Diffusion-Weighted Image and Fluid-Attenuated Inversion Recovery Image Mismatch

Kim, Bum Joon; Kim, Hye-Jin; Lee, Deok Hee; Kwon, Sun U.; Kim, Sang Joon; Kim, Jong Seung; Kang, Dong‐Wha

doi:10.1161/strokeaha.113.002830

Cited by 22 publications

(14 citation statements)

References 25 publications

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“…However, this is controversial and in the PRE-FLAIR study an improvement over quantitative analysis of FLAIR signal was not better than visual analysis (48, 54). It has been shown that a significant amount of wake-up-stroke patients has such a DWI/FLAIR mismatch pattern (55). There are limitations though of the sole use of DWI/FLAIR mismatch to select patients for therapy.…”

Section: Resultsmentioning

confidence: 99%

Wake-Up Stroke and Stroke of Unknown Onset: A Critical Review

et al. 2014

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Patients, who wake up with an ischemic stroke, account for a large number of the total stroke population, due to circadian morning predominance of stroke. Currently, this subset of patients is excluded from revascularization-therapy since no exact time of onset is known. A large group of these patients might be eligible for therapy. In this review, we assessed the current literature about the hypothesis that wake-up-strokes occur just prior on awakening and if this subgroup differs in characteristics compared to the overall stroke population. We looked at the safety and efficacy of thrombolysis and interventional techniques in the group of patients with unknown stroke-onset. We performed a meta-analysis of the diagnostic accuracy of the diffusion-FLAIR mismatch in identifying stroke within 3 and 4.5 h. The different imaging-selection criteria that can be used to treat these patients are discussed. Additional research on imaging findings associated with recent stroke and penumbral imaging will eventually lead to a shift from a rigid time-frame based therapy to a tissue-based individualized treatment approach.

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Section: Resultsmentioning

confidence: 99%

Wake-Up Stroke and Stroke of Unknown Onset: A Critical Review

et al. 2014

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“…Detailed information from the Clinical Research Center for Stroke-5th division registry was reported previously. 11,12 Fourteen stroke centers with nationwide coverage registered 28 348 acute stroke patients consecutively between April 2008 and November 2013. For the current study, 17 976 patients registered between January 2011 and November 2013 were initially screened.…”

Section: Subjectsmentioning

confidence: 99%

Clinical Outcomes of Posterior Versus Anterior Circulation Infarction With Low National Institutes of Health Stroke Scale Scores

Kim

Park

Choi

et al. 2017

Stroke

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Background and Purpose-We compared baseline characteristics and outcomes at 3 months between patients with minor anterior circulation infarction (ACI) versus minor posterior circulation infarction (PCI), including the influence of large vessel disease on outcomes. Methods-This study is an analysis of a prospective multicenter registry database in South Korea. Eligibility criteria were patients with ischemic stroke admitted within 7 days of stroke onset, lesions in either anterior or posterior circulation, and National Institutes of Health Stroke Scale score of ≤4 at baseline. Patients were divided into 4 groups for further analysis: minor ACI with and without internal carotid artery/middle cerebral artery large vessel disease and minor PCI with and without vertebrobasilar large vessel disease. Results-A total of 7178 patients (65.2±12.6 years) were analyzed in this study, and 2233 patients (31.1%) had disability (modified Rankin Scale score 2-6) at 3 months. Disability was 32.3% in minor PCI and 30.3% in minor ACI (P=0.07), and death was 1.3% and 1.5%, respectively (P=0.82). In a multivariable logistic regression analysis, minor PCI was significantly associated with disability at 3 months when compared with minor ACI (odds ratio, 1.23; 95% confidence interval, 1.09-1.37; P<0.001). In pairwise comparisons, minor PCI with vertebrobasilar large vessel disease was independently associated with disability at 3 months, compared with the other 3 groups. Conclusions-Our study showed that minor PCI exhibited more frequent disability at 3 months than minor ACI. Especially, the presence of vertebrobasilar large vessel disease in minor PCI had a substantially higher risk of disability. Our results suggest that minor PCI with vertebrobasilar large vessel disease could require more meticulous care and are important targets for further study.

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“… 76 Therefore, DWI-FLAIR mismatch (i.e., lesion visible on DWI but not on FLAIR) has been used as a surrogate marker for estimating the lesion age of unknown stroke onset, and can help determine the use of thrombolytic agent ( Figure 7 ). 77 , 78 Patients with DWI-FLAIR mismatch are likely to be within the time window for thrombolysis, the specificity and predictive value of which have both been shown to be high (93% and 94%, respectively). 77 Finally, in the reperfusion therapy in unclear-onset stroke based on MRI evaluation (RESTORE), patients with unclear stroke onset, within 6 hours of symptom detection with PWI-DWI mismatch >20% and negative or subtle FLAIR change, were treated with tPA or endovascular therapy, and MRI-based reperfusion therapy was found to be feasible and safe.…”

Section: Patient Selection For Acute Stroke Treatmentmentioning

confidence: 99%

Magnetic Resonance Imaging in Acute Ischemic Stroke Treatment

et al. 2014

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Although intravenous administration of tissue plasminogen activator is the only proven treatment after acute ischemic stroke, there is always a concern of hemorrhagic risk after thrombolysis. Therefore, selection of patients with potential benefits in overcoming potential harms of thrombolysis is of great importance. Despite the practical issues in using magnetic resonance imaging (MRI) for acute stroke treatment, multimodal MRI can provide useful information for accurate diagnosis of stroke, evaluation of the risks and benefits of thrombolysis, and prediction of outcomes. For example, the high sensitivity and specificity of diffusion-weighted image (DWI) can help distinguish acute ischemic stroke from stroke-mimics. Additionally, the lesion mismatch between perfusion-weighted image (PWI) and DWI is thought to represent potential salvageable tissue by reperfusion therapy. However, the optimal threshold to discriminate between benign oligemic areas and the penumbra is still debatable. Signal changes of fluid-attenuated inversion recovery image within DWI lesions may be a surrogate marker for ischemic lesion age and might indicate risks of hemorrhage after thrombolysis. Clot sign on gradient echo image may reflect the nature of clot, and their location, length and morphology may provide predictive information on recanalization by reperfusion therapy. However, previous clinical trials which solely or mainly relied on perfusion-diffusion mismatch for patient selection, failed to show benefits of MRI-based thrombolysis. Therefore, understanding the clinical implication of various useful MRI findings and comprehensively incorporating those variables into therapeutic decision-making may be a more reasonable approach for expanding the indication of acute stroke thrombolysis.

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Diffusion-Weighted Image and Fluid-Attenuated Inversion Recovery Image Mismatch

Cited by 22 publications

References 25 publications

Wake-Up Stroke and Stroke of Unknown Onset: A Critical Review

Wake-Up Stroke and Stroke of Unknown Onset: A Critical Review

Clinical Outcomes of Posterior Versus Anterior Circulation Infarction With Low National Institutes of Health Stroke Scale Scores

Magnetic Resonance Imaging in Acute Ischemic Stroke Treatment

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