Diffusion-Weighted Imaging-Fluid-Attenuated Inversion Recovery Mismatch Is Associated with 90-Day Functional Outcomes in Patients Undergoing Mechanical Thrombectomy

2020 ◽  
Vol 49 (3) ◽  
pp. 292-300
Author(s):  
Fumihiro Sakakibara ◽  
Shinichi Yoshimura ◽  
Soichiro Numa ◽  
Kazutaka Uchida ◽  
Norito Kinjo ◽  
...  
Keyword(s):  
Functional Outcomes ◽  
Diffusion Weighted Imaging ◽  
Mechanical Thrombectomy ◽  
Inversion Recovery ◽  
Favorable Outcome ◽  
Ischemic Lesion ◽  
Historical Cohort ◽  
Diffusion Weighted ◽  
Fluid Attenuated Inversion Recovery ◽  
To Receive

Background and Purpose: Diffusion-weighted imaging-fluid-attenuated inversion recovery (DWI-FLAIR) mismatch is an early sign of acute ischemic stroke. DWI-FLAIR mismatch was reported to be valuable to select patients with unknown onset stroke who are eligible to receive intravenous thrombolysis (IVT), but its utility is less studied in patients undergoing mechanical thrombectomy (MT) for acute large vessel occlusion (LVO). We thus investigated the functional outcomes at 90 days between patients with DWI-FLAIR mismatch and those with match who underwent MT for LVO. Methods: We conducted a historical cohort study in consecutive patients who were evaluated by magnetic resonance imaging for suspected stroke at a single center. We enrolled patients with occlusion of internal carotid artery or horizontal or vertical segment of middle cerebral artery who underwent MT within 24 h after they were last known to be well. DWI-FLAIR mismatch was defined when a visible acute ischemic lesion was present on DWI without traceable parenchymal hyperintensity on FLAIR. Image analysis was done by 2 stroke neurologists independently. We estimated the adjusted odds ratio (OR) of DWI-FLAIR mismatch relative to DWI-FLAIR match for moderate outcome defined as modified Rankin Scale (mRS) 0–3, favorable outcome defined as mRS 0–2 and mortality at 90 days after the onset, and symptomatic intracranial hemorrhage (sICH) within 72 h after the onset. Results: Of the 380 patients who received MT, 202 were included. Patients with DWI-FLAIR mismatch (146 [72%]) had significantly higher baseline National Institutes of Health Stroke Scale (median 16 vs. 13, p = 0.01), more transferred-in (78 vs. 63%, p = 0.02), more IVT (45 vs. 18%, p = 0.0003), more cardioembolism (69 vs. 54%, p = 0.03), and shorter onset-to-hospital door times (median 175 vs. 371 min, p < 0.0001) than patients with DWI-FLAIR match. Patients with DWI-FLAIR mismatch had more moderate outcome than those with DWI-FLAIR match (61 vs. 52%, p = 0.24), and the adjusted OR was 3.12 (95% confidence interval [CI]: 1.35–7.19, p = 0.008). sICH within 72 h was less frequent in the DWI-FLAIR mismatch group (10 vs. 20%, p = 0.06), with an adjusted OR of 0.36 (95% CI: 0.13–0.97, p = 0.044). The adjusted ORs for favorable outcome and mortality were 0.87 (95% CI: 0.39–1.94, p = 0.73) and 0.63 (95% CI: 0.20–2.05, p = 0.44), respectively. Conclusions: DWI-FLAIR mismatch was associated with more moderate outcome and less sICH in the adjusted analysis in patients receiving MT for acute LVO. DWI-FLAIR mismatch could be useful to select patients with unknown onset stroke who are eligible to receive MT for acute LVO.

Abstract TP69: Association Between DWI-FLAIR Mismatch and Functional Outcomes in Patients Undergoing Mechanical Thrombectomy

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Fumihiro Sakakibara ◽  
Kazutaka Uchida ◽  
Soichiro Numa ◽  
Shinichi Yoshimura ◽  
Takeshi Morimoto
Keyword(s):  
Intracranial Hemorrhage ◽  
Functional Outcomes ◽  
Mechanical Thrombectomy ◽  
Intravenous Thrombolysis ◽  
Vessel Occlusion ◽  
Ischemic Lesion ◽  
Historical Cohort ◽  
Good Marker ◽  
Fluid Attenuated Inversion Recovery ◽  
Symptomatic Intracranial Hemorrhage

Background and Purpose: Diffusion weighted imaging-fluid attenuated inversion recovery (DWI-FLAIR) mismatch was well recognized as an early sign of acute ischemic stroke lesions. In the era of mechanical thrombectomy (MT), DWI-FLAIR mismatch could be a good marker for candidates of MT. We thus investigated the association between DWI-FLAIR mismatch and functional outcomes in patients who received MT for acute large vessel occlusion (LVO). Methods: We conducted historical cohort study in consecutive patients who were evaluated by MRI for suspected stroke at single stroke center. We enrolled patients with occlusion of the ICA or M1 or M2 segment of MCA who were underwent MT within 24 hours after the last known to be well. FLAIR negative was defined when a visible acute ischemic lesion was present on DWI without traceable parenchymal hyperintensity on FLAIR. We estimated the adjusted OR of FLAIR negative for moderate outcome defined as mRS 0-3 at 90 days after onset. We also estimated the adjusted OR for symptomatic intracranial hemorrhage within 72 hours and mortality at 90 days. Results: Among 380 patients who received MT for acute LVO, 202 patients were included in this study. Patients with FLAIR negative was 146 (72%), and the rest were FLAIR positive. Patients with FLAIR negative had significantly higher baseline NIHSS (median 16 vs 13, p=0.01), more transferred-in (78% vs 63%, p=0.02), more intravenous thrombolysis (IVT) (45% vs 18%, P=0.0003), more cardioembolism (69% vs 54%, p=0.03), and shorter times from the onset to hospital door (median 175 vs 371 minutes, p<0.0001). Patients with FLAIR negative had more moderate outcome than the counterparts (61% vs 52%, p=0.24). The adjusted OR of FLAIR negative compared to positive was 2.97 (95%CI, 1.33-6.60, p=0.008). Symptomatic intracranial hemorrhage within 72 hours was less frequent in the FLAIR negative group (10% vs 20%, p=0.06), with an adjusted OR of 0.34 (95%CI, 0.13-0.87, p=0.02). Conclusions: DWI-FLAIR mismatch was associated with better functional outcome in patients received MT for acute LVO at 90 days. DWI-FLAIR mismatch should be a good marker for the candidate of MT for acute LVO. Future randomized trial to evaluate the effectiveness of MRI-based MT using DWI-FLAIR mismatch should be considered.

Abstract W MP19: Diffusion-Weighted Imaging-Fluid-Attenuated Inversion Recovery Mismatch at 1.5T VS 3T MRI in Acute Ischemic Stroke

Stroke ◽  
2015 ◽  
Vol 46 (suppl_1) ◽  
Author(s):  
Kenta Seki ◽  
Masatoshi Koga ◽  
Shoichiro Sato ◽  
Kazunari Homma ◽  
Sohei Yoshimura ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Predictive Value ◽  
Diffusion Weighted Imaging ◽  
Inversion Recovery ◽  
Stroke Onset ◽  
Ischemic Lesion ◽  
3T Mri ◽  
Diffusion Weighted ◽  
Fluid Attenuated Inversion Recovery

Background and purpose: Although the diffusion-weighted imaging (DWI)-fluid-attenuated inversion recovery (FLAIR) mismatch (DFM) can be a surrogate marker of stroke onset time, DFM at 3T MRI may represent different clinical implications from that at 1.5T MRI. We aimed to compare the prevalence of DFM between 1.5T and 3T MRI, and assess factors associated with the FLAIR lesion positivity, and analyze a sensitivity and a specificity of DFM to identify patients ≤ 4.5h of stroke onset. Methods: Consecutive patients with acute ischemic stroke who underwent 3T or 1.5T MRI including DWI and FLAIR ≤ 12h of onset were enrolled. Random allocation regarding the magnetic field strength was performed according to the MRI availability. More than two stroke neurologists judged whether there is DFM. We identified ischemic lesion corresponding to stroke symptom on DWI and then determined whether the FLAIR lesion positivity is negative, subtle (only slightly different from adjacent parenchyma) or evident (a clearly high signal). DFM was defined as the FLAIR negative or subtle corresponding to the DWI lesion. Results: Of 179 patients (women, 39%; 72±11 years) studied, 89 and 90 received 3T and 1.5T MRI, respectively. The median onset to MRI time (OMT) was 2.5h at both 3T and 1.5T MRI. The FLAIR positivity was negative in 51% at 3T vs. 30% at 1.5T, subtle in 22% vs. 27% and evident in 27% vs. 43%, respectively (p=0.015); thus DFM was identified in 73% vs. 57% (p=0.028). On ordinal logistic regression with backward stepwise selection, 3T MRI (OR 0.40, 95%CI 0.22-0.71) and infratentorial infarction (OR 0.29, 95%CI 0.12-0.68) were negatively, and OMT (per 1h, OR 1.18, 95%CI 1.07-1.30) was positively associated with the FLAIR lesion positivity. DFM ≤ 4.5h was more frequently observed at 3T than 1.5T MRI (80% vs. 60%, p=0.015). Using DFM, patients ≤ 4.5h of onset were detected with a sensitivity of 0.80, a specificity of 0.42, a positive predictive value of 0.77 and a negative predictive value of 0.46 at 3T MRI and 0.60, 0.53, 0.82 and 0.26, respectively, at 1.5T MRI. Conclusions: DFM was more frequently observed at 3T than at 1.5T MRI. Because the FLAIR lesion was associated with 1.5T rather than 3T, DFM at 3T may have different implications regarding time after stroke onset from that at 1.5T.

Rhombencephalitis in Children: Diffusion Magnetic Resonance Imaging (MRI) Correlation With Clinical Outcomes

2020 ◽  
Vol 35 (6) ◽  
pp. 404-409
Author(s):  
Alex Mun-Ching Wong ◽  
Chih-Hua Yeh ◽  
Jainn-Jim Lin ◽  
I-Jun Chou ◽  
Kuang-Lin Lin
Keyword(s):  
Clinical Outcomes ◽  
Diffusion Weighted Imaging ◽  
Multivariate Logistic Regression Analysis ◽  
Inversion Recovery ◽  
Unfavorable Outcome ◽  
Multivariate Logistic Regression ◽  
Diffusion Weighted ◽  
Disturbance Of Consciousness ◽  
Outcome Group ◽  
Fluid Attenuated Inversion Recovery

In children with rhombencephalitis, neuroimaging abnormalities have been infrequently correlated with clinical outcome. We investigated whether magnetic resonance (MR) neuroimaging studies could predict clinical outcomes and disturbance of consciousness in patients with rhombencephalitis. We retrospectively analyzed the MR studies of 19 pediatric patients with rhombencephalitis (median age: 4.2 years, range 0.5-17; sex: 32% male). Fluid-attenuated inversion recovery imaging and diffusion-weighted imaging findings were graded to create imaging scores according to the extent of imaging abnormality. Clinical outcomes in the first week and 12th month were graded by using Glasgow Outcome Scale scores (1-5) and dichotomized to unfavorable or favorable outcome. Correlations of the imaging scores with the clinical outcomes and with disturbance of consciousness were assessed by using multivariate logistic regression analysis. No significant correlation was found between fluid-attenuated inversion recovery score or diffusion-weighted imaging score ( P = .608, P = .132, respectively) and disturbance of consciousness. In the first week, the unfavorable outcome group (n = 11) had significantly higher diffusion-weighted imaging score than did the favorable outcome group (n = 8) (Mann-Whitney U test, P = .005). Multivariate logistic regression analysis showed that the diffusion-weighted imaging score (odds ratio, 18.182; 95% confidence interval: 1.36, 243.01; P = .028) was significantly associated with unfavorable outcome. In the 12th month, the fluid-attenuated inversion recovery score or diffusion-weighted imaging score ( P = .994, P = .997, respectively) were not significantly associated with unfavorable outcome. Patients with rhombencephalitis who have a higher diffusion-weighted imaging score are more likely to have an unfavorable 1-week clinical outcome.

scholarly journals Thrombolysis With Alteplase at 0.6 mg/kg for Stroke With Unknown Time of Onset

Stroke ◽  
2020 ◽  
Vol 51 (5) ◽  
pp. 1530-1538 ◽  
Author(s):  
Masatoshi Koga ◽  
Haruko Yamamoto ◽  
Manabu Inoue ◽  
Koko Asakura ◽  
Junya Aoki ◽  
...  
Keyword(s):  
Intravenous Thrombolysis ◽  
Inversion Recovery ◽  
Favorable Outcome ◽  
Control Group ◽  
Open Label ◽  
Unique Identifier ◽  
Ischemic Lesion ◽  
Fluid Attenuated Inversion Recovery ◽  
Standard Medical Treatment ◽  
And Control

Background and Purpose— We assessed whether lower-dose alteplase at 0.6 mg/kg is efficacious and safe for acute fluid-attenuated inversion recovery-negative stroke with unknown time of onset. Methods— This was an investigator-initiated, multicenter, randomized, open-label, blinded-end point trial. Patients met the standard indication criteria for intravenous thrombolysis other than a time last-known-well >4.5 hours (eg, wake-up stroke). Patients were randomly assigned (1:1) to receive alteplase at 0.6 mg/kg or standard medical treatment if magnetic resonance imaging showed acute ischemic lesion on diffusion-weighted imaging and no marked corresponding hyperintensity on fluid-attenuated inversion recovery. The primary outcome was a favorable outcome (90-day modified Rankin Scale score of 0–1). Results— Following the early stop and positive results of the WAKE-UP trial (Efficacy and Safety of MRI-Based Thrombolysis in Wake-Up Stroke), this trial was prematurely terminated with 131 of the anticipated 300 patients (55 women; mean age, 74.4±12.2 years). Favorable outcome was comparable between the alteplase group (32/68, 47.1%) and the control group (28/58, 48.3%; relative risk [RR], 0.97 [95% CI, 0.68–1.41]; P =0.892). Symptomatic intracranial hemorrhage within 22 to 36 hours occurred in 1/71 and 0/60 (RR, infinity [95% CI, 0.06 to infinity]; P >0.999), respectively. Death at 90 days occurred in 2/71 and 2/60 (RR, 0.85 [95% CI, 0.06–12.58]; P >0.999), respectively. Conclusions— No difference in favorable outcome was seen between alteplase and control groups among patients with ischemic stroke with unknown time of onset. The safety of alteplase at 0.6 mg/kg was comparable to that of standard treatment. Early study termination precludes any definitive conclusions. Registration— URL: https://www.clinicaltrials.gov ; Unique identifier: NCT02002325.

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