Automated MRI perfusion-diffusion mismatch estimation may be significantly different in individual patients when using different software packages.

Objective: To compare two established software applications in terms of apparent diffusion coefficient (ADC) lesion volumes, volume of critically hypoperfused brain tissue, and calculated volumes of perfusion-diffusion mismatch in brain MRI of patients with acute ischemic stroke.

Methods: Brain MRI examinations of 81 patients with acute stroke due to large vessel occlusion of the anterior circulation were analyzed. The volume of hypoperfused brain tissue, ADC volume, and the volume of perfusion-diffusion mismatch were calculated automatically with two different software packages. The calculated parameters were compared quantitatively using formal statistics.

Results: Significant difference was found for the volume of hypoperfused tissue (median 91.0 ml vs. 102.2 ml; p < 0.05) and the ADC volume (median 30.0 ml vs. 23.9 ml; p < 0.05) between different software packages. The volume of the perfusion-diffusion mismatch differed significantly (median 47.0 ml vs. 67.2 ml; p < 0.05). Evaluation of the results on a single-subject basis revealed a mean absolute difference of 20.5 ml for hypoperfused tissue, 10.8 ml for ADC volumes, and 27.6 ml for mismatch volumes, respectively. Application of the DEFUSE 3 threshold of 70 ml infarction core would have resulted in dissenting treatment decisions in 6/81 (7.4%) patients.

Conclusion: Volume segmentation in different software products may lead to significantly different results in the individual patient and may thus seriously influence the decision for or against mechanical thrombectomy.

Key Points: • Automated calculation of MRI perfusion-diffusion mismatch helps clinicians to apply inclusion and exclusion criteria derived from randomized trials. • Infarct volume segmentation plays a crucial role and lead to significantly different result for different computer programs. • Perfusion-diffusion mismatch estimation from different computer programs may influence the decision for or against mechanical thrombectomy.