On the Origins of Diffusion MRI Signal Changes in Stroke

The Imaging-Neuropathological Gap in Acute Large Vessel Occlusive Stroke

While imaging has traditionally played a fundamental role in the selection of patients undergoing endovascular thrombectomy, recent thrombectomy trials involving patients with large ischemic strokes demonstrated a consistent benefit of endovascular thrombectomy across all imaging strata, suggesting that reperfusion benefit may exist independent of current imaging constructs. Although these findings attest to the uniformly beneficial effects of reperfusion, they also shed doubt on the accuracy and utility of our imaging modalities in defining reversible versus irreversible ischemia and challenge the premise of imaging-based selection. We aimed to review the histopathologic studies and clinical trials that have shaped our understanding of current imaging constructs aiming to outline the existing imaging-neuropathological gap that may be far wider than previously perceived.

Technical Basics of Diffusion-Weighted Imaging

Diffusion-weighted images provide a unique contrast that shows the ability to assess tissue structure and condition on a micrometer scale. Notably, these equations are necessary to understand diffusion MR imaging as a theory but not for real imaging, particularly in clinical practice. The diffusion phenomenon can be observed only through MR measurements. One of the emerging fields of diffusion MRI is to probe the tissue microstructure by altering the diffusion time t, the time interval over which spin displacements are sampled. However, the diffusion time is, in a sense, more important than the b-value for diffusion-weighted images and their quantitative metrics.