How often is the MRI normal following ischaemic stroke?

Diagnosis of DWI-negative acute ischemic stroke: a meta-analysis.

Edlow BL, Hurwitz S, Edlow JA.

Neurology 2017; 89:256-262.



To determine the prevalence of diffusion-weighted imaging (DWI)-negative acute ischemic stroke (AIS) and to identify clinical characteristics of patients with DWI-negative AIS.


We systematically searched PubMed and Ovid/MEDLINE for relevant studies between 1992, the year that the DWI sequence entered clinical practice, and 2016. Studies were included based upon enrollment of consecutive patients presenting with a clinical diagnosisof AIS prior to imaging. Meta-analysis was performed to synthesize study-level data, estimate DWI-negative stroke prevalence, and estimate the odds ratios (ORs) for clinical characteristics associated with DWI-negative stroke.


Twelve articles including 3,236 AIS patients were included. The meta-analytic synthesis yielded a pooled prevalence of DWI-negative AIS of 6.8%, 95% confidence interval (CI) 4.9-9.3. In the 5 studies that reported proportion data for DWI-negative and DWI-positive AIS based on the ischemic vascular territory (n = 1,023 AIS patients), DWI-negative stroke was strongly associated with posterior circulation ischemia, as determined by clinical diagnosis at hospital discharge or repeat imaging (OR 5.1, 95% CI 2.3-11.6, p < 0.001).


A small but significant percentage of patients with AIS have a negative DWI scan. Patients with neurologic deficits consistent with posterior circulation ischemia have 5 times the odds of having a negative DWI scan compared to patients with anterior circulation ischemia. AIS remains a clinical diagnosis and urgent reperfusion therapy should be considered even when an initial DWI scan is negative.


The following is a related reference:

Doubal FN, Dennis MS, Wardlaw JM. Characteristics of patients with minor ischaemic strokes and negative MRI: a cross-sectional study. JNNP 2011; 82:540-542.

Both references are included in the neurochecklist:

Ischaemic stroke imaging: magnetic resonance imaging (MRI)

Abstract link 1

Abstract link 2

By John S. To, M.D. – Own work, Public Domain, Link

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