Negative Fluid-Attenuated Inversion Recovery- Based Intravenous Thrombolysis Using Recombinant Tissue Plasminogen Activator in Acute Stroke Patients with Unknown Onset Time

TLDR

MRI can detect early ischemic lesions before tPA administration in hyperacute ischemic stroke patients. The study aimed to determine whether early ischemic changes on diffusion‑weighted imaging predict outcomes in anterior‑circulation stroke patients treated with tPA within 3 h. Prospectively, 49 consecutive anterior‑circulation stroke patients received tPA within 3 h; NIHSS scores were recorded pre‑treatment and 7 days post‑treatment, and MRI with DWI was performed before thrombolysis to assess the DWI Alberta Stroke Programme Early CT Score (ASPECTS) and its relationship to outcomes. Patients with a DWI ASPECTS ≤5 had markedly worse outcomes (OR 33.4, 95 % CI 2.7–410.8) and were less likely to improve, whereas those with ASPECTS >5 showed better recovery; thus DWI ASPECTS is a reliable predictor of outcome and patients with ASPECTS >5 should be considered eligible for tPA.

Abstract

MRI is useful for detecting early ischemic lesions before administration of tissue plasminogen activator in patients with hyperacute ischemic stroke. However, it is unclear whether early ischemic change seen on diffusion-weighted imaging (DWI) can be used to predict patient outcomes.Consecutive patients with anterior circulation ischemic stroke treated with tissue plasminogen activator within 3 hours of stroke onset were prospectively studied. The National Institutes of Health Stroke Scale score was obtained before and 7 days after tissue plasminogen activator administration. MRI, including DWI, was done before tissue plasminogen activator thrombolysis. The relationship between the DWI Alberta Stroke Programme Early CT Score (ASPECTS) and patients' outcomes was assessed.The subjects consisted of 49 consecutive patients with stroke (27 males; mean age, 72.9+/-10.3 years). The median (range) of the baseline DWI ASPECTS value was 9 (3-10). Dramatic improvement was seen in one of 8 patients with an ASPECTS < or = 5 compared with 21 of 41 patients with a DWI ASPECTS > 5 (P=0.0592). On the other hand, worsening was noted more frequently in patients with a DWI ASPECTS < or = 5 (3 of 8 patients) than in patients with an ASPECTS > 5 (4 of 41 patients; P=0.0753). Bad outcome was seen more frequently in patients with a DWI ASPECTS < or = 5 (6 of 8 patients) than in patients with a DWI ASPECTS > 5 (2 of 41 patients; P<0.0001). Multivariate logistic regression analysis demonstrated that a DWI ASPECTS < or = 5 was the only independent predictor of a bad outcome (OR, 33.4; 95% CI, 2.7 to 410.8; P=0.0062).DWI ASPECTS appears to be a reliable tool for predicting bad outcome. Patients with a DWI ASPECTS > 5 should be considered eligible for tissue plasminogen activator therapy.