What the fuck difference does it make when the stroke stated? THE STROKE MEDICAL WORLD SHOULD HAVE PROTOCOLS FOR ALL SCENARIOS LEADING TO 100% RECOVERY.
If they don't they should get them created. Until we get survivors in charge nothing will change. Your hospital has been incompetent for DECADES in not having these protocols right now.
Lesion Age Imaging in Acute Stroke: Water Uptake in CT Versus DWI‐FLAIR Mismatch
Abstract
Purpose
In acute ischemic stroke with unknown time of onset, magnetic resonance (MR)‐based diffusion‐weighted imaging (DWI) and fluid‐attenuated inversion recovery (FLAIR) estimates lesion age to guide intravenous thrombolysis. Computed tomography (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 magnetic resonance imaging (MRI) at identifying patients with lesion age < 4.5 hours from symptom onset.
Methods
Fifty patients with acute anterior circulation stroke were analyzed with both imaging modalities at admission between 0.5 and 8.0 hours 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 4.5 hours. Multiparametric MRI signal was compared with NWU using logistic regression analyses. The empirical distribution of NWU was analyzed in a consecutive cohort of patients with wake‐up stroke.
Results
The median time between CT and MRI was 35 minutes (interquartile range [IQR] = 24–50). The accuracy of DWI‐FLAIR mismatch was 68.8% (95% confidence interval [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 area under the curve (AUC) of multiparametric MRI signal to classify lesion age <4.5 hours 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 patients with wake‐up stroke, 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 patients with wake‐up stroke exhibit low NWU and may therefore be potentially suitable for thrombolysis. ANN NEUROL 2020
In acute ischemic stroke, efficacy of intravenous thrombolysis depends on the time from symptom onset to admission, although some patients after a stroke may benefit even in an extended time window.1, 2 Current guidelines limit the application of intravenous thrombolysis to patients within a time window of ≤ 4.5 hours.3, 4 In approximately 25% of all ischemic strokes, symptoms are first apparent on awakening (“wake‐up strokes”) as onset occurs during sleep leading to an exclusion from treatment with alteplase. In these cases, neuroimaging can help to potentially enable intravenous lysis, a notion that is supported by the results of the WAKE‐UP and EXTEND trial that were based on imaging 2 different aspects of stroke pathophysiology. Based on tissue diffusion and tissue water content, the WAKE‐UP trial used magnetic resonance imaging (MRI) primarily as an indicator of lesion age in patients with an unknown time window.5 In contrast, the EXTEND trial used perfusion computed tomography (CT) to detect patients with stroke with a specific imaging pattern of tissue at risk, indicating a likely benefit from intravenous thrombolysis beyond 4.5 hours from symptom onset and in wake‐up stroke.6
As the number of patients who may receive intra‐arterial treatment increases (eg, more distal vessel occlusions, low ASPECTS, and extended time window), correspondingly, the proportion of patients who receive CT imaging at admission to ensure fast times from admission to recanalization rises.2, 7, 8 Therefore, CT‐based methods of patient eligibility for reperfusion treatment for patients with wake‐up strokes should be investigated further to enable intravenous treatment while maintaining options for rapid transfer to endovascular intervention.9 Translating the “tissue clock criteria” as used in WAKE‐UP from MRI to CT would complement the “tissue at risk” criteria by CT perfusion, as used in the EXTEND trial. Quantitative lesion water uptake is a CT‐based imaging biomarker that has been described as a precise method to estimate lesion age.10 Yet, this method has not been compared directly in patients who received both imaging modalities, CT and MRI, at admission. In the past, performing CT and MRI was often part of standard imaging upon admission.11
The aim of this study was (1) to compare CT‐based quantitative net water uptake (NWU) to multiparametric MRI (diffusion‐weighted imaging [DWI] and fluid‐attenuated inversion recovery [FLAIR]) in classifying patients below or above an acute ischemic lesion age of 4.5 hours, and (2) to analyze the distribution of NWU in a cohort of consecutive patients with wake‐up strokes to investigate potential eligibility of CT‐guided thrombolysis. We hypothesized that CT‐based NWU may represent a feasible alternative to MRI‐based DWI‐FLAIR mismatch to distinguish patients within a 4.5 hours time window.
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