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Optimized Management of Endovascular Treatment for Acute Ischemic Stroke
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Hyperacute-phase computed tomography-diffusion-weighted imaging discrepancy and response to thrombolysis.

Hiroyuki Kawano1, Teruyuki Hirano, Yuichiro Inatomi

  • 1Department of Neurology, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan.

Journal of Stroke and Cerebrovascular Diseases : the Official Journal of National Stroke Association
|October 18, 2011
PubMed
Summary

Reversed discrepancy (RD) on CT scans in hyperacute ischemic stroke patients predicts poor outcomes. The presence of basal ganglia RD with a deep white matter lesion on DWI indicates a higher risk of infarction and less dramatic improvement after treatment.

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Area of Science:

  • Neurology
  • Radiology
  • Emergency Medicine

Background:

  • Hyperacute ischemic stroke requires rapid diagnosis and treatment.
  • Reversed discrepancy (RD) is an imaging finding where early ischemic changes are seen on CT but not on diffusion-weighted imaging (DWI).
  • The clinical significance of RD in anterior circulation ischemic stroke treated with intravenous tissue plasminogen activator (IV tPA) is not well understood.

Purpose of the Study:

  • To investigate the incidence and clinical features of RD in patients with hyperacute ischemic stroke.
  • To assess the relationship between RD, imaging findings, and treatment outcomes.
  • To determine if RD can predict the progression of infarction and patient response to IV tPA.

Main Methods:

  • Sixty-two patients with anterior circulation ischemic stroke received CT and MRI within 3 hours of symptom onset and IV tPA therapy.
  • RD was identified when early ischemic changes were seen on CT but not on DWI.
  • Relationships between RD, Alberta Stroke Programme Early CT Score, DWI, deep white matter lesions (DWI-W), dramatic improvement (NIHSS change ≥ 10 or final score ≤ 1), and hemorrhage were analyzed.

Main Results:

  • RD was identified in 10 patients (16.1%), most commonly in the basal ganglia.
  • Patients with both basal ganglia RD and a DWI-W lesion (bRD+W+) had basal ganglia infarction within 24 hours.
  • Dramatic improvement after IV tPA was significantly less frequent in the bRD+W+ group (0%) compared to the bRD without DWI-W group (bRD+W-, 75%; P = .0285).

Conclusions:

  • The presence of RD, particularly in the basal ganglia with a concomitant DWI-W lesion, is associated with a higher risk of infarction.
  • This imaging pattern can predict a lack of dramatic improvement following IV tPA therapy.
  • RD findings may aid in predicting stroke progression and guiding treatment decisions in hyperacute ischemic stroke.