Background: The MRI-based mismatch concept has been used to estimate the risk of infarction in ischemic stroke. Based on multiple studies on magnetic resonance perfusion imaging, it seems unlikely that any perfusion parameter threshold will provide a reliable prediction of radiological or clinical outcome for all patients. The goal of our study was to find a minimally biased yet maximally useful perfusion postprocessing protocol which would offer the treating physician a useful estimate of tissue fate. Methods: One hundred and forty-five acute ischemic stroke patients, admitted within 24 h after stroke to the Charité – University Medicine Hospital in Berlin between March 2008 and November 2009, were included in this study. Using three different software packages (Perfscape/Neuroscape, PMA and Stroketool), maps of mean transit time, cerebral blood flow (CBF) and Tmax were created. Three different thresholds were applied on each parameter map and subsequent volumes of hypoperfused tissue were calculated. Results: Overall, the maps and thresholds giving the least amount of overestimation of the final infarct volume were Tmax 8 s in Perfscape/Neuroscape, CBF 20 ml/100 g/min in PMA and CBF 15% (of the highest value on the scale for a given patient) in Stroketool. In patients with persistent vessel occlusion, a CBF map with a restrictive threshold showed volumes of tissue at definite risk of infarction in up to 100% of patients. The additional use of a CBF map with a high threshold enabled identification of patients without penumbras. Conclusions: No combination of software, map and threshold was able to give a reliable estimate of tissue fate for either all patients or any subgroup of patients. However, in patients with vessel occlusion, combination of a CBF map with a low and a high threshold can enable calculation of the minimum volume of brain tissue that will inevitably be lost if the occlusion persists.

1.
Warach S, Dashe JF, Edelman RR: Clinical outcome in ischemic stroke predicted by early diffusion-weighted and perfusion magnetic resonance imaging: a preliminary analysis. J Cereb Blood Flow Metab 1996;16:53–59.
2.
Davis SM, Donnan GA, Butcher KS, Parsons M: Selection of thrombolytic therapy beyond 3 h using magnetic resonance imaging. Curr Opin Neurol 2005;18:47–52.
3.
Hacke W, Albers G, Al-Rawi Y, Bogousslavsky J, Davalos A, Eliasziw M, Fischer M, Furlan A, Kaste M, Lees KR, Soehngen M, Warach S: The Desmoteplase in Acute Ischemic Stroke Trial (DIAS): a phase II MRI-based 9-hour window acute stroke thrombolysis trial with intravenous desmoteplase. Stroke 2005;36:66–73.
4.
Kohrmann M, Juttler E, Fiebach JB, Huttner HB, Siebert S, Schwark C, Ringleb PA, Schellinger PD, Hacke W: MRI versus CT-based thrombolysis treatment within and beyond the 3 h time window after stroke onset: a cohort study. Lancet Neurol 2006;5:661–667.
5.
Campbell BCV, Christensen S, Foster SJ, Desmond PM, Parsons MW, Butcher KS, Barber PA, Levi CR, Bladin CF, Donnan GA, Davis SM: Visual assessment of perfusion-diffusion mismatch is inadequate to select patients for thrombolysis. Cerebrovasc Dis 2010;29:592–596.
6.
Schellinger PD, Bryan RN, Caplan LR, Detre JA, Edelman RR, Jaigobin C, Kidwell CS, Mohr JP, Sloan M, Sorensen AG, Warach S: Evidence-based guideline: the role of diffusion and perfusion MRI for the diagnosis of acute ischemic stroke. Neurology 2010;75:177–185.
7.
Sorensen AG, Copen WA, Ostergaard L, Buonanno FS, Gonzalez RG, Rordorf G, Rosen BR, Schwamm LH, Weisskoff RM, Koroshetz WJ: Hyperacute stroke: simultaneous measurement of relative cerebral blood volume, relative cerebral blood flow, and mean tissue transit time. Radiology 1999;210:519–527.
8.
Yamada K, Wu O, Gonzalez RG, Bakker D, Ostergaard L, Copen WA, Weisskoff RM, Rosen BR, Yagi K, Nishimura T, Sorensen AG: Magnetic resonance perfusion-weighted imaging of acute cerebral infarction effect of the calculation methods and underlying vasculopathy. Stroke 2002;33:87–94.
9.
Rose SE, Janke AL, Griffin M, Finnigan S, Chalk JB: Improved prediction of final infarct volume using bolus delay-corrected perfusion-weighted MRI. Stroke 2004;35:2466–2471
10.
Kane I, Carpenter T, Chappell F, Rivers C, Armitage P, Sandercock P, Wardlaw J: Comparison of 10 different magnetic resonance perfusion imaging processing methods in acute ischemic stroke effect on lesion size, proportion of patients with diffusion/perfusion mismatch, clinical scores, and radiologic outcomes. Stroke 2007;38:3158–3164.
11.
Christensen S, Mouridsen K, Wu O, Hjort N, Karstoft H, Thomalla G, Röther J, Fiehler J, Kucinski T, Ostergaard L: Comparison of 10 perfusion MRI parameters in 97 sub-6-hour stroke patients using voxel-based receiver operating characteristics analysis. Stroke 2009;40:2055–2061.
12.
Ma H, Zavala JA, Teoh H, Churilov L, Gunawan M, Ly J, Wright P, Phan T, Arakawa S, Davis SM, Donnan GA: Penumbral mismatch is underestimated using standard volumetric methods and this is exacerbated with time. J Neurol Neurosurg Psychiatry 2009;80:991–997.
13.
Luby M, Warach S: Reliability of MR perfusion-weighted and diffusion-weighted imaging mismatch measurement methods. Am J Neuroradiol 2007;28:1674–1678.
14.
Bristow MS, Poulin BW, Simon JE, Hill MD, Kosior JC, Coutts SB, Frayne R, Mitchell JR, Demchuk AM: Identifying lesion growth with MR Imaging in acute ischemic stroke. J Magn Reson Imaging 2008;28:837–846.
15.
Fiehler J, von Bezold M, Kucinski T, Knab R, Eckert B, Wittkugel O, Zeumer H, Röther J: Cerebral blood flow predicts lesion growth in acute stroke patients. Stroke 2002;33:2421–2425.
16.
Ma L, Gao PY, Lin Y, Xue J, Wang XC, Wang YJ, Wang YL, Liao XL, Liu ML, Cui SM, Yu L, Tong SJ, Huang YL, Zhou YM: Can baseline magnetic resonance angiography (MRA) status become a foremost factor in selecting optimal acute stroke patients for recombinant tissue plasminogen activator (rt-PA) thrombolysis beyond 3 hours? Neurol Res 2009;31:355–361.
17.
Hotter B, Pittl S, Ebinger M, Oepen G, Jegzentis K, Kudo K, Rozanski M, Schmidt WU, Brunecker P, Xu C, Martus P, Endres M, Jungehülsing GJ, Villringer A, Fiebach JB: Prospective study on the mismatch concept in acute stroke patients within the first 24 h after symptom onset – 1000Plus study. BMC Neurol 2009;doi:10.1186/1471-2377-9-60.
18.
Ebinger M, Brunecker P, Jungehuelsing GJ, Malzahn U, Kunze C, Endres M, Fiebach JB: Reliable perfusion maps in stroke MRI using arterial input functions derived from distal middle cerebral artery branches. Stroke 2010;41:95–101.
19.
Olivot JM, Mlynash M, Thijs VN, Kemp S, Lansberg MG, Wechsler L, Bammer R, Marks MP, Albers GW: Optimal Tmax threshold for predicting penumbral tissue in acute stroke. Stroke 2009;40:469–475.
20.
Schellinger PD, Fiebach JB, Jansen O, Ringleb PA, Mohr A, Steiner T, Heiland S, Schwab S, Pohlers O, Ryssel H, Orakcioglu B, Sartor K, Hacke W: Stroke magnetic resonance imaging within 6 hours after onset of hyperacute cerebral ischemia. Ann Neurol 2001;49:460–469.
21.
Sobesky J, Weber OZ, Lehnhardt FG, Hesselmann V, Neveling M, Jacobs A, Heiss WD: Does the Mismatch Match the Penumbra? Magnetic resonance imaging and positron emission tomography in early ischemic stroke. Stroke 2005;36:980–985.
22.
Heiss W-D, Sobesky J, Smekal UV, Kracht LW, Lehnhardt FG, Thiel A, Jacobs AH, Lackner K: Probability of cortical infarction predicted by flumazenil binding and diffusion-weighted imaging signal intensity: a comparative positron emission tomography/magnetic resonance imaging study in early ischemic stroke. Stroke 2004;35:1892–1898.
23.
Kosior RK, Kosior JC, Frayne R: Improved dynamic susceptibility contrast (DSC)-MR perfusion estimates by motion correction. J Magn Reson Imaging 2007;26:1167–1172.
24.
Kim J, Leirab EC, Callison RC, Ludwiga B, Moritani T, Magnotta VA, Madsen MT: Toward fully automated processing of dynamic susceptibility contrast perfusion MRI for acute ischemic cerebral stroke. Comput Methods Programs Biomed 2010;98:204–213.
25.
Rivers CS, Wardlaw JM, Armitage PA, Bastin ME, Carpenter TK, Cvoro V, Hand PJ, Dennis MS: Do acute diffusion- and perfusion-weighted MRI lesions identify final infarct volume in ischemic stroke? Stroke 2006;37:98–104.
26.
Zaro-Weber O, Moeller-Hartmann W, Heiss WD, Sobesky J: A simple positron emission tomography-based calibration for perfusion-weighted magnetic resonance maps to optimize penumbral flow detection in acute stroke. Stroke 2010;41:1939–1945.
27.
Fiebach JB, Hopt A, Vucic T, Brunecker P, Nolte CH, Doege C, Villringer K, Jungehulsing GJ, Kunze C, Wegener S, Villringer A: Inverse mismatch and lesion growth in small subcortical ischaemic stroke. Eur Radiol 2010;20:2983–2989.
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