J Korean Neurosurg Soc.  2016 Jul;59(4):346-351. 10.3340/jkns.2016.59.4.346.

Perfusion-Weighted MRI Parameters for Prediction of Early Progressive Infarction in Middle Cerebral Artery Occlusion

• Kim H
• Kim Y
• Kim YW
• Kim SR
• Yang SH

• KMID: 2315968
• DOI: http://doi.org/10.3340/jkns.2016.59.4.346

Abstract

OBJECTIVE
Early progressive infarction (EPI) is frequently observed and related to poor functional outcome in patients with middle cerebral artery (MCA) infarction caused by MCA occlusion. We evaluated the perfusion parameters of magnetic resonance imaging (MRI) as a predictor of EPI.
METHODS
We retrospectively analyzed patients with acute MCA territory infarction caused by MCA occlusion. EPI was defined as a National Institutes of Health Stroke Scale increment ≥2 points during 24 hours despite receiving standard treatment. Regional parameter ratios, such as cerebral blood flow and volume (rCBV) ratio (ipsilateral value/contralateral value) on perfusion MRI were analyzed to investigate the association with EPI.
RESULTS
Sixty-four patients were enrolled in total. EPI was present in 18 (28%) subjects and all EPI occurred within 3 days after hospitalization. Diabetes mellitus, rCBV ratio and regional time to peak (rTTP) ratio showed statically significant differences in both groups. Multi-variate analysis indicated that history of diabetes mellitus [odds ratio (OR), 6.13; 95% confidence interval (CI), 1.55-24.24] and a low rCBV ratio (rCBV, <0.85; OR, 6.57; 95% CI, 1.4-30.27) was significantly correlated with EPI.
CONCLUSION
The incidence of EPI is considerable in patients with acute MCA territory infarction caused by MCA occlusion. We suggest that rCBV ratio is a useful neuro-imaging parameter to predict EPI.

Keyword

Acute ischemic stroke; Cerebral blood volume; Hemodynamic failure; Magnetic resonance imaging; Middle cerebral artery occlusion

MeSH Terms

Cerebrovascular Circulation
Diabetes Mellitus
Hospitalization
Humans
Incidence
Infarction*
Infarction, Middle Cerebral Artery*
Magnetic Resonance Imaging*
Middle Cerebral Artery*
National Institutes of Health (U.S.)
Perfusion
Retrospective Studies
Stroke

Figure

• 

  Fig. 1 A 68 year-old female patient visited the emergency room, 8 hours after symptom onset. Initial NIHSS was 5. A and B : MR images revealed occlusion in the left, proximal middle cerebral artery and multiple subcortical infarctions on the frontal. C : Region of interest (yellow line) is highlighted in the affected cerebral hemisphere within the middle cerebral artery territory by manual segmentation and then mirrored to the contralateral cerebral hemisphere for assessment of perfusion ratio. rCBV ratio was decreased and rTTP ratio was increased. D : Fourteen hours after hospitalization, neurologic deterioration had occurred and follow-up MR image revealed extended infarction. E : We performed urgent superficial-middle cerebral artery bypass surgery and brain CT angiogram revealed transcranial passage of STA parietal branch (yellow arrow). F : Patients improved gradually and finally, the presence of neurological deficit was assessed using modified Rankin scale 2, three months later. NIHSS: National Institutes of Health Stroke Scale, rCBV : regional cerebral blood volume, rTTP : regional time to peak, STA : superficial temporal artery.

• 

  Fig. 2 The correlation between rCBV ratio and the rTTP ratio according to early progressive infarction. Red circle represents EPI and blue represents the non-EPI group. Area above the blue dotted line may represent early collateral build up (although the rTTP ratio increases, rCBV ratio >1). In contrast, the gray area has a high risk of EPI because of poor collateral circulation.

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