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. 2025 Aug 14.
doi: 10.1007/s00234-025-03721-y. Online ahead of print.

Predictor value of pCASL maps on final core in acute ischemic stroke: an observational single‑center study

Fabrizio Giammello  1   2 , Agostino Tessitore  3 , Francesco Grillo  3 , Cristina Dell'Aera  3 , Ludovica Ferraù  3 , Valentina Tudisco  3   4 , Antonio Ciacciarelli  5 , Davide Vicari  3 , Valeria Garufi  3 , Sergio Lucio Vinci  3 , Sara Rosa Maria Martino  6 , Luigi Simonetti  6 , Michele Romoli  4 , Rosa Fortunata Musolino  3 , Mauro Silvestrini  7 , Danilo Toni  5 , Andrea Zini  6 , Antonio Toscano  3
Affiliations

Predictor value of pCASL maps on final core in acute ischemic stroke: an observational single‑center study

Fabrizio Giammello et al. Neuroradiology. .

Abstract

Purpose: The three-compartment model of acute ischemic stroke (AIS) includes non-viable tissue (NVT), tissue at risk (TAR), and benign oligoemia. After assessing a multimodal computed tomography (CT)-based protocol, we assessed a hyperacute stroke imaging protocol with magnetic resonance imaging (MRI), aiming to better characterize the reliability of the two methods in predicting follow-up infarction.

Methods: We retrospectively reviewed 627 consecutive AIS patients evaluated for the selection for reperfusive treatments at comprehensive stroke center. We employed an MRI-based protocol for proper patient selection, including pseudocontinuous arterial spin labeling (pCASL) and diffusion-weighted imaging (DWI). To assess prognostic accuracy of pCASL maps in predicting final infact, we assumed the best correlation between NVT and final infarct in patients with favorable clinico-radiological outcomes. On the other hand, the TAR should better correlate with final infarct in untreated patients and in treatment failure.

Results: We recruited 349 patients undergoing MRI-based protocol with DWI and pCASL, showing diagnostic accuracy of 84.8%. In anterior circulation perfusion deficit, DWI was highly reliable for NVT in patients with favorable clinical-instrumental outcomes. PCASL tended to overestimate TAR in patients with unfavorable outcome, but the rate of complete overlap with the final infarct was high. The previously assessed CT-based protocol showed a lower prognostic accuracy, as the CT-perfusion using time-to-maximum overestimated both the NVT and the TAR.

Conclusions: We found a highly reliable prognostic accuracy for DWI-pCASL. Even if pCASL proved reliable to identify the area of total hypoperfusion, there was an overestimation of TAR in many cases, with a tendency to incorporate the benign oligoemia.

Keywords: Acute ischemic stroke; Arterial spin labeling; Final infarct detection; MR perfusion; Prognostic accuracy.

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Conflict of interest statement

Declarations. Ethical approval: All procedures performed in the studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. The paper does not report on primary research. Our analysis looked retrospectively at outcomes for a large cohort of patients treated. All data analysed were collected as part of routine diagnosis and treatment. Consent to participate: Informed consent was not necessary to be obtained from all individual participants included in the study, as long as information is anonymized and the submission does not include images that may identify the person. Consent for publication: Informed consent was waived given to the retrospective anonymous collection of data, according to Italian regulations. Study subjects or cohorts overlap: We previously published the first part of this work in La radiologia medica (Radiol Med. 2022 Apr;127(4):414–425. doi: https://doi.org/10.1007/s11547-022-01467-8 . Epub 2022 Feb 28.). Competing interests: The authors declare no competing interests.

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