Infarct growth

Karonen JO, Vanninen RL, Liu Y, 0stergaard L, Kuikka JT, Nuutinen J, Vanninen EJ, Partanen PL, Vainio PA, Korbonen K, Perkio J, Roivainen R, Sivenius J, Aronen HJ. Combined diffusion and perfusion MRI with correlation to single-photon emission CT in acute ischemic stroke. Ischemic penumbra predicts infarct growth. Stroke 1999 30 1583-1590. 

Grandin CB, Duprez TP, Smith AM, Mataigne F, Peeters A, Oppenheim C, Cosnard G. Usefulness of magnetic resonance-derived quantitative measurements of cerebral blood flow and volume in prediction of infarct growth in hyperacute stroke. Stroke. 2001 32 1147-1153. 

Combined diffusion and perfusion MRI with correlation to single-photon emission CT in acute ischemic stroke. Ischemic penumbra predicts infarct growth. Stroke 30 1583-1590... 

Hartings JA, RoUi ML, Lu XC, TorteUa PC. Delayed secondary phase of peri-infarct depolarizations after focal cerebral ischemia Relation to infarct growth and neuroprotection. J Neurosci. 2003 23 11602-11610... 

Fig. 5.9 Prediction of infarct growth. A 65-year-old man, improving clinically at 5 h postictus, was monitored in the Neurology ICU based on his labile blood pressure, a fixed left M2 occlusion on CTA, and a significant core/penumbra mismatch on CTP/MRP. His 24-h follow-up DWI showed a small infarction. However, 24 h after cessation of hypertensive therapy there was infarct growth into the region of penumbra. Admission CTA (top) CTP (CBV/CBF/ MTT) at 4.5 h second row) MR-perfusion weighted imaging (MR-PWI) (CBV/CBF/MTT) at 5.25 h (third row) DWI at 24 h (fourth row) and follow-up DWI at 48 h (bottom). The CTP and MR-PWI demonstrate a mismatch between the CBV (no abnormality) and the CBF/MTT penumbra (arrows). After cessation of hypertensive therapy, the DWI abnormahty grows into the region predicted by the CBF/MTT maps...

A number of studies have shown that infarcts tend to grow into the region of diffusion-perfusion mismatch, and that patients with larger mismatches tend to demonstrate more infarct growth. These studies have been performed using various different PWI-measured parameters to define the ischemic penumbra, including MTT [57-59], TTP [55, 60], CBF [56], and a nondeconvolution-based numerical approximation of MTT [61],... 

There is solid empirical evidence that the existence of a diffusion-perfusion mismatch predicts a greater likelihood of infarct growth. Some studies, but not others, have successfully used the existence of a mismatch to select patients for thrombolysis. In evaluating the findings and implications of the many studies of PWl in acute stroke, it is important to consider the many different ways in which raw PWI images have been post-processed to yield different perfusion maps and some of the technical pitfalls that can lead to artifactual and potentially misleading results. Some of these are summarized in Table 8.3. 

On the other hand, if no arterial occlusion is seen, the prognosis is much improved. In a study of 35 acute stroke patients who underwent MRA in the first 24 h [30], the average amount of infarct growth at 2-A days in patients without a visible occlusion was only 1.7 cml Another study examined 283 consecutive stroke patients who underwent catheter angiography for intended I AT [31]. The authors found 28 patients without a visible occlusion, of whom 21 (75%) had a good 3-month outcome (mRS<2). Twenty-seven patients had follow-up imaging 5 normal scans, 8 lacunar strokes, 2 striatocapsular strokes, and 12 small/medium infarcts. 

In a retrospective study of 34 patients who underwent pretreatment diffusion- and perfusion-weighted MRI followed by I AT [43], there were six patients with baseline DWI lesion size >70 cm ( Futile group ), aU of whom had a poor 3-month outcome (mRS 3-6) despite reperfusion in three patients. The Futile group patients had the largest infarct growth on follow-up imaging. 

Grandin CB, Duprez TP, Smith AM et al (2002) Which MR-deiived perfusion parameters are the best predictors of infarct growth in hyperacute stroke Comparative study between relative and quantitative measurements. Radiology 223 361-370... 

Ohvot JM, Mlynash M, Thijs VN et al (2008) Relationships between infarct growth, chnical outcome, and early recanalization in diffusion and perfusion imaging for understanding stroke evolution (DEFUSE). Stroke 39 2257-2263... 

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