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xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cdiv class=\u0022article fulltext-view \u0022\u003E\u003Cspan class=\u0022highwire-journal-article-marker-start\u0022\u003E\u003C\/span\u003E\u003Cdiv class=\u0022section abstract\u0022 id=\u0022abstract-1\u0022\u003E\u003Ch2\u003ESummary\u003C\/h2\u003E\n            \u003Cp id=\u0022p-1\u0022\u003EThis article discusses the current status and future of neuroimaging, including the DEFUSE-EPITHET Pooled Analysis, the treatment implications of the malignant MRI profile, as well as whole-brain perfusion CT imaging, among other things.\u003C\/p\u003E\n         \u003C\/div\u003E\u003Cul class=\u0022kwd-group\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003ENeuroimaging\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003ENeuroimaging\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EExclusive Article - For home page\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EFeatured Meeting - Specialty page\u003C\/li\u003E\u003C\/ul\u003E\u003Cp id=\u0022p-2\u0022\u003EAccording to results from the Diffusion-Weighted Imaging Evaluation for Understanding Stroke Evaluation Study 2 [DEFUSE-2; \u003Ca class=\u0022external-ref external-ref-type-clintrialgov\u0022 href=\u0022\/lookup\/external-ref?link_type=CLINTRIALGOV\u0026amp;access_num=NCT01349946\u0026amp;atom=%2Fspmdc%2F12%2F1%2F24.atom\u0022\u003ENCT01349946\u003C\/a\u003E], Target Mismatch (TMM) patients who achieve early reperfusion have less infarct growth and more favorable clinical outcomes. Gregory W. Albers, MD, Stanford Stroke Center, Palo Alto, California, USA, presented results from the study.\u003C\/p\u003E\u003Cp id=\u0022p-3\u0022\u003EThe DEFUSE-EPITHET Pooled Analysis [Lansberg MG et al. \u003Cem\u003EStroke\u003C\/em\u003E 2011] showed that diffusion-and perfusion-weighted imaging (DWI\/PWI) can identify subgroups with a differential response to reperfusion following intravenous tissue plasminogen activator (tPA) therapy. Yet, there have been controversy and contradictory data surrounding the scope and clinical relevance of DWI reversibility and uncertainty regarding the accuracy of PWI for detecting critical hypoperfusion.\u003C\/p\u003E\u003Cp id=\u0022p-4\u0022\u003EThe aim of the DEFUSE 2 study was to demonstrate that automated software (RAPID) can allow clinicians to prospectively identify magnetic resonance imaging (MRI) profiles that predict clinical and radiographic outcomes following endovascular reperfusion. The definitions of TMM, reperfusion (PWI criteria), reperfusion digital subtraction angiography ([DSA] criteria), and favorable clinical response are shown in \u003Ca id=\u0022xref-table-wrap-1-1\u0022 class=\u0022xref-table\u0022 href=\u0022#T1\u0022\u003ETable 1\u003C\/a\u003E.\u003C\/p\u003E\u003Cdiv id=\u0022T1\u0022 class=\u0022table pos-float\u0022\u003E\u003Cdiv class=\u0022table-inline\u0022\u003E\u003Cdiv class=\u0022callout\u0022\u003E\u003Cspan\u003EView this table:\u003C\/span\u003E\u003Cul class=\u0022callout-links\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022\/\u0022 class=\u0022table-expand-inline\u0022 data-table-url=\u0022\/highwire\/markup\/12724\/expansion?postprocessors=highwire_figures%2Chighwire_math%2Chighwire_inline_linked_media%2Chighwire_embed\u0026amp;table-expand-inline=1\u0022 html=\u00221\u0022 fragment=\u0022#\u0022 external=\u00221\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView inline\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022\/highwire\/markup\/12724\/expansion?width=1000\u0026amp;height=500\u0026amp;iframe=true\u0026amp;postprocessors=highwire_figures%2Chighwire_math%2Chighwire_inline_linked_media\u0022 class=\u0022colorbox colorbox-load table-expand-popup\u0022 rel=\u0022gallery-fragment-tables\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView popup\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/12724\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cdiv class=\u0022table-caption\u0022\u003E\u003Cspan class=\u0022table-label\u0022\u003ETable 1.\u003C\/span\u003E \n            \u003Cp id=\u0022p-5\u0022 class=\u0022first-child\u0022\u003EDefinitions of TMM, Reperfusion (PWI Criteria), Reperfusion (DSA Criteria), and Favorable Clinical Response.\u003C\/p\u003E\n         \u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cp id=\u0022p-6\u0022\u003EThe primary imaging hypothesis was that reperfusion is associated with reduced infarct growth in TMM patients compared with patients who had other MRI profiles. The study results demonstrated that median lesion growth (5 day FLAIR volume - baseline DWI volume) was significantly less in TMM patients who reperfused (n=42) versus those who did not reperfuse (n=23). Respective rates were 39% in the former versus 412% in the latter (p\u0026lt;0.003). The clinical outcomes of the TMM patients were also significantly better if they experienced reperfusion. In non-TMM patients (n=19), median lesion growth was not significantly different with reperfusion than without it (56% vs 11%; p=0.5). Furthermore, the clinical outcomes of these patients were less favorable if they experienced reperfusion (OR, 0.1; 95% CI, 0.007 to 0.93).\u003C\/p\u003E\u003Cp id=\u0022p-7\u0022\u003EThe second imaging hypothesis focused on whether DWI lesions are reversible with endovascular therapy. Data demonstrate that DWI reversibility (volume not incorporated into coregistered 5-day FLAIR) is rare and that patients with reperfusion had slightly larger volumes of DWI reversal; median reversal volume was 2.5 cc (IQR, 0.2 to 5.0) versus 0.6 cc (IQR, 0.1to2.2;p=0.03).\u003C\/p\u003E\u003Cp id=\u0022p-8\u0022\u003EThe third imaging hypothesis was whether posttreatment PWI lesions predict the volume of infarction at Day 5. Findings indicate that among patients who did not reperfuse (n=28), 69% of PWI Tmax\u0026gt;6 sec voxels were incorporated into the coregistered 5-day FLAIR.\u003C\/p\u003E\u003Cp id=\u0022p-9\u0022\u003EThese findings indicate that baseline DWI lesions are reliably incorporated into the 5-day FLAIR lesion; ie, that \u201cDWI reversibility\u201d is minimal. In addition, tissue that remains hypoperfused (Tmax \u0026gt;6 sec) following endovascular therapy is very likely to progress to infarction.\u003C\/p\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-1\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003ETreatment Implications of the Malignant MRI Profile\u003C\/h2\u003E\n         \u003Cp id=\u0022p-10\u0022\u003EMichael Mlynash, MD, MS, Stanford Stroke Center, Palo Alto, California, USA, discussed the endovascular treatment implications of the malignant MRI profile, which is defined as a large baseline DWI lesion and\/or a large and severe baseline PWI lesion. This profile has previously been shown to predict poor outcomes following intravenous tPA therapy [Albers GW et al. \u003Cem\u003EAnn Neuro\u003C\/em\u003E 2006] (\u003Ca id=\u0022xref-table-wrap-2-1\u0022 class=\u0022xref-table\u0022 href=\u0022#T2\u0022\u003ETable 2\u003C\/a\u003E).\u003C\/p\u003E\n         \u003Cdiv id=\u0022T2\u0022 class=\u0022table pos-float\u0022\u003E\u003Cdiv class=\u0022table-inline\u0022\u003E\u003Cdiv class=\u0022callout\u0022\u003E\u003Cspan\u003EView this table:\u003C\/span\u003E\u003Cul class=\u0022callout-links\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022\/\u0022 class=\u0022table-expand-inline\u0022 data-table-url=\u0022\/highwire\/markup\/12725\/expansion?postprocessors=highwire_figures%2Chighwire_math%2Chighwire_inline_linked_media%2Chighwire_embed\u0026amp;table-expand-inline=1\u0022 html=\u00221\u0022 fragment=\u0022#\u0022 external=\u00221\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView inline\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022\/highwire\/markup\/12725\/expansion?width=1000\u0026amp;height=500\u0026amp;iframe=true\u0026amp;postprocessors=highwire_figures%2Chighwire_math%2Chighwire_inline_linked_media\u0022 class=\u0022colorbox colorbox-load table-expand-popup\u0022 rel=\u0022gallery-fragment-tables\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView popup\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/12725\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cdiv class=\u0022table-caption\u0022\u003E\u003Cspan class=\u0022table-label\u0022\u003ETable 2.\u003C\/span\u003E \n               \u003Cp id=\u0022p-11\u0022 class=\u0022first-child\u0022\u003EOptimal Definitions for Predicting Poor Outcomes Following Reperfusion.\u003C\/p\u003E\n            \u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\n         \u003Cp id=\u0022p-13\u0022\u003EAccording to Dr. Mlynash, patients who meet these criteria are likely to have unfavorable outcomes and infarct growth despite endovascular reperfusion. Mlynash et al. [\u003Cem\u003EStroke\u003C\/em\u003E 2011] found that among patients with a malignant profile who achieved reperfusion following intravenous tPA (n=9), 89% had a Rankin score of 5 to 6 at 90 days versus 39% of patients without reperfusion (n=18; p=0.02). The respective figures for parenchymal hemorrhage were 67% and 11% (p\u0026lt;0.01).\u003C\/p\u003E\n         \u003Cp id=\u0022p-14\u0022\u003EThe aims of the DEFUSE-2 malignant profile substudy were to investigate whether those who have the malignant profile are more likely to suffer severe disability, parenchymal hemorrhage, infarct growth, or death following endovascular reperfusion and to clarify the optimal definition of the profile in endovascular patients. Clinical response was assessed at 30 and 90 days.\u003C\/p\u003E\n         \u003Cp id=\u0022p-15\u0022\u003EStudy results show that 0% of malignant profile patients who achieved reperfusion (n=8) had a Rankin score of 0 to 2 at 30 days versus 48% of non-malignant profile patients who reperfused (n=50; p=0.02). The Rankin 5\u20136 outcomes were 50% in the malignant profile patients versus 22% in the non-malignant group (p=0.19). The respective figures for parenchymal hematoma (PH)1 or PH2 hemorrhages were 63% versus 20% (p=0.02). Those for median (IQR) infarct growth were 136 mL (92 to 209; n=8) versus 31 mL (5 to 67; n=45; p\u0026lt;0.001).\u003C\/p\u003E\n         \u003Cp id=\u0022p-16\u0022\u003EOptimal definitions for predicting poor outcomes following reperfusion are approximately 50 mL for DWI and\/or 90 mL for Tmax\u0026gt;10. According to Dr. Mlynash, automated imaging software can prospectively and rapidly identify these patients, improving the efficacy and safety of reperfusion therapies.\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-2\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003EWhole-Brain Perfusion CT Imaging \u2013 A New Method for Mapping Cerebral Vascular Territories\u003C\/h2\u003E\n         \u003Cp id=\u0022p-17\u0022\u003ECollateral blood supply is believed to be a key determinant of tissue survival in acute stroke. It sustains the penumbra before recanalization and offsets infarct growth [Bang OY et al. \u003Cem\u003EStroke\u003C\/em\u003E 2011]; yet, its characterization remains elusive. Soren Christensen, PhD, Aarhus University Hospital, Aarhus, Denmark, discussed computed tomography perfusion-based (CTP) Vascular Territory Maps.\u003C\/p\u003E\n         \u003Cp id=\u0022p-18\u0022\u003EThe hypothesis was that such maps would display redistribution of flow territories that were concordant with CT angiography (CTA). The research entailed a quantitative comparison of territory maps with the CTA-determined site of occlusion.\u003C\/p\u003E\n         \u003Cp id=\u0022p-19\u0022\u003ESubjects were 19 acute stroke patients who were imaged \u0026lt;6 hours from symptom onset. Data were acquired on a Toshiba Aquilon One 320 slice system using standard perfusion protocol. Regions of interest (ROI) were placed in the middle cerebral artery, posterior cerebral artery, and anterior cerebral artery. An algorithm tracked the inflow patterns from the ROIs, and the territories were then labeled with colors.\u003C\/p\u003E\n         \u003Cp id=\u0022p-20\u0022\u003EFourteen images were interpretable; 5 were excluded due to head motion and\/or poor signal enhancement during the bolus passage. The CTA findings included 2 M1 and 1 internal carotid artery occlusion. In the affected hemisphere, the vascular territory of the occluded vessel was either diminished or absent, with the tissue supplied instead by adjacent territories. In 2 of 14 cases, the estimated collateral territory appeared inconsistent with physiological expectations.\u003C\/p\u003E\n         \u003Cp id=\u0022p-21\u0022\u003EAccording to Dr. Christensen, the initial results are promising. Vascular territory imaging using CTP data would open a window on the importance of the extent and origin of collateral blood supply in acute stroke by quantifying it with a technique that is complementary to standard perfusion and requires no additional hardware or higher radiation doses.\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cul class=\u0022copyright-statement\u0022\u003E\u003Cli class=\u0022fn\u0022 id=\u0022copyright-statement-1\u0022\u003E\u00a9 2012 MD Conference Express\u00ae\u003C\/li\u003E\u003C\/ul\u003E\u003Cspan class=\u0022highwire-journal-article-marker-end\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Cspan id=\u0022related-urls\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Ca href=\u0022http:\/\/mdc.sagepub.com\/content\/12\/1\/24.abstract\u0022 class=\u0022hw-link hw-link-article-abstract\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView Summary\u003C\/a\u003E\u003C\/div\u003E  \u003C\/div\u003E\n\n  \n  \u003C\/div\u003E\n\u003C\/div\u003E\n  \u003C\/div\u003E\n\u003C\/div\u003E\n\u003C\/div\u003E\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_openurl.js?nzniwq\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_tables.js?nzniwq\u0022\u003E\u003C\/script\u003E\n\u003C\/body\u003E\u003C\/html\u003E"}