Clinical characteristics of unknown symptom onset stroke patients with and without diffusion-weighted imaging and fluid-attenuated inversion recovery mismatch

Abstract

Background

Diffusion-weighted imaging (DWI) and fluid-attenuated inversion recovery (FLAIR) mismatch was suggested to identify stroke patients with unknown time of symptom onset likely to be within the time window for thrombolysis.

Aims

We aimed to study clinical characteristics associated with DWI-FLAIR mismatch in patients with unknown onset stroke.

Methods

We analyzed baseline MRI and clinical data from patients with acute ischemic stroke proven by DWI from WAKE-UP, an investigator-initiated, randomized, placebo-controlled trial of MRI-based thrombolysis in stroke patients with unknown time of symptom onset. Clinical characteristics were compared between patients with and without DWI-FLAIR mismatch.

Results

Of 699 patients included, 418 (59.8%) presented with DWI-FLAIR mismatch. A shorter delay between last seen well and symptom recognition (p = 0.0063), a shorter delay between symptom recognition and arrival at hospital (p = 0.0025), and history of atrial fibrillation (p = 0.19) were predictors of DWI-FLAIR mismatch in multivariate analysis. All other characteristics were comparable between groups.

Conclusions

There are only minor differences in measured clinical characteristics between unknown symptom onset stroke patients with and without DWI-FLAIR mismatch. DWI-FLAIR mismatch as an indicator of stroke onset within 4.5 h shows no relevant association with commonly collected clinical characteristics of stroke patients.

Clinical Trial Registration

URL: http://www.clinicaltrials.gov. Unique identifier: NCT01525290; URL: https://www.clinicaltrialsregister.eu. Unique identifier: 2011-005906-32.

Keywords

Acute ischemic stroke magnetic resonance imaging clinical trial diffusion-weighted imaging fluid-attenuated inversion recovery imaging diffusion-weighted imaging and fluid-attenuated inversion recovery mismatch WAKE-UP

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References

Wahlgren

Moreira

Michel

et al.

Mechanical thrombectomy in acute ischemic stroke: consensus statement by ESO-Karolinska Stroke Update 2014/2015, supported by ESO, ESMINT, ESNR and EAN. Int J Stroke 2016; 11: 134–147.

Rimmele

Thomalla

. Wake-up stroke: clinical characteristics, imaging findings, and treatment option – an update. Front Neurol 2014; 5: 35.

Thomalla

Rossbach

Rosenkranz

et al.

Negative fluid-attenuated inversion recovery imaging identifies acute ischemic stroke at 3 hours or less. Ann Neurol 2009; 65: 724–732.

Thomalla

Cheng

Ebinger

et al.

DWI-FLAIR mismatch for the identification of patients with acute ischaemic stroke within 4.5 h of symptom onset (PRE-FLAIR): a multicentre observational study. Lancet Neurol 2011; 10: 978–986.

Aoki

Kimura

Iguchi

Shibazaki

Sakai

Iwanaga

. FLAIR can estimate the onset time in acute ischemic stroke patients. J Neurol Sci 2010; 293: 39–44.

Petkova

Rodrigo

Lamy

et al.

MR imaging helps predict time from symptom onset in patients with acute stroke: implications for patients with unknown onset time. Radiology 2010; 257: 782–792.

Ebinger

Galinovic

Rozanski

Brunecker

Endres

Fiebach

. Fluid-attenuated inversion recovery evolution within 12 hours from stroke onset: a reliable tissue clock? Stroke 2010; 41: 250–255.

Aoki

Kimura

Iguchi

et al.

Intravenous thrombolysis based on diffusion-weighted imaging and fluid-attenuated inversion recovery mismatch in acute stroke patients with unknown onset time. Cerebrovasc Dis 2011; 31: 435–441.

Wei

Zhou

Zhao

. MRI based thrombolysis for FLAIR-negative stroke patients within 4.5-6h after symptom onset. J Neurol Sci 2016; 372: 421–427.

10.

Thomalla

Fiebach

Ostergaard

et al.

A multicenter, randomized, double-blind, placebo-controlled trial to test efficacy and safety of magnetic resonance imaging-based thrombolysis in wake-up stroke (WAKE-UP). Int J Stroke 2014; 9: 829–836.

11.

Viskin

Golovner

Malov

et al.

Circadian variation of symptomatic paroxysmal atrial fibrillation. Data from almost 10 000 episodes. Eur Heart J 1999; 20: 1429–1434.

12.

Kim

Kwon

Kim

Kang

. Unclear-onset stroke: daytime-unwitnessed stroke vs. wake-up stroke. Int J Stroke 2016; 11: 212–220.

13.

Riccio

Klein

Pagani Cassara

et al.

Newly diagnosed atrial fibrillation linked to wake-up stroke and TIA: hypothetical implications. Neurology 2013; 80: 1834–1840.

14.

Huisa

Liebeskind

Raman

et al.

Diffusion-weighted imaging-fluid attenuated inversion recovery mismatch in nocturnal stroke patients with unknown time of onset. J Stroke Cerebrovasc Dis 2013; 22: 972–977.

15.

Kim

Lee

et al.

Diffusion-weighted image and fluid-attenuated inversion recovery image mismatch: unclear-onset versus clear-onset stroke. Stroke 2014; 45: 450–455.

16.

Donnan

Baron

Davis

. Penumbral selection of patients for trials of acute stroke therapy. Lancet Neurol 2009; 8: 261–269.

17.

Wouters

Dupont

Norrving

et al.

Prediction of stroke onset is improved by relative fluid-attenuated inversion recovery and perfusion imaging compared to the visual diffusion-weighted imaging/fluid-attenuated inversion recovery mismatch. Stroke 2016; 47: 2559–2564.

18.

Wouters

Dupont

Ringelstein

et al.

Association between the perfusion/diffusion and diffusion/FLAIR mismatch: data from the AXIS2 trial. J Cereb Blood Flow Metab 2015; 35: 1681–1686.