Related previous study

Saur et al. (2003) had under taken a study compared the diffusion-weighted(DW) images
and CT scans obtained with a short time delay in patients with acute stroke to define the
sensitivity and interrater agreement of both imaging techniques. The mean delay between
imaging with both modalities was 24.5 minutes varied from 10–41 minutes. Forty-five of
46 patients had an ischemic stroke. Early ischemic signs (EIS) were seen on 33 of 45 CT
scans having 73.0% sensitivity with 95.0% confidence interval [CI]: 58.0% –85% and on
42 of 45 DW images having 93.0% sensitivity; 94% CI: 82–99%. Interrater agreement
was moderate (κ = 0.57) for CT and excellent (κ=0.85) for DW imaging. CT studies had a
moderate interrater agreement for estimation of EIS greater than one-third of the MCA
territory (κ = 0.40), whereas DW imaging showed good results (κ = 0.68). Sensitivity for
detection of greater than one-third of the MCA territory was equally poor (57%, 95% CI:
29–82%) for both CT and DW imaging. DW imaging helped identify EIS with higher
sensitivity than that of CT. The interrater variability of the one-third rule was high for CT
and thus the clinical applicability of CT is limited. Their results supported the application
of stroke MR imaging for the treatment of patients with acute stroke.

Mitomi et al. (2014) study compared the detection rate of ischemic lesions within 3 hours
of onset by computed tomography (CT) and diffusion-weighted magnetic resonance
imaging (DWI). Their study group comprised 130 patients, out of which 71 man having
median age 75 years with an anterior territory stroke who underwent CT and DWI within
3 hours of onset. The detection rate of ischemic lesions was higher on DWI than on CT
(76.9% and 30.0%; p<0.05). The DWI-ASPECTS score was not correlated with the CT-
ASPECTS score (r=0.51; p<0.05). Ischemic lesions were detected in the insula 59.2% for
DWI and 15.4% for CT; p<0.05), lentiform nucleus (43.8% and 20.0%; p<0.05), and the
M1 (30.8% and 6.9%, p<0.05), M2 (50.8% and 6.2%; p<0.05), M3 (28.5% and 3.1%;
p<0.05), M4 (32.3% and 6.9%; p<0.05), M5 (48.5% and 10.8%; p<0.05), and M6 (31.5%
and 4.6%, p<0.05) areas of the middle cerebral artery. DWI detected ischemic lesions
significantly more frequently than CT in all ASPECTS regions except the caudate head
and internal capsule.
Kimura et al. (2001) study assesses the findings of diffusion-weighted MR imaging
(DWI) and other clinical characteristics in patients with acute ischemic stroke and
microembolic signals (MESs). They performed transcranial Doppler sonography (TCD)
and DWI within 48 hours and 7 days, respectively, after stroke onset in 28 patients with
acute brain infarction. Ten patients had MES s detected by TCD (MES group) and 18 had
no MES s (control group). The frequency of hypertension, diabetes mellitus,
hyperlipidemia , and smoking; NIHSS score; blood-coagulation parameters; and interval
between stroke onset and DWI study did not differ between the two groups. However,
arterial disease was more frequent in the MES group than in the control group. Small,
multifocal ischemic lesions (<10 mm in diameter) on DWI were more frequent in the
MES group than in the control group. Conventional CT and MR imaging often failed to
show these lesions. Small, often asymptomatic DWI abnormalities were more frequent in
patients with MES s detected by TCD and with large-vessel occlusive diseases than in
stroke patients without MES s. TCD and DWI may provide early clues to the mechanism
of stroke in the acute phase.

Brazzelli et al. (2009) study compared the diagnostic accuracy of diffusion-weighted

MRI (DWI) and CT for acute ischaemic stroke, and to estimate the diagnostic accuracy of
MRI for acute haemorrhagic stroke. The investigators mentioned in their reviewed study
that eight studies with a total of 308 participants met their inclusion criteria. Seven
studies contributed to the assessment of ischaemic stroke and two studies to the
assessment of haemorrhagic stroke. Amongst the patients subsequently confirmed to have
acute ischaemic stroke (161/226), the summary estimates for DWI were: sensitivity
99.0% (95% CI 23.0% to 100.0%), specificity 92.0% (95% CI 83.0% to 97.0%). The
summary estimates for CT were: sensitivity 39.0% (95% CI 16.0% to 69.0%), specificity
100.0 (95% CI 94.0% to 100.0%). The two studies on haemorrhagic stroke reported high
estimates for diffusion-weighted and gradient-echo sequences but had inconsistent
reference standards. The investigators DWI appears to be more sensitive than CT for the
early detection of ischaemic stroke in highly selected patients. However, the variability in
the quality of included studies and the presence of spectrum and incorporation biases
render the reliability and generalisability of observed results questionable.
Perkins et al. (2001) evaluated echo-planar imaging in 117 consecutive patients with
signs and symptoms of acute stroke. DWI was more sensitive than was FLAIR for the
detection of stroke for all subtypes in all anatomic distributions and at all tested time
intervals. Although DWI exhibited its greatest benefit over FLAIR during the first 6
hours, it was still superior to FLAIR even after 24 hours. PWI abnormalities were
detected in 49.0% of patients with DWI abnormalities. In the majority of these cases, the
PWI-DWI mismatch was substantially larger than the DWI lesion itself. Both the largest
DWI lesion volumes and the largest mismatch volumes occurred in patients with carotid
disease. DWI nearly doubles the likelihood of detecting acute ischemic stroke lesions
compared with FLAIR for all etiologies and in all anatomic locations. In the hyperacute
period (0 to 6 hours), DWI more than triples the likelihood of acute-stroke detection over
FLAIR. PWI reveals a measurable mismatch compared with DWI nearly 50.0% of the
time and in more than half of these patients, the ratio of the volume of the PWI lesion to
the DWI lesion is several times larger than the core ischemic lesion itself. In the final
analysis, approximately one fourth of all stroke patients present with a large volume of
potentially salvageable tissue at risk for infarction.

Vilela and Rowley (2017) compared conventional MR imaging, echo-planar diffusion

weighted imaging (EP-DWI) and spin-echo diffusion-weighted imaging (SE) DWI at
radiological diagnosis of acute stroke. A total of 27 patients were examined having age
ranged 30 - 85 years. In EP-DWI, every patient had a lesion corresponding to the clinical
findings. EP-DWI was used as the gold standard. In conventional PD+T2 imaging, 23/59
focal lesions were interpreted as acute, which was false in 11 lesions, and 36/59 lesions
were considered to be old, 6 were in fact acute. Nine acute lesions were only detected
retrospectively and 12 acute lesions were not detected at all on PD+T2. SE-DWI
including the apparent diffusion coefficient correlated fairly well with EP-DWI but the
procedure was impractical. EP-DWI is reliable for diagnosis of early ischemic stroke,
while SE-DWI performs reasonably well. Conventional PD+T2 imaging is not reliable
for diagnosis of early ischemia.
Wessels et al. (2006) study analyzes the subtype of ischemic lesions as determined by the
Trial of Org 10172 in Acute Stroke Treatment (TOAST) criteria by using DW MR
imaging. In their study a total of 510 consecutive patients with ischemic stroke 95.0%
and transient ischemic attack 5.0% aged 65±12 years were investigated by use of DW
MR imaging within 48 hours of the clinical onset of symptoms They found a significant
overall association of DW imaging lesion patterns and classification with stroke subtype
by using the TOAST criteria (p<005). Single corticosubcortical lesions (p<0.05) and
multiple bilateral lesions in the anterior (AC) and posterior circulation (p<0.05) on DW
imaging were significantly associated with a cardiac embolic source. Multiple unilateral
lesions in the AC were significantly associated with large-artery arteriosclerosis. Because
of the 15-mm criterion for small artery occlusion, cryptogenic stroke was significantly
associated with subcortical lesions ≥15mm. They found a strong relationship between
stroke subtype and DW imaging lesion pattern. The finding of multiple bilateral lesions
was significantly associated with a cardiac embolic source, which may be caused by a
specific thrombu texture with a tendency for embolus dissemination.

Fiebach et al. (2002) mentioned in their study that diffusion-weighted MRI (DWI) has
become a commonly used imaging modality in stroke centers. The value of this method
as a routine procedure is still being discussed. In previous studies, CT was always
performed before DWI. Therefore, infarct progression could be a reason for the better
result in DWI obtained by Fiebach et al. (2002). A total of 50 patients with ischemic
stroke and 4 patients with transient symptoms of acute stroke were analyzed. Of the 50
patients, 55.0% were examined with DWI first. The mean delay from symptom onset
until CT was 180 minutes; that from symptom onset until DWI was 189 minutes. The
mean delay between DWI and CT was 30 minutes. The sensitivity of infarct detection by
the experts was significantly better when based on DWI (CT/DWI, 61/91%). Accuracy
was 91.0% when based on DWI (CT, 61.0%). Interrater variability of lesion detection
was also significantly better for DWI (CT/DWI, κ = 0.51/0.84). The assessment of lesion
extent was less homogeneous on CT (CT/DWI, κ = 0.38/0.62). The differences between
the 2 modalities were stronger in the residents’ ratings (CT/DWI: sensitivity, 46/81%; κ =
0.38/0.76). CT and DWI performed with the same delay after onset of ischemic stroke
resulted in significant differences in diagnostic accuracy. DWI gives good interrater
homogeneity and has a substantially better sensitivity and accuracy than CT even if the
raters have limited experience.

Caso et al. (2005) study evaluated the prevalence of MABI and their impact on
aetiological classification and prevention of stroke in patients with acute ischaemic stroke
examined with DWI. A total of 182 consecutive patients defined by DWI were evaluated.
Type 1 MABI were detected in 29.0% patients with lacunar stroke, and type 2 MABI in
7.0% with non-lacunar stroke. A possible stroke mechanism different from SAD was
found in nine type 1 MABI cases 43.0%: cardiac embolism (4); other determined
aetiology (3); aortic embolism (2). Cardiac (2) or aortic (1) sources of embolism were
detected in eight type 2 MABI cases. MABI patients with cardiac or aortic sources of
embolism were treated with warfarin, the remainder with aspirin. Detection of type 1
MABI in patients with lacunar stroke improved diagnostic confidence and the choice of
antithrombotic treatment.

Saur et al. (2003) compared DW images and CT scans obtained with a short time delay in
patients with acute stroke to define the sensitivity and interrater agreement of both
imaging techniques. CT scans and DW images were obtained within 6 hours of symptom
onset in 46 patients with acute stroke. The mean delay between imaging with both
modalities was 24.5 minutes varied from 10–41 minutes. Forty-five of 46 patients had an
ischemic stroke. EIS were seen on 33 of 45 CT scans having 73.0% sensitivity; 95%
confidence interval [CI]: 58–85% and on 42 of 45 DW images having 93.0% sensitivity;
94% CI: 82–99%. Interrater agreement was moderate (κ=0.57) for CT and excellent
(κ=0.85) for DW imaging. CT studies had a moderate interrater agreement for estimation
of EIS greater than one-third of the MCA territory (κ=0.40), whereas DW imaging
showed good results (κ=0.68). Sensitivity for detection of greater than one-third of the
MCA territory was equally poor (57%, 95% CI: 29–82%) for both CT and DW imaging.
DW imaging helped identify EIS with higher sensitivity than that of CT. The interrater
variability of the one-third rule was high for CT, and thus the clinical applicability of CT
is limited.
Stroke is an important morbidity for low and middle income countries like Bangladesh.
Bhowmik et al. (2016) established the first stroke registry in Bangladesh. Data was
collected from stroke patients who were admitted in Department of Neurology of
BIRDEM with first ever stroke, aged between 30 and 90 years. Patients with intracerebral
hemorrhage, subarachnoid and subdural hemorrhage, and posttrauma features were
excluded. Data was gathered from 679 stroke patients. Mean age was 60.6 years. Almost
68.0% of patients were male. Small vessel strokes were the most common accounting for
45.4% of all the patients followed by large vessel getting affected in 32.5% of the cases.
Only 2.4% died during treatment, and 64.2% patients had their m RS score of 3 to 5. Age
greater than 70 years was associated with poor outcome on discharge [OR 1.79 (95% CI:
1.05 to 3.06)] adjusting for gender, duration of hospital stay, HDL, and pneumonia. Age,
m RS, systolic blood pressure, urinary tract infection, pneumonia, and stroke severity
explained the Barthel score. Mortality was low but most of patient had moderate to
severe disability at discharge. Age, m RS, systolic blood pressure, urinary tract infection,
pneumonia, and stroke severity influenced the Barthel score.
Reference:

Saur, D., Kucinski, T., Grzyska, U., Eckert, B., Eggers, C., Niesen, W., Schoder, V.,
Zeumer, H., Weiller, C. and Röther, J., 2003. Sensitivity and interrater agreement of CT
and diffusion-weighted MR imaging in hyperacute stroke. American journal of
neuroradiology, 24(5), pp.878-885.

Mitomi, M., Kimura, K., Aoki, J. and Iguchi, Y., 2014. Comparison of CT and DWI
findings in ischemic stroke patients within 3 hours of onset. Journal of Stroke and
Cerebrovascular Diseases, 23(1), pp.37-42.

Kimura, K., Minematsu, K., Koga, M., Arakawa, R., Yasaka, M., Yamagami, H.,
Nagatsuka, K., Naritomi, H. and Yamaguchi, T., 2001. Microembolic signals and
diffusion-weighted MR imaging abnormalities in acute ischemic stroke.American journal
of neuroradiology, 22(6), pp.1037-1042.

Brazzelli, M., Sandercock, P.A., Chappell, F.M., Celani, M.G., Righetti, E., Arestis, N.,
Wardlaw, J.M. and Deeks, J.J., 2009. Magnetic resonance imaging versus computed
tomography for detection of acute vascular lesions in patients presenting with stroke
symptoms. Cochrane database of systematic reviews, (4).

Perkins, C.J., Kahya, E., Roque, C.T., Roche, P.E. and Newman, G.C., 2001. Fluid-
attenuated inversion recovery and diffusion-and perfusion-weighted MRI abnormalities
in 117 consecutive patients with stroke symptoms. STROKE-DALLAS-, 32(12), pp.2774-
2780.

Vilela, P. and Rowley, H.A., 2017. Brain ischemia: CT and MRI techniques in acute
ischemic stroke. European journal of radiology, 96, pp.162-172.

Wessels, T., Wessels, C., Ellsiepen, A., Reuter, I., Trittmacher, S., Stolz, E. and Jauss, M.,
2006. Contribution of diffusion-weighted imaging in determination of stroke
etiology.American Journal of Neuroradiology, 27(1), pp.35-39.
Fiebach, J.B., Schellinger, P.D., Jansen, O., Meyer, M., Wilde, P., Bender, J., Schramm,
P., Juttler, E., Oehler, J., Hartmann, M. and Hahnel, S., 2002. 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. Stroke, 33(9), pp.2206-2210.

Caso, V., Budak, K., Georgiadis, D., Schuknecht, B. and Baumgartner, R.W., 2005.
Clinical significance of detection of multiple acute brain infarcts on diffusion weighted
magnetic resonance imaging. Journal of Neurology, Neurosurgery & Psychiatry, 76(4),
pp.514-518.

Saur, D., Kucinski, T., Grzyska, U., Eckert, B., Eggers, C., Niesen, W., Schoder, V.,
Zeumer, H., Weiller, C. and Röther, J., 2003. Sensitivity and interrater agreement of CT
and diffusion-weighted MR imaging in hyperacute stroke. American journal of
neuroradiology, 24(5), pp.878-885.

Bhowmik, N.B., Abbas, A., Saifuddin, M., Islam, M., Habib, R., Rahman, A., Haque, M.,
Hassan, Z. and Wasay, M., 2016. Ischemic strokes: Observations from a hospital based
stroke registry in Bangladesh. Stroke research and treatment, 2016.