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Review
. 2018 Sep;38(9):1517-1532.
doi: 10.1177/0271678X17700666. Epub 2017 Mar 27.

Infarct Topography and Functional Outcomes

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Free PMC article
Review

Infarct Topography and Functional Outcomes

Mark R Etherton et al. J Cereb Blood Flow Metab. .
Free PMC article

Abstract

Acute ischemic stroke represents a major cause of long-term adult disability. Accurate prognostication of post-stroke functional outcomes is invaluable in guiding patient care, targeting early rehabilitation efforts, selecting patients for clinical research, and conveying realistic expectations to families. The involvement of specific brain regions by acute ischemia can alter post-stroke recovery potential. Understanding the influences of infarct topography on neurologic outcomes holds significant promise in prognosis of functional recovery. In this review, we discuss the recent evidence of the contribution of infarct location to patient management decisions and functional outcomes after acute ischemic stroke.

Keywords: Acute ischemic stroke; neuroimaging; outcomes; topography; voxel-based lesion symptom mapping.

Figures

Figure 1.
Figure 1.
Stroke severity is dependent on location of ischemic stroke. DWI images of two patients admitted with AIS with identical admission NIHSS but different functional outcomes. (a) 56-year-old male found unresponsive. Neurologic exam notable for fixed pupils, present corneal and gag reflexes, absent oculocephalic reflexes, and flaccid paralysis of all extremities. MRI brain showed restricted diffusion in the medial thalami bilaterally and dorsal midbrain. Magnetic resonance angiography (MRA) of the head and neck (not shown) showed occlusive thrombus at the top of the basilar artery extending into the P1 segments of the posterior cerebral arteries bilaterally. Admission NIHSS 24; 90-day mRS 6. (b) 48-year-old male with atrial fibrillation presented with left middle cerebral artery (MCA) syndrome. Neurologic exam notable for a global aphasia and weakness of his right face and arm. MRI of the brain showed restricted diffusion in the left frontal operculum and anterior temporal lobe. Admission NIHSS 24; 90 day mRS 1. Images are shown in radiographic orientation.
Figure 2.
Figure 2.
The NIHSS emphasize dominant/left hemisphere functions. Representative MR images of two patients admitted with right and left hemisphere ischemic strokes. Each patient had the same admission NIHSS and 90-day mRS; however, the ischemic stroke volume was greater in the right hemisphere lesion. (a–d) 53-year-old man with atrial fibrillation and hypertension presents with left facial droop and arm weakness, dysarthria, and decreased sensation in his left arm. NIHSS 11 for right MCA syndrome including left hemineglect. MRI of the brain shows ischemic stroke involving the right insula, frontal operculum, and superior and middle temporal gyri on DWI sequences (a) without evidence of perfusion mismatch on Mean Transit Time (MTT) (b), time to maximum value of the deconvolved residue function (Tmax) (c), and cerebral blood flow (CBF) (d) maps. (e–h) 79-year-old male with coronary artery disease and hyperlipidemia that developed a non-fluent aphasia and right arm weakness. NIHSS 11 for left MCA syndrome involving language output and mild right face and arm weakness. MRI shows a subacute infarct involving the left inferior frontal gyrus on DWI sequences (e) with a matched focal perfusion abnormality on MTT (f), Tmax (g), and CBF (h) to suggest no additional territory at risk.
Figure 3.
Figure 3.
Does perfusion-weighted imaging provide a more accurate correlation with stroke severity? (a–d) DWI and PWI images for a 60-year-old male with hypertension that presented with a right MCA syndrome. NIHSS 14 for left facial droop and homonymous hemianopsia, weakness of the left arm and leg, dysarthria, and left hemineglect. MRI shows a small area of restricted diffusion in the right insula on DWI (a) with PWI evidence of mismatch and a potentially large territory at risk on MTT (b), Tmax (c), and CBF (d). (e–h) DWI and PWI images for a 18-year-old male that presented with sudden onset left sided hemiplegia. NIHSS 14 for right MCA syndrome including right gaze deviation and left hemineglect. MRI brain shows a large area of restricted diffusion in the right basal ganglia, frontal operculum, insula, and inferior parietal lobe on DWI (e), with PWI showing additional territory at risk on MTT (f), Tmax (g), and CBF (h).
Figure 4.
Figure 4.
Voxel-based lesion symptom mapping results for acute ischemic stroke functional outcomes (mRS). T-score maps with voxel-wise threshold of p < 0.001 and permutation method for follow-up mRS scores without covariates (a), using sex and age (b), or sex, age, and lesion volume as covariates (c). Subset analysis for patients alive at 6 months post AIS (d). A voxel with a high T-score (red) indicates that patients with lesions involving the individual voxel had worse mRS scores than patients who did not have a lesion at that voxel. Conversely, a voxel with a low T-score reflects no statistically significant difference (p > 0.001) in mRS scores between patients with and without a lesion at that voxel. From Ona Wu, Lisa Cloonan, Steven JT Mocking, Mark JRJ Bouts, William A Copen, Pedro T Cougo-Pinto, Kaitlin Fitzpatrick, Allison Kanakis, Pamela W Schaefer, Jonathan Rosand, Karen L Furie, Natalia S Rost. Role of acute lesion topography in initial ischemic stroke severity and long-term functional outcomes. Stroke 2015; 46: 2438–2444 and reproduced with permission from Wolters Kluwer Health.

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