Fluid-Attenuated Inversion Recovery Hyperintense Ischemic Stroke Predicts Less Favorable 90-Day Outcome after Intravenous Thrombolysis

2021 ◽  
pp. 1-8
Author(s):  
Yongwoo Kim ◽  
Marie Luby ◽  
Nina-Serena Burkett ◽  
Gina Norato ◽  
Richard Leigh ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Visual Inspection ◽  
Intravenous Thrombolysis ◽  
Inversion Recovery ◽  
Stroke Patients ◽  
Contrast Extravasation ◽  
Ischemic Lesion ◽  
Fluid Attenuated Inversion Recovery ◽  
Multivariable Regression ◽  
Early Lesion

<b><i>Introduction:</i></b> The absence of an ischemic lesion on MRI fluid-attenuated inversion recovery (FLAIR) is helpful in predicting stroke onset within 4.5 h. However, some ischemic strokes become visible on FLAIR within 4.5 h. We hypothesized that the early lesion visibility on FLAIR may predict stroke outcome 90 days after intravenous (IV) thrombolysis, independent of time. <b><i>Materials and Methods:</i></b> We analyzed data from acute ischemic stroke patients presenting over the last 10 years who were screened with MRI and treated with IV thrombolysis within 4.5 h from onset. Three independent readers assessed whether ischemic lesions seen on diffusion-weighted imaging were also FLAIR positive based on visual inspection. Multivariable regression analyses were used to obtain an adjusted odds ratio of favorable clinical and radiological outcomes based on FLAIR positivity. <b><i>Results:</i></b> Of 297 ischemic stroke patients, 25% had lesion visibility on initial FLAIR. The interrater agreement for the FLAIR positivity assessment was 84% (<i>κ</i> = 0.604, 95% CI: 0.557–0.652). Patients with FLAIR-positive lesions had more right hemispheric strokes (57 vs. 41%, <i>p</i> = 0.045), were imaged later (129 vs. 104 min, <i>p</i> = 0.036), and had less frequent favorable 90-day functional outcome (49 vs. 63%, <i>p</i> = 0.028), less frequent early neurologic improvement (30 vs. 58%, <i>p</i> = 0.001), and more frequent contrast extravasation to the cerebrospinal fluid space (44 vs. 26%, <i>p</i> = 0.008). <b><i>Conclusions:</i></b> Early development of stroke lesion on FLAIR within 4.5 h of onset is associated with reduced likelihood of favorable 90-day outcome after IV thrombolysis.

Abstract P353: FLAIR-Positive Acute Ischemic Stroke and Less Favorable 90-Day Outcome After IV Thrombolysis

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Yongwoo Kim ◽  
Marie Luby ◽  
Nina-serena F Burkett ◽  
Gina Norato ◽  
Richard Leigh ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Diffusion Weighted Imaging ◽  
Visual Inspection ◽  
Interrater Agreement ◽  
Stroke Patients ◽  
Blood Brain Barrier Disruption ◽  
Positive Assessment ◽  
Multivariable Regression ◽  
Brain Barrier Disruption

Background and Purpose: It is well established that earlier treatment times are associated with better outcomes in acute stroke patients receiving thrombolysis. There is also an association between time from stroke onset and lesion visibility on FLAIR MRI. We hypothesized that lesion visibility on FLAIR, independent of time, may be a predictor of outcome in stroke patients with known onset. Methods: We analyzed data from acute ischemic stroke patients presenting over the last 10 years who were screened with MRI and treated with IV thrombolysis within 4.5 hours from known onset. Three independent readers assessed whether acute ischemic lesions seen on Diffusion Weighted Imaging were also FLAIR-positive based on visual inspection. Multivariable regression analysis was used to obtain an adjusted odds ratio of favorable clinical and radiological outcomes based on FLAIR-positivity. Results: Of 310 stroke patients, 24% had lesion visibility on initial FLAIR MRI. The interrater agreement for the FLAIR-positive assessment was 84% (κ=0.604, 95% CI 0.557-0.652). Patients with FLAIR-positive lesions were younger (67 vs 73 years, p=0.028), had more right hemispheric strokes (57% vs 42%, p=0.018), were imaged later (127 vs 104 minutes, p=0.010), had more frequent blood-brain barrier disruption (44% vs 26%, p=0.004), less frequent early neurologic improvement (30% vs 58%, p<0.001), and less frequent favorable 90-day functional outcome (49% vs 63%, p=0.039). Following multivariable logistic regression, older age, greater NIH Stroke Scale, lesion visibility on FLAIR, but not time-from-onset, were independently associated with less favorable outcome. Conclusions: FLAIR-positive acute ischemic stroke within 4.5 hours of known onset was associated with less favorable 90-day outcome after IV thrombolysis. When compared with time, lesion visibility on FLAIR was more strongly associated with 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.

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.

scholarly journals Management of acute ischemic stroke in patients with COVID-19 infection: Report of an international panel

2020 ◽  
Vol 15 (5) ◽  
pp. 540-554 ◽  
Author(s):  
Adnan I Qureshi ◽  
Foad Abd-Allah ◽  
Fahmi Al-Senani ◽  
Emrah Aytac ◽  
Afshin Borhani-Haghighi ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Current Knowledge ◽  
Intravenous Thrombolysis ◽  
Adult Patients ◽  
World Health ◽  
Stroke Patients ◽  
International Panel ◽  
Health Organization ◽  
Tract Infections

Background and purpose On 11 March 2020, World Health Organization (WHO) declared the COVID-19 infection a pandemic. The risk of ischemic stroke may be higher in patients with COVID-19 infection similar to those with other respiratory tract infections. We present a comprehensive set of practice implications in a single document for clinicians caring for adult patients with acute ischemic stroke with confirmed or suspected COVID-19 infection. Methods The practice implications were prepared after review of data to reach the consensus among stroke experts from 18 countries. The writers used systematic literature reviews, reference to previously published stroke guidelines, personal files, and expert opinion to summarize existing evidence, indicate gaps in current knowledge, and when appropriate, formulate practice implications. All members of the writing group had opportunities to comment in writing on the practice implications and approved the final version of this document. Results This document with consensus is divided into 18 sections. A total of 41 conclusions and practice implications have been developed. The document includes practice implications for evaluation of stroke patients with caution for stroke team members to avoid COVID-19 exposure, during clinical evaluation and performance of imaging and laboratory procedures with special considerations of intravenous thrombolysis and mechanical thrombectomy in stroke patients with suspected or confirmed COVID-19 infection. Conclusions These practice implications with consensus based on the currently available evidence aim to guide clinicians caring for adult patients with acute ischemic stroke who are suspected of, or confirmed, with COVID-19 infection. Under certain circumstances, however, only limited evidence is available to support these practice implications, suggesting an urgent need for establishing procedures for the management of stroke patients with suspected or confirmed COVID-19 infection.

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