Diffusion-weighted imaging as predictor of acute ischemic stroke etiology.

Alejandro Michel Brunser,Pablo Manuel Lavados,Gabriel Cavada,Victor Navia,Enrico Mazzon,Alexis Rojo,Paula Muñoz Venturelli,Eloy Mansilla,Verónica Olavarría

doi:10.1590/0004-282x-anp-2021-0080

Alejandro Michel Brunser, Pablo Manuel Lavados + Show 7 more

Open Access

https://doi.org/10.1590/0004-282x-anp-2021-0080

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Abstract

Topographic patterns may correlate with causes of ischemic stroke. To investigate the association between diffusion-weighted imaging (DWI) and Trial of Org 10172 in Acute Stroke Treatment (TOAST) classification. We included 1019 ischemic stroke patients. DWI were classified as: i) negative; ii) DWI single lesion (cortico-subcortical, cortical, subcortical ≥20 mm, or subcortical <20 mm); iii) scattered lesions in one territory (small scattered lesions or confluent with additional lesions); and iv) multiple lesions (multiple unilateral anterior circulation [MAC], multiple posterior circulation [MPC], multiple bilateral anterior circulation [MBAC], and multiple anterior and posterior circulations [MAP]). There was a relationship between DWI patterns and TOAST classification (p<0.001). Large artery atherosclerosis was associated with small, scattered lesions in one vascular territory (Odds Ratio [OR] 4.22, 95% confidence interval [95%CI] 2.61-6.8), MPC (OR 3.52; 95%CI 1.54-8.03), and subcortical lesions <20 mm (OR 3.47; 95%CI 1.76-6.85). Cardioembolic strokes correlated with MAP (OR 4.3; 95%CI 1.64-11.2), cortico-subcortical lesions (OR 3.24; 95%CI 1.9-5.5) and negative DWI (OR 2.46; 95%CI 1.1-5.49). Cryptogenic strokes correlated with negative DWI (OR 4.1; 95%CI 1,84-8.69), cortical strokes (OR 3.3; 95%CI 1.25-8.8), MAP (OR 3.33; 95%CI 1.25-8.81) and subcortical lesion ≥20 mm (OR 2.44; 95%CI 1,04-5.73). Lacunar strokes correlated with subcortical lesions diameter <20 mm (OR 42.9; 95%CI 22.7-81.1) and negative DWI (OR 8.87; 95%CI 4.03-19.5). Finally, MBAC (OR 9.25; 95%CI 1.12-76.2), MAP (OR 5.54; 95%CI 1.94-15.1), and MPC (OR 3.61; 95%CI 1.5-8.7) correlated with stroke of other etiologies. A relationship exists between DWI and stroke subtype.

Highlights

A precise and early diagnosis of acute ischemic stroke (AIS) etiologic subtype is important for therapeutic decisions that may influence stroke recurrence, management, and prognosis[1,2]
Previous studies demonstrating this association were limited to specific stroke etiologies or Diffusion-weighted imaging (DWI) patterns, included transient ischemic attacks, were retrospective, included AIS of the anterior circulation only, or did not consider negative DWI results[5-13], which could represent a proportion as high as 13% of the AIS admitted to the emergency room (ER)[4]
In this study we found an association between DWI lesion patterns and the TOAST causative classification; these have been previously described by some authors, but their studies included a limited number of patients[12,13], they were mainly retrospective, and did not include negative or normal DWI results[10,11], which are very frequent in the ER4,5 especially in patients with low NIHSS14

Summary

Introduction

A precise and early diagnosis of acute ischemic stroke (AIS) etiologic subtype is important for therapeutic decisions that may influence stroke recurrence, management, and prognosis[1,2]. The most frequently used method for causative subtype classification is the Trial of Org 10172 in Acute Stroke Treatment (TOAST), which divides AIS into subtypes, based primarily on infarction mechanism[1,2]. Ischemic lesion topography on DWI may correlate with stroke subtypes. Previous studies demonstrating this association were limited to specific stroke etiologies or DWI patterns, included transient ischemic attacks, were retrospective, included AIS of the anterior circulation only, or did not consider negative DWI results[5-13], which could represent a proportion as high as 13% of the AIS admitted to the emergency room (ER)[4]. In this study we aimed to determine the association between DWI ischemic topography and AIS stroke subtype using the causative TOAST classification. Objective: To investigate the association between diffusionweighted imaging (DWI) and Trial of Org 10172 in Acute Stroke Treatment (TOAST) classification. Cardioembolic strokes correlated with MAP (OR 4.3; 95%CI 1.64–11.2), cortico-subcortical lesions (OR 3.24; 95%CI 1.9–5.5) and negative DWI (OR 2.46; 95%CI 1.1–5.49).

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