Lesion Age Imaging in Acute Stroke: Water Uptake in CT Versus DWI‐FLAIR Mismatch

 It should make no difference of time of onset. You should have 100% recovery protocols for every eventuality. This shows a lack of innovative thinking.

Lesion Age Imaging in Acute Stroke: Water Uptake in CT Versus DWI‐FLAIR Mismatch

Gabriel Broocks MD

Hannes Leischner MD PhD

Uta Hanning MD MHBA

Fabian Flottmann MD

Tobias D. Faizy MD

Gerhard Schön M.Sc

Peter Sporns MD MHBA

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First published: 16 September 2020

https://doi.org/10.1002/ana.25903

This article has been accepted for publication and undergone full peer review but has not been through the copyediting, typesetting, pagination and proofreading process, which may lead to differences between this version and the Version of Record. Please cite this article as doi: 10.1002/ana.25903.

Abstract

Purpose

In acute ischemic stroke with unknown time of onset, MR‐based diffusion‐weighted imaging (DWI) and fluid‐attenuated inversion recovery (FLAIR) estimates lesion age to guide intravenous thrombolysis. CT‐based quantitative net water uptake (NWU) may be a potential alternative. The purpose of this study was to directly compare CT‐based NWU to MRI at identifying patients with lesion age <4.5h from symptom onset.(If you don't hit this 4.5 hour time, WHAT THE FUCK ARE YOU DOING TO GET THEM RECOVERED? NOTHING?)

Methods

50 acute anterior circulation stroke patients were analyzed with both imaging modalities at admission between 0.5h‐8.0h after known symptom onset. DWI‐FLAIR lesion mismatch was rated and NWU was measured in admission‐CT. An established NWU‐threshold (11.5%) was used to classify patients within and beyond 4.5h. Multiparametric MRI signal was compared to NWU using logistic regression analyses. The empirical distribution of NWU was analyzed in a consecutive cohort of wake‐up stroke patients.

Results

The median time between CT and MRI was 35 minutes (IQR: 24‐50). The accuracy of DWI‐FLAIR mismatch was 68.8% (95%CI: 53.7‐81.3%) with a sensitivity of 58% and specificity of 82%. The accuracy of NWU‐threshold was 86.0% (95%CI: 73.3‐94.2%) with a sensitivity of 91% and specificity of 78%. The AUC of multiparametric MRI to classify lesion age <4.5h was 0.86 (95%CI: 0.64‐0.97), and the AUC of quantitative NWU was 0.91 (95%CI: 0.78‐0.98). Among 87 wake‐up stroke patients, 46 patients (53%) showed low NWU (<11.5%).

Conclusion

The predictive power of CT‐based lesion water imaging to identify patients within the time window of thrombolysis was comparable to multiparametric DWI‐FLAIR MRI. A significant proportion of wake‐up stroke patients with low NWU may be potentially suitable for thrombolysis.

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