Related Experiment Video
Updated: May 5, 2026
The Stroke Preclinical Assessment Network Multi-Laboratory Model of Thromboembolic Stroke with Thrombolysis: TE-MCAo
Published on: December 19, 2025
Intravenous thrombolysis for patients with reverse magnetic resonance angiography and diffusion-weighted imaging
1Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan.
Background And Purpose:
The characteristics of reverse magnetic resonance angiography and diffusion-weighted imaging (MRA-DWI) mismatch (RMM), defined as a large DWI lesion in the absence of major artery occlusion (MAO), remain unknown, especially in patients treated with intravenous recombinant tissue plasminogen activator (rt-PA).
Methods:
Patients with stroke in the middle cerebral artery territory were included. Early ischaemic changes (EIC) were assessed with the Alberta Stroke Program Early CT Score on DWI (DWI-ASPECTS). All patients were divided into four groups based on the presence of MAO and a DWI-ASPECTS cut-off value of <7. RMM was defined as DWI-ASPECTS <7 without MAO. Clinical characteristics, symptomatic intracerebral hemorrhage (sICH) and favorable functional outcome (modified Rankin Scale score 0-2) at 90 days were compared amongst the four groups.
Results:
Of the 486 patients enrolled (167 women, median age 74 years, median initial National Institutes of Health Stroke Scale score 13), reverse MRA-DWI mismatch was observed in 24 (5%). Of the clinical characteristics, cardioembolism was the only factor that was independently associated with RMM [odds ratio (OR) 5.49, 95% confidence interval (CI) 1.25-24.1]. Multivariable analyses revealed that patients with RMM more commonly had sICH than those with DWI-ASPECTS ≥ 7 irrespective of the presence (OR 5.44, 95% CI 1.13-26.1) or absence (13.1, 2.07-83.3) of MAO, and they had a more favorable functional outcome than those with DWI-ASPECTS < 7 plus MAO (7.45, 2.39-23.2).
Conclusion:
RMM was observed in 5% of patients treated with rt-PA and associated with cardioembolism. Patients with RMM may benefit from thrombolysis compared with those with EIC with MAO, although increment in the rate of sICH is a concern.
Insights
Reverse magnetic resonance angiography and diffusion-weighted imaging (MRA-DWI) mismatch (RMM) in stroke patients treated with rt-PA was observed in 5% and linked to cardioembolism. RMM patients may benefit from thrombolysis, but symptomatic intracerebral hemorrhage risk increases.
Area of Science:
- Neuroimaging
- Stroke Medicine
- Thrombolytic Therapy
Background:
- Reverse magnetic resonance angiography and diffusion-weighted imaging (MRA-DWI) mismatch (RMM) is defined as a large DWI lesion without major artery occlusion (MAO).
- Characteristics of RMM, particularly in patients receiving intravenous recombinant tissue plasminogen activator (rt-PA), are not well understood.
Purpose of the Study:
- To investigate the characteristics of RMM in stroke patients treated with rt-PA.
- To compare clinical features, symptomatic intracerebral hemorrhage (sICH), and functional outcomes in patients with and without RMM.
Main Methods:
- Retrospective analysis of 486 stroke patients in the middle cerebral artery territory treated with rt-PA.
- Assessment of early ischemic changes using DWI-ASPECTS and identification of MAO.
- Classification into four groups based on MAO and DWI-ASPECTS (<7 or ≥7).
Main Results:
- RMM was identified in 5% of patients.
- Cardioembolism was the only independent predictor of RMM (OR 5.49).
- RMM patients had higher rates of sICH and more favorable functional outcomes compared to specific control groups.
Conclusions:
- RMM occurs in 5% of rt-PA treated stroke patients and is associated with cardioembolism.
- Patients with RMM may benefit from thrombolysis, but increased sICH risk warrants caution.
- Further research is needed to optimize treatment strategies for RMM patients.
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