Different mismatch concepts for MRI-guided thrombolysis in unknown onset stroke

Scheldeman, L. et al. (2020) Different mismatch concepts for MRI-guided thrombolysis in unknown onset stroke. Annals of Neurology, 87(6), pp. 931-938. (doi: 10.1002/ana.25730) (PMID:32227638)

Abstract

Objective: To explore the prevalence of the perfusion‐weighted imaging (PWI) ‐ diffusion‐weighted imaging (DWI) mismatch and response to intravenous thrombolysis in the WAKE‐UP trial. Methods: We performed a prespecified post‐hoc analysis of ischemic stroke patients screened for DWI ‐ fluid‐attenuated inversion recovery (FLAIR) mismatch in WAKE‐UP who underwent PWI. We defined PWI‐DWI mismatch as ischemic core volume < 70 ml, mismatch volume > 10 ml and mismatch ratio > 1.2. Primary efficacy endpoint was a modified Rankin Scale score of 0–1 at 90 days, adjusted for age and symptom severity. Results: Of 1,362 magnetic resonance imaging (MRI) screened patients, 431 underwent PWI. Of these, 57 (13%) had a double mismatch, 151 (35%) only a DWI‐FLAIR mismatch and 54 (13%) only a PWI‐DWI mismatch. DWI‐FLAIR mismatch was more prevalent than PWI‐DWI mismatch (48%; 95% CI 43%–53% vs 26%; 95% CI 22%–30%, p < 0.0001). Screening for either one of the mismatch profiles resulted in a yield of 61% (95% CI 56%–65%). Prevalence of PWI‐DWI mismatch was similar in patients with (27%) or without (24%) DWI‐FLAIR mismatch (p = 0.52). In an exploratory analysis in the small subgroup of 208 randomized patients with PWI, PWI‐DWI mismatch status did not modify the treatment response (p for interaction = 0.73). Interpretation: Evaluating both the DWI‐FLAIR and PWI‐DWI mismatch pattern in patients with unknown time of stroke onset will result in the highest yield of thrombolysis treatment. The treatment benefit of alteplase in patients with a DWI‐FLAIR mismatch seems not merely driven by the presence of a PWI‐DWI mismatch, although this analysis was underpowered.

• Item Type: Articles
• Keywords: Neurology, clinical neurology.
• Status: Published
• Refereed: Yes
• Glasgow Author(s) Enlighten ID: Muir, Professor Keith
• Authors: Scheldeman, L., Wouters, A., Boutitie, F., Dupont, P., Christensen, S., Cheng, B., Ebinger, M., Endres, M., Fiebach, J. B., Gerloff, C., Muir, K. W., Nighoghossian, N., Pedraza, S., Simonsen, C. Z., Thijs, V., Thomalla, G., Lemmens, R., and for the WAKE‐UP Investigators,
• College/School: College of Medical Veterinary and Life Sciences > School of Psychology & Neuroscience
• Journal Name: Annals of Neurology
• Publisher: Wiley
• ISSN: 0364-5134
• ISSN (Online): 1531-8249
• Published Online: 30 March 2020
• Copyright Holders: Copyright © 2020 American Neurological Association
• First Published: First published in Annals of Neurology 87(6): 931-938
• Publisher Policy: Reproduced in accordance with the publisher copyright policy