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In this issue of Neurology, two articles describe how the additional information derived from diffusion-weighted MRI (DWI) influences clinical decision-making and management of acute stroke. Lansberg et al.1 compared early CT scanning and early DWI with respect to localization, final infarct size, and sensitivity and specificity in identifying lesions involving more than one-third of the middle cerebral artery territory. They showed that DWI was superior to CT in all three aspects and had better inter-rater reliability. Since the publication of the European Cooperative Acute Stroke Study I trial,2 there has been concern that the one-third rule defined and used in that trial to identify patients with large infarcts at increased risk of hemorrhage associated with thrombolysis was imprecise. Thus, with CT, inter-observer agreement may be too low for CT to be clinically useful. The Lansberg et al. report supports the advantage of DWI for this decision in patient selection for thrombolysis.
In the second article, Albers et al. describe …
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