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Osama Jaafari,1 Helen Gallagher,2 Muhammed Alshehri,1 Khalid Hakami,1 Majedh AlShammari1 1Royal Commission Medical Centre, King Fahd, Al-Nakheel, Yanbu, Saudi Arabia; 2School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, ScotlandCorrespondence: Osama JaafariRoyal Commission Medical Centre, King Fahd, Al-Nakheel, Yanbu, 46451, Saudi ArabiaTel +966-14-393-7700Fax +966143922483Email jaafario@rcymc.med.saBackground: Stroke is one of the most burdensome neurological conditions affecting young and older adult populations worldwide, and notably it has remained one of the leading causes of disability and premature mortality within its disease category. Timely and accurate diagnosis and characterization of stroke with cross-sectional imaging impacts significantly on treatment planning and patient outcomes, particularly with the advent of early reperfusion therapies. Recently, there has been growing recognition that perfusion-weighted MRI (PW-MRI) may offer a significant advantage in diagnosing and characterizing the ischemia induced by stroke, as it can detect diffusion–perfusion deficits that may influence treatment decisions to prevent infarction. This structured literature review sought to explore the diagnostic utility and accuracy of PW-MRI compared to other MRI protocols.Methods: A literature search was performed using Medline, Embase, and the Cochrane Library, with articles limited to the English language and publication in the last 15 years. Eligible articles were appraised using the QUADAS-2 framework, and given marked interstudy heterogeneity, the diagnostic outcomes were analyzed using a narrative approach.Results: A total of ten studies were reviewed — retrospective and one prospective — and found to observe a moderate–high risk of bias. The studies revealed that PW-MRI offers beneficial diagnostic capabilities when compared to other MRI sequences and ability to detect significant diffusion–perfusion mismatches. However, PW-MRI was found to overestimate the degree of oligemia and ischemia in brain tissue. As ischemia does not always progress to infarction, thrombolytic treatment may be unnecessary in some cases and expose patients to adverse effects.Conclusion: These findings indicate that PW-MRI should be considered for routine imaging as an adjunct to other MRI protocols and an alternative to CT thereby reducing ionizing radiation exposure.Keywords: perfusion–diffusion deficits, cross-sectional diagnostic imaging