Do you see what I see? Diffusion imaging protocol heterogeneity biases ischemic core volume, location, and clinical associations in acute stroke

Abstract Purpose Diffusion-weighted magnetic resonance imaging (DWI) is essential for diagnosing ischemic stroke and identifying targets for emergency revascularization. Apparent diffusion coefficient (ADC) maps derived from DWI are commonly used to locate the infarct core, but they are not strictly quantitative and can vary across platforms and sites due to technical factors. This retrospective study was conducted to examine how differences in ADC map generation, resulting from varied protocols across platforms and sites, affect the determination of infarct core size, location, and related clinical outcomes in acute stroke. Methods In this retrospective study, 726 acute anterior circulation stroke patients admitted to the Lausanne University Hospital between May 2018 and January 2021 were selected. DWI data were used to generate ADC maps as they would appear from different protocols: two simulated with low and medium angular resolution (4 and 12 diffusion gradient directions) and one with high angular resolution (20 directions). Using a DEFUSE like criteria and image post-processing, ischemic cores were localized; core volume, location, and associations to National Institutes of Health Stroke Scale (NIHSS) and modified Rankin Scale (mRS) scores were compared between the two imaging sequences. Results Significant differences were observed in the ADC distribution within white matter, particularly in the kurtosis and skewness, with the segmented infarct core volume being higher in protocols with reduced angular resolution compared to the 20-directions data (7.63 ml vs. 3.78 ml). The volumetric differences persisted after correcting for age, sex, and type of intervention. Infarcted voxels locations varied significantly between the two protocols. This variability affected associations between infarct core volume and clinical scores, with lower associations observed for 4-directions data compared to 20-directions data for NIHSS at admission and after 24 hours, and mRS after 3 months, further confirmed by multivariate regression. Conclusions Imaging protocol heterogeneity leads to significant changes in the ADC distribution, ischemic core location, size, and association with clinical scores. Work is needed in standardizing imaging protocols to improve the reliability of ADC as an imaging biomarker in stroke management.protocols to improve the reliability of ADC as an imaging biomarker in stroke management. Key Results Orientation changes in diffusion imaging significantly impact ADC distribution and threshold-based infarct core volume determination, affecting multi-centric studies. Lower number of directions in DWI acquisitions weakens associations between infarct volume measurements and clinical scores. Findings emphasize the impact of DWI acquisition protocol heterogeneity and image processing on acute stroke workups.