Difficulty of MRI based identification of lesion age by acute infra-tentorial ischemic stroke

Florian Grosse-Dresselhaus, Ivana Galinovic, Kersten Villringer, Heinrich J Audebert, Jochen B Fiebach, Florian Grosse-Dresselhaus, Ivana Galinovic, Kersten Villringer, Heinrich J Audebert, Jochen B Fiebach

Abstract

Background: Systemic thrombolysis in acute ischemic stroke is restricted to the 4.5 h time window. Many patients are excluded from this treatment because symptom onset is unknown. Magnetic resonance imaging (MRI) studies have shown that stroke patients presenting with acute supra-tentorial diffusion-weighted imaging (DWI) lesions that do not have matching lesions on fluid attenuated inversion recovery (FLAIR) are likely to be within a 4.5 hour time window. This study examines the DWI-FLAIR mismatch in infra-tentorial stroke.

Methods: This was a retrospectively conducted substudy of the "1000+" study; a prospective, single-center observational study (https://ichgcp.net/clinical-trials-registry/NCT00715533" title="See in ClinicalTrials.gov">NCT00715533). Fifty-six patients with infra-tentorial stroke confirmed by MRI and known symptom onset who underwent the scan within 24 h after symptom onset were analysed. Two neurologists blinded to clinical information separately rated the DWI lesion visibility on FLAIR. Lesion volume, relative signal intensities of DWI and relative apparent diffusion coefficient values were determined.

Results: Regarding baseline characteristics our study population had a median age of 66 years, a median time from symptom onset to MRI of 616.5 minutes, a median NIHSS of 3 and a median DWI lesion volume of 0.26 ml. A negative FLAIR allocated patients to a time window under 4.5 h correctly with a sensitivity of 55% and a specificity of 61%, a positive predictive value of 44% and a negative predictive value of 71%. FLAIR positivity decreased with age (p = 0.018), and showed no significant correlation to lesion volume (p = 0.145).

Conclusions: In our study the DWI-FLAIR-Mismatch does not help to reliably identify patients within 4.5 h of symptom onset in acute ischemic infra-tentorial stroke. Thus therapeutical decisions based on the DWI-FLAIR mismatch estimation of time from onset cannot be recommended in patients with infra-tentorial stroke.

Conflict of interest statement

Competing Interests: The authors have the following conflicts: Jochen B. Fiebach has received consultant or lecture fees from Boehringer-Ingelheim, Lundbeck, Siemens, Sygnis and Synarc. He is Steering Committee member of the WAKE-UP trial (FP7/2007-2013), Grant Agreement Nr. 278276 (WAKE-UP). The other authors have declared that no competing interests exist.

Figures

Figure 1. Examples of late FLAIR changes…
Figure 1. Examples of late FLAIR changes of acute infra-tentorial DWI lesions.
The DWI shows a left cerebellar lesion (A) and a right mesencephal lesion (B) 22 h and 16,5 h after symptom onset, respectively. Both have no clear FLAIR visibility on the day of admission but are demarcated on the follow-up examination.
Figure 2. Visibility of FLAIR lesions and…
Figure 2. Visibility of FLAIR lesions and time from symptom onset.
Numbers in the columns represent patients within each time interval.

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Source: PubMed

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