Percentage Insula Ribbon Infarction of &gt;50% Identifies Patients Likely to Have Poor Clinical Outcome Despite Small DWI Infarct Volume

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Fig 1.
Scatterplot showing clinical outcome for patients stratified by infarct volume and DWI-PIRI. There was a 100% specific admission 70-mL DWI volume cutoff value for poor outcome.
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Fig 2.
In patients with DWI infarct volumes of <70 mL, 90-day mRS was significantly worse when the DWI-PIRI was >50% compared with a DWI-PIRI of ≤50% (P = .036). In patients with DWI infarct volumes of >70 mL, DWI-PIRI did not have added predictive value for poor outcome (P = .931).
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Fig 3.
Sample imaging from 2 patients with ICA terminus occlusions. Patients A and B had similar baseline NIHSS scores (11 and 8), similar small volume infarcts on DWI (50 and 59 mL), the same collateral score (2), the same treatment (IV tPA), but differing degrees of insula involvement. The patient with >50% DWI-PIRI (patient A) had a poor clinical outcome (mRS 5 at 90 days), whereas the patient with ≤50% DWI-PIRI (patient B) had a good clinical outcome (mRS 1 at 90 days).

Admission clinical and imaging variables, stratified by good-versus-poor outcome (3-month mRS 0–2 versus 3–6, respectively)

Variable^{^a}	All Patients	Good Outcome (mRS 0–2)	Poor Outcome (mRS 3–6)	P Value^{^b}
Patient (No.) (%)	55	23 (42)	32 (58)	–
Female sex (No.) (%)	26 (4)	12 (52)	14 (43)	.731
Age (yr) (mean)	67 ± 15	63 ± 17	70 ± 13	.064
Right hemisphere (No.) (%)	23 (42)	8 (35)	15 (47)	.535
Baseline NIHSS (median) (IQR)	14 (6–18)	6 (4–11)	17 (14–20)	<.001
IV treatment (No.) (%)	18 (33)	9 (39)	9 (28)	.392
IA treatment (No.) (%)	4 (7)	1 (4)	3 (9)	.466
Any treatment (IV or IA) (No.) (%)	10 (18)	3 (13)	7 (22)	.395
No IV or IA treatment (No.) (%)	23 (42)	10 (43)	13 (41)	.628
Ictus to DWI (min) (mean)	286 ± 108	277 ± 134	291 ± 87	.68
Ictus to CT perfusion (min) (mean)	229 ± 107	224 ± 140	232 ± 79	.79
DWI volume >70 mL (No.) (%)	15 (27)	0 (0)	15 (27)	<.001
DWI-PIRI >50% (No.) (%)	22 (40)	3 (5)	19 (35)	<.001
NCCT ASPECTS (median) (IQR)	8 (6–10)	9 (8–10)	7 (5–8)	<.001
Collateral score (median) (IQR)	2 (1–3)	2 (2–3)	1 (1–2)	.002
Malignant collateral pattern (No.) (%)	4 (7)	0 (0)	4 (7)	.131
NCCT-PIRI >50% (No.) (%)	17 (31)	2 (4)	15 (27)	.003
DWI motor strip score, (median) (IQR)	0 (0–0)	0 (0–0)	0 (0–1.5)	.010
CT-CBF-PIRI >50% (No.) (%)	39 (71)	14 (25)	25 (45)	.133
CT-MTT-PIRI >50% (No.) (%)	44 (80)	17 (31)	27 (49)	.294

Note:—IA indicates intra-arterial.
↵a Results expressed as absolute numbers (%), mean (±SD), or median (IQR).
↵b Continuous, ordinal, and discrete variables compared with the unpaired t test, Mann-Whitney U test, and Fisher exact test, respectively.