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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 - 18/10/11

Doi : 10.1016/S1474-4422(11)70192-2 
Götz Thomalla, DrMD a, ⁎ , Bastian Cheng, MD a, Martin Ebinger, MD e, Qing Hao, MD g, Thomas Tourdias, ProfMD h, Ona Wu, PhD i, Jong S Kim, ProfMD j, Lorenz Breuer, MD k, Oliver C Singer, MD m, Steven Warach, ProfMD n, Soren Christensen, PhD o, Andras Treszl, MSc b, Nils D Forkert, MSc c, Ivana Galinovic, MD e, Michael Rosenkranz, MD a, Tobias Engelhorn, ProfMD l, Martin Köhrmann, MD k, Matthias Endres, ProfMD f, Dong-Wha Kang, ProfMD j, Vincent Dousset, ProfMD h, A Gregory Sorensen, ProfMD i, David S Liebeskind, ProfMD g, Jochen B Fiebach, MD e, Jens Fiehler, ProfMD d, Christian Gerloff, ProfMD a

for the STIR and VISTA Imaging Investigators

a Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany 
b Institut für Medizinische Biometrie und Epidemiologie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany 
c Institut für Computational Neuroscience, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany 
d Klinik und Poliklinik für Neuroradiologische Diagnostik und Intervention, Diagnostikzentrum, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany 
e Centrum für Schlaganfallforschung, Charité-Universtitätsmedizin Berlin, Berlin, Germany 
f Department of Neurology, Charité-Universtitätsmedizin Berlin, Berlin, Germany 
g Department of Neurology, University of California, Los Angeles, CA, USA 
h Université de Bordeaux, Institut de Bio-Imagerie de Bordeaux, CNRS UMS 3428, CHU de Bordeaux, Service de NeuroImagerie Diagnostique et Thérapeutique, Bordeaux, France 
i Athinoula A Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA 
j Department of Neurology, Asan Medical Centre, University of Ulsan College of Medicine, Seoul, South Korea 
k Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany 
l Department of Neuroradiology, University of Erlangen-Nuremberg, Erlangen, Germany 
m Klinik für Neurologie, Universitätsklinikum, Goethe-Universität, Frankfurt, Germany 
n National Institute of Neurological Disorders and Stroke, Bethesda, MD, USA 
o Department of Neurology, Royal Melbourne Hospital, University of Melbourne, Melbourne, Australia 

* Correspondence to: Dr Götz Thomalla, Kopf- und Neurozentrum, Klinik und Poliklinik für Neurologie, Universitätsklinikum Hamburg-Eppendorf, Martinistraße 52, D-20246 Hamburg, Germany

Summary

Background

Many patients with stroke are precluded from thrombolysis treatment because the time from onset of their symptoms is unknown. We aimed to test whether a mismatch in visibility of an acute ischaemic lesion between diffusion-weighted MRI (DWI) and fluid-attenuated inversion recovery (FLAIR) MRI (DWI-FLAIR mismatch) can be used to detect patients within the recommended time window for thrombolysis.

Methods

In this multicentre observational study, we analysed clinical and MRI data from patients presenting between Jan 1, 2001, and May 31, 2009, with acute stroke for whom DWI and FLAIR were done within 12 h of observed symptom onset. Two neurologists masked to clinical data judged the visibility of acute ischaemic lesions on DWI and FLAIR imaging, and DWI-FLAIR mismatch was diagnosed by consensus. We calculated predictive values of DWI-FLAIR mismatch for the identification of patients with symptom onset within 4·5 h and within 6 h and did multivariate regression analysis to identify potential confounding covariates. This study is registered with ClinicalTrials.gov, number NCT01021319.

Findings

The final analysis included 543 patients. Mean age was 66·0 years (95% CI 64·7–67·3) and median National Institutes of Health Stroke Scale score was 8 (IQR 4–15). Acute ischaemic lesions were identified on DWI in 516 patients (95%) and on FLAIR in 271 patients (50%). Interobserver agreement for acute ischaemic lesion visibility on FLAIR imaging was moderate (κ=0·569, 95% CI 0·504–0·634). DWI-FLAIR mismatch identified patients within 4·5 h of symptom onset with 62% (95% CI 57–67) sensitivity, 78% (72–84) specificity, 83% (79–88) positive predictive value, and 54% (48–60) negative predictive value. Multivariate regression analysis identified a longer time to MRI (p<0·0001), a lower age (p=0·0009), and a larger DWI lesion volume (p=0·0226) as independent predictors of lesion visibility on FLAIR imaging.

Interpretation

Patients with an acute ischaemic lesion detected with DWI but not with FLAIR imaging are likely to be within a time window for which thrombolysis is safe and effective. These findings lend support to the use of DWI-FLAIR mismatch for selection of patients in a future randomised trial of thrombolysis in patients with unknown time of symptom onset.

Funding

Else Kröner-Fresenius-Stiftung, National Institutes of Health.

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Vol 10 - N° 11

P. 978-986 - novembre 2011 Regresar al número
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