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Clinical-Diffusion Mismatch Is Associated with Early Neurological Improvement after Late-Window Endovascular
Bum Joon Kim1, Yoojin Lee1, Boseong Kwon1,2
1Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea.
Insights
Patients with clinical-diffusion mismatch (CDM) and perfusion-diffusion mismatch (PDM) show better outcomes after endovascular thrombectomy (EVT) in the late window. This highlights CDM as a crucial factor for selecting stroke patients for EVT.
Area of Science:
- Neurology
- Radiology
- Interventional Cardiology
Background:
- Clinical-diffusion mismatch (CDM) and perfusion-diffusion mismatch (PDM) are key imaging biomarkers for selecting patients for endovascular thrombectomy (EVT) in the late window (6-24 hours post-stroke).
- CDM is considered a more accurate reflection of the ischemic penumbra compared to PDM.
Purpose of the Study:
- To investigate whether patients with both CDM and PDM respond better to late-window EVT compared to those with PDM only.
- To identify factors associated with early neurological improvement (ENI) after EVT in acute ischemic stroke patients.
Main Methods:
- Retrospective analysis of 94 acute ischemic stroke patients who underwent EVT between 6-24 hours post-stroke.
- Patients were categorized based on the presence of CDM (DAWN criteria) and PDM (perfusion-/diffusion-weighted imaging lesion volume >1.8).
- Early neurological improvement (ENI) was defined as an improvement of >4 points on the NIHSS score 1 day post-EVT. Multivariable analysis was used to determine independent predictors of ENI.
Main Results:
- Out of 94 patients, all had PDM, and 44 (46.3%) had CDM. ENI was observed in 48 patients (51.1%).
- Patients with CDM exhibited higher rates of ENI, greater NIHSS score improvement, and a stronger correlation between DWI lesion volume and initial NIHSS score.
- Independent predictors of ENI included onset-to-door time, complete recanalization, initial NIHSS score, and the presence of CDM.
Conclusions:
- The presence of both clinical-diffusion mismatch (CDM) and perfusion-diffusion mismatch (PDM) is associated with a better response to late-window endovascular thrombectomy (EVT).
- CDM is an independent predictor of early neurological improvement following EVT in the late time window.
Background:
Clinical-diffusion mismatch (CDM) and perfusion-diffusion mismatch (PDM) are used to select patients for endovascular thrombectomy (EVT) in the late-window period. As CDM well reflects true penumbra, we hypothesized that patients with CDM and PDM would respond better to EVT than those with PDM only at the late-window period.
Methods:
Acute ischemic stroke patients who received EVT 6-24 h after stroke onset were included. PDM (perfusion-/diffusion-weighted image (DWI) lesion volume >1.8) was used to select candidates for EVT in this time-period in our center. CDM was defined according to the DAWN trial criteria. Response to EVT was compared between patients with and without CDM. Early neurological improvement (ENI) was defined as improvement >4 points on National Institutes of Health Stroke Scale (NIHSS) score 1 day after EVT. Multivariable analysis was performed to investigate independent factors associated with ENI. The correlation between DWI lesion volume and NIHSS score was investigated in those with and without CDM.
Results:
Among 94 patients enrolled, all patients had PDM and 44 (46.3%) had CDM. Forty-eight patients (51.1%) showed ENI. The prevalence of hypertension, initial NIHSS score, improvement in NIHSS score after EVT, and prevalence of ENI were greater in patients with CDM than those without. ENI was independently associated with onset-to-door time (odds ratio [95% confidence interval]: 0.998 [0.997-1.000]; p = 0.042), complete recanalization (23.912 [2.238-255.489]; p = 0.009), initial NIHSS score (1.180 [1.012-1.377]; p = 0.034), and the presence of CDM (5.160 [1.448-18.386]; p = 0.011). The correlation between DWI lesion volume and initial NIHSS score was strong in patients without CDM (r = 0.731) but only moderate in patients with CDM (r = 0.355).
Conclusion:
Patients with both CDM and PDM had a better response to late-window EVT than those with PDM only.
