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Italo Linfante, MD; Rafael H. Llinas, MD; Gottfried Schlaug, MD; Claudia Chaves, MD; Steven Warach, MD, PhD; Louis R. Caplan, MD

Arch Neurol. 2001;58:621-628.

Background  Occlusive disease of the posterior circulation represents a heterogeneous group of strokes that differ in etiology, clinical presentation, and prognosis. Computed tomography provides suboptimal visualization of posterior-circulation infarcts. Anatomic definition of traditional magnetic resonance imaging sequences has been used for clinicoradiologic correlation in patients with posterior-circulation disease. These studies focused on the subacute rather than the acute phase of ischemia. Lesion volumes on diffusion-weighted imaging (DWI) and perfusion imaging were found to have a good correlation with 24-hour National Institutes of Health stroke scale (NIHSS) score in ischemia of the anterior circulation. Correlation between NIHSS score and lesion volume in posterior-circulation infarcts is unknown.

Objectives  To investigate whether DWI is useful for clinicoradiologic correlation of posterior-circulation ischemia within 24 hours after symptom onset and whether NIHSS score correlates with lesion volumes in patients with posterior-circulation stroke.

Patients and Methods  In a database analysis of 631 patients with stroke from June 26, 1996, to July 30, 1999, 115 patients (18%) had symptoms of posterior-circulation ischemia by imaging and clinical criteria. Among these 115, we included all patients (n = 40) who underwent DWI within 24 hours from symptom onset (mean, 9.7 ± 7.1 hours). All 40 patients also underwent magnetic resonance angiography and T2-weighted imaging. Seventy-five did not meet inclusion criteria: in 45, magnetic resonance imaging was performed more than 24 hours after symptom onset; 12 did not have DWI; in 11 patients, symptoms resolved within 24 hours; 6 had hemorrhages; and 1 had a border zone infarct.

Results  An acute lesion on DWI corresponding to the patient's symptoms was detected in all 40 patients, 16 (40%) of whom had detectable acute lesions on T2-weighted images. The lesions on DWI were larger in 11 of the 16 patients with positive T2-weighted images. Acute lesion volume did not correlate with NIHSS score (n = 40; = 0.30; P = .06, Spearman rank) also when DWI lesion volumes were divided by cause and territory.

Conclusions  Diffusion-weighted imaging is more effective than T2-weighted imaging in patients with acute posterior-circulation strokes. The DWI lesion volume did not significantly correlate with NIHSS score, suggesting that NIHSS is more weighted toward anterior-circulation stroke symptoms.

From the Department of Neurology, Beth Israel Deaconess Medical Center, Boston, Mass (Drs Linfante, Llinas, Schlaug, Chaves, and Caplan); and Section of Stroke Diagnostics and Therapeutics, Stroke Branch, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Md (Dr Warach).

Corresponding author and reprints: Italo Linfante, MD, Division of Cerebrovascular Diseases, Department of Neurology, Beth Israel Deaconess Medical Center, East Campus DA 779, 330 Brookline Ave, Boston, MA 02115 (e-mail: ilinfant{at}caregroup.harvard.edu).

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