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Apparent diffusion coefficient (ADC) thresholds have been proposed to distinguish salvageable from irreversibly damaged tissue. This study aimed to evaluate the predictive value of a single ADC threshold for DWI-R following rapid and successful recanalization with voxel-level methodology.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Materials and methods<\/jats:title>\n                    <jats:p>\n                      In this cohort study, we retrospectively analysed consecutive patients examined with DWI before and the day after endovascular therapy, with successful recanalization within 120\u2009min of baseline MRI. DWI-R was assessed voxel-wise for ADC values between 200\u2009mm\n                      <jats:sup>2<\/jats:sup>\n                      \/s and 760\u2009\u00d7\u200910\n                      <jats:sup>\u22126<\/jats:sup>\n                      \u2009mm\n                      <jats:sup>2<\/jats:sup>\n                      \/s. Predictive accuracy of ADC thresholds was evaluated using receiver operating characteristic (ROC) analyses.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>\n                      Seventy-one patients with a mean baseline DWI lesion volume of 18.13\u2009mL (IQR: 6.15, 26.25) were included. Median time from MRI to recanalization was 84.0\u2009min (IQR: 72.0, 95.5). On average, 37.5% of voxels demonstrated reversal. The area under the curve for predicting reversal based on ADC was 0.708, and the optimal threshold was 555\u2009\u00d7\u200910\n                      <jats:sup>\u20136<\/jats:sup>\n                      \u2009mm\n                      <jats:sup>2<\/jats:sup>\n                      \/s (sensitivity 73.8%, specificity 58.6%). The voxel-wise probability of reversal declined with lower ADC, but even low ADC values exhibited some degree of reversal.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>This study reinforces existing concerns about using fixed ADC thresholds to define irreversible injury. A single ADC cut-off showed only modest sensitivity and poor specificity for predicting DWI-R. No definitive lower ADC boundary was identified across clinically relevant ranges below which the likelihood of DWI-R became negligible.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Key Points<\/jats:title>\n                    <jats:p>\n                      <jats:bold>\n                        <jats:italic>Question<\/jats:italic>\n                      <\/jats:bold>\n                      <jats:italic>Identifying penumbra from permanent ischaemic damage remains challenging, and the role of ADC evaluation before thrombectomy in predicting tissue viability is debated<\/jats:italic>\n                      .\n                    <\/jats:p>\n                    <jats:p>\n                      <jats:bold>\n                        <jats:italic>Findings<\/jats:italic>\n                      <\/jats:bold>\n                      <jats:italic>An ADC threshold of 555\u2009\u00d7\u200910\u22126\u2009mm\u00b2\/s yielded moderate sensitivity (73.8%) and low specificity (58.6%) for predicting DWI-R (AUC 0.708)<\/jats:italic>\n                      .\n                    <\/jats:p>\n                    <jats:p>\n                      <jats:bold>\n                        <jats:italic>Clinical relevance<\/jats:italic>\n                      <\/jats:bold>\n                      <jats:italic>A uniform ADC threshold has limited utility in identifying salvageable brain tissue in thrombectomy triage. Our findings emphasise the need for caution when excluding acute ischaemic stroke patients from recanalization therapy based on restrictive diffusion<\/jats:italic>\n                      .\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Graphical Abstract<\/jats:title>\n                  <\/jats:sec>","DOI":"10.1007\/s00330-025-12014-0","type":"journal-article","created":{"date-parts":[[2025,9,29]],"date-time":"2025-09-29T17:45:57Z","timestamp":1759167957000},"page":"1733-1743","update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":4,"title":["Predicting lesion reversal in acute cerebral ischaemia via apparent diffusion coefficient threshold on diffusion-weighted MRI"],"prefix":"10.1007","volume":"36","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-6746-1579","authenticated-orcid":false,"given":"Thor H\u00e5kon","family":"Skatt\u00f8r","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Atle","family":"Bj\u00f8rnerud","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Terje","family":"Nome","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kine Mari","family":"Bakke","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Brian Anthony","family":"Enriquez","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ingrid","family":"Digernes","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Cecilie M\u00f8rck","family":"Offersen","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mona Kristiansen","family":"Beyer","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Geir","family":"Ringstad","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Anne Hege","family":"Aamodt","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2025,9,29]]},"reference":[{"key":"12014_CR1","doi-asserted-by":"publisher","first-page":"939","DOI":"10.1161\/01.STR.29.5.939","volume":"29","author":"G Rordorf","year":"1998","unstructured":"Rordorf G, Koroshetz WJ, Copen WA et al (1998) Regional ischemia and ischemic injury in patients with acute middle cerebral artery stroke as defined by early diffusion-weighted and perfusion-weighted MRI. 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Clin Neuroradiol 32:939\u2013950","journal-title":"Clin Neuroradiol"}],"container-title":["European Radiology"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1007\/s00330-025-12014-0.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/article\/10.1007\/s00330-025-12014-0","content-type":"text\/html","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1007\/s00330-025-12014-0.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,3,5]],"date-time":"2026-03-05T14:03:07Z","timestamp":1772719387000},"score":1,"resource":{"primary":{"URL":"https:\/\/link.springer.com\/10.1007\/s00330-025-12014-0"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,9,29]]},"references-count":47,"journal-issue":{"issue":"3","published-online":{"date-parts":[[2026,3]]}},"alternative-id":["12014"],"URL":"https:\/\/doi.org\/10.1007\/s00330-025-12014-0","relation":{},"ISSN":["1432-1084"],"issn-type":[{"value":"1432-1084","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025,9,29]]},"assertion":[{"value":"12 June 2025","order":1,"name":"received","label":"Received","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"5 August 2025","order":2,"name":"revised","label":"Revised","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"21 August 2025","order":3,"name":"accepted","label":"Accepted","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"29 September 2025","order":4,"name":"first_online","label":"First Online","group":{"name":"ArticleHistory","label":"Article History"}},{"order":1,"name":"Ethics","group":{"name":"EthicsHeading","label":"Compliance with ethical standards"}},{"value":"The scientific guarantor of this publication is Anne Hege Aamodt.","order":2,"name":"Ethics","group":{"name":"EthicsHeading","label":"Guarantor"}},{"value":"The authors report no conflicts of interest.","order":3,"name":"Ethics","group":{"name":"EthicsHeading","label":"Conflict of interest"}},{"value":"No complex statistical methods were necessary for this paper.","order":4,"name":"Ethics","group":{"name":"EthicsHeading","label":"Statistics and biometry"}},{"value":"Written informed consent was obtained from all subjects (patients) in this study.","order":5,"name":"Ethics","group":{"name":"EthicsHeading","label":"Informed consent"}},{"value":"The present study received approval from the regional ethics committee (REK 2015\/1844) Institutional Review Board approval was obtained.","order":6,"name":"Ethics","group":{"name":"EthicsHeading","label":"Ethical approval"}},{"value":"Some study subjects or cohorts have been previously reported in: (1) Skattor TH et al (2025) Mapping DWI signal reversal and long-term tissue outcomes following endovascular therapy in acute ischaemic stroke. Eur Radiol.\n                      \n                      . (2)\u00a0Nome T et al (2024) Clinical outcome after thrombectomy in patients with MeVO stroke: importance of clinical and technical factors. J Neurol 271:877\u2013886. (3) Enriquez BAB et al (2024) External validation of clinical risk prediction score for the elderly treated with endovascular thrombectomy. J Neurol 271:5838\u20135845. (4) Enriquez BAB et al (2023) Predictors of outcome after endovascular treatment for tandem occlusions: a single centre retrospective analysis. BMC Neurol 23:82.","order":7,"name":"Ethics","group":{"name":"EthicsHeading","label":"Study subjects or cohorts overlap"}},{"order":8,"name":"Ethics","group":{"name":"EthicsHeading","label":"Methodology"}}]}}