Acquision of MR perfusion images and contrast-enhanced MR angiography in acute ischaemic stroke patients: Which procedure should be done first?

Multimodal MRI for acute ischaemic stroke usually includes perfusion imaging (PI) and contrast-enhanced neck MR angiography (CE-MRA), as well as diffusion-weighted imaging and T₂* weighted imaging. Because both PI and CE-MRA require the infusion of contrast medium, the likelihood exists that one study may conflict with the other due to the accumulation of previously injected contrast medium. The purpose of this study is to determine the appropriate order of PI and CE-MRA in this multimodal MRI protocol for evaluation of acute ischaemic stroke. We studied 35 patients with acute ischaemic stroke in the unilateral middle cerebral artery territory. 17 patients underwent CE-MRA following PI (group A) and 18 patients underwent PI following CE-MRA (group B). For qualitative analysis of the CE-MRA and colour-coded maps of the PI, two independent observers graded the image quality. Interobserver agreement was assessed using kappa statistics, and we assessed the statistical differences of imaging quality between groups A and B using the Mann-Whitney U-test). For the quantitative analysis of PI, two parameters - the maximum change in the transverse relaxation rate (ΔR2_max) and the relative signal drop (ΔS/S₀) - were calculated from the time-signal intensity curve of an unaffected middle cerebral artery territory, and we compared the differences in the parameters of group A and B (t-test). Interobserver agreements for CE-MRA and PI were good. In the qualitative analysis of CE-MRA and PI, no significant difference was observed between groups A and B. In the quantitative analysis of PI, there were no relevant differences in ΔR2_max and ΔS/ S₀ between the two groups. In simultaneous CE-MRA and PI, there was no deterioration of diagnostic imaging quality with regard to the order of the two post-contrast sequences. They can be performed according to the preference of each institution.