaces (white arrowheads) were depicted in higher detail at 7 T and the delineation of the lesion (red arrowheads) from healthy tissue was higher at 7 T. C) Same patient as in B). Also in the region of the deep nuclei T2-weighted imaging at 7 T showed better delineation, e.g. between deep nuclei (red asterisks) and fibre bundles of the internal capsule (white asterisks).</p

Comparison of T₁-weighted images derived from T1-MPRAGE at 3 T and 7 T.

<p>In all patients, MPRAGE at 7 T depicted the internal structure of stroke lesion in higher detail compared with 3 T. Boxed areas are shown at higher magnification. A) Patient No. 3. The tissue defect area appeared larger and less well confined at 3 T in contrast to 7 T (white arrowheads). Virchow-Robin spaces were seen in more detail and higher frequency at 7 T (red arrowheads). B) In patient No. 1, the chronic stroke lesion (white arrowheads) presented as an hypointense area – indicating gliosis – and as a disruption of the cortical band. These characteristics of the lesion were depicted in higher detail level and contrast at 7 T. The subacute lesion (red arrowheads) showed a different internal structure of the cortical band compared with healthy cortex. Within the lesion, the cortical band was divided into a superficial hyperintense layer and a deeper hypointense layer (asterisks). Differentiation of the two layers was much easier at 7 T. C) Patient No. 4. In this large infarct, differentiation of hypointense gliosis (white arrowheads) and healthy tissue was again clearer at 7 T. Inhomogeneities between the frontal and occipital cortex and paramedian deep structures – typical for 7 T – were more pronounced in this patient compared to A) and B).</p

Comparison of MR-angiographies derived from 3D TOF acquisitions at 3 T and 7 T.

<p>In all patients, TOF at 7 T was able to depict the branches of the main cerebral arteries in higher anatomical detail. In patients No. 4 (A) and No. 7 (B), the left MCA territory is shown in higher magnification. In comparison with 3 T, clearly more first and second order branches were visible at 7 T in comparison with 3 T (white arrowheads).</p

Comparison of T2-FLAIR images obtained at 3 T and 7 T.

<p>In all patients, all lesions detected at 3 T were also visible at 7 T. Boxed areas are shown at higher magnification. A) Patient No. 3, with a small chronic lesion consisting of hyperintense postischemic tissue (white arrowheads) surrounding a tissue defect area (asterisk); compare also <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0037631#pone-0037631-g002" target="_blank">figure 2</a> A. At 7 T, the intensity values of the tissue defect area were comparable to CSF, while at 3 T, the intensity values were comparable to white matter. Contrast between postischemic and healthy brain tissue was higher at 3 T. However, small white matter lesions (red arrowheads) were easier to identify at 7 T. B) Patient No. 1, with a chronic stroke lesion (white arrowheads) and a subacute lesion (red arrowheads). Both lesion types were readily identifiable at both field strengths. As in A), contrast between the lesion and healthy tissue appeared to be higher at 3 T. C) Patient No. 4, with a large chronic infarct, consisting of hyperintense lesion areas (white arrowheads) and hypointense defect areas (asterisks). Again, CSF-filled tissue defect areas were easier to identify at 7 T, while the lesion to healthy tissue contrast was higher at 3 T. Compare also fig. 2 A–C.</p