title: Favorable Bridging Therapy Based on DWI-FLAIR Mismatch in Patients with Unclear-Onset Stroke.
abstract: OBJECTIVE
  Standard selection criteria for revascularization therapy usually exclude patients with unclear-onset stroke. Our aim was to evaluate the efficacy and safety of revascularization therapy in patients with unclear-onset stroke in the anterior circulation and to identify the predictive factors for favorable clinical outcome.
  
  
  METHODS
  We retrospectively analyzed 41 consecutive patients presenting with acute stroke with unknown time of onset treated by intravenous thrombolysis and/or mechanical thrombectomy. Only patients without well-developed fluid-attenuated inversion recovery changes of acute diffusion lesions on MR imaging were enrolled. Twenty-one patients were treated by intravenous thrombolysis; 19 received, simultaneously, intravenous thrombolysis and mechanical thrombectomy (as a bridging therapy); and 1 patient, endovascular therapy alone. Clinical outcome was evaluated at 90 days by using the mRS. Mortality and symptomatic intracranial hemorrhage were also reported.
  
  
  RESULTS
  Median patient age was 72 years (range, 17-89 years). Mean initial NIHSS score was 14.5 ± 5.7. Successful recanalization (TICI 2b-3) was assessed in 61% of patients presenting with an arterial occlusion, symptomatic intracranial hemorrhage occurred in 2 patients (4.9%), and 3 (7.3%) patients died. After 90 days, favorable outcome (mRS 0-2) was observed in 25 (61%) patients. Following multivariate analysis, initial NIHSS score (OR, 1.43; 95% CI, 1.13-1.82; P = .003) and bridging therapy (OR, 37.92; 95% CI, 2.43-591.35; P = .009) were independently associated with a favorable outcome at 3 months.
  
  
  CONCLUSIONS
  The study demonstrates the safety and good clinical outcome of acute recanalization therapy in patients with acute stroke in the anterior circulation and an unknown time of onset and a DWI/FLAIR mismatch on imaging. Moreover, bridging therapy versus intravenous thrombolysis alone was independently associated with favorable outcome at 3 months.
authors.affiliation: From Departments of Neurology (I.M., D.M., C.A., X.A.) i-mourand@chu-montpellier.fr.
authors.forename: I
authors.identifier: http://orcid.org/0000-0001-9788-4516
authors.initials: I
authors.lastname: Mourand
authors.affiliation: From Departments of Neurology (I.M., D.M., C.A., X.A.).
authors.forename: D
authors.initials: D
authors.lastname: Milhaud
authors.affiliation: From Departments of Neurology (I.M., D.M., C.A., X.A.).
authors.forename: C
authors.identifier: http://orcid.org/0000-0001-7347-1039
authors.initials: C
authors.lastname: Arquizan
authors.affiliation: Neuroradiology (K.L., P.M., O.F.E., A.B., V.C.).
authors.forename: K
authors.identifier: http://orcid.org/0000-0001-5093-9751
authors.initials: K
authors.lastname: Lobotesis
authors.affiliation: Medical Information (R.S.), University Hospital Center of Montpellier, Gui de Chauliac Hospital, Montpellier, France.
authors.forename: R
authors.initials: R
authors.lastname: Schaub
authors.affiliation: Neuroradiology (K.L., P.M., O.F.E., A.B., V.C.).
authors.forename: P
authors.identifier: http://orcid.org/0000-0001-8333-0352
authors.initials: P
authors.lastname: Machi
authors.affiliation: From Departments of Neurology (I.M., D.M., C.A., X.A.).
authors.forename: X
authors.identifier: http://orcid.org/0000-0003-3834-2981
authors.initials: X
authors.lastname: Ayrignac
authors.affiliation: Neuroradiology (K.L., P.M., O.F.E., A.B., V.C.).
authors.forename: O F
authors.identifier: http://orcid.org/0000-0002-5696-5368
authors.initials: OF
authors.lastname: Eker
authors.affiliation: Neuroradiology (K.L., P.M., O.F.E., A.B., V.C.).
authors.forename: A
authors.identifier: http://orcid.org/0000-0002-9187-1375
authors.initials: A
authors.lastname: Bonafé
authors.affiliation: Neuroradiology (K.L., P.M., O.F.E., A.B., V.C.).
authors.forename: V
authors.identifier: http://orcid.org/0000-0001-8428-9101
authors.initials: V
authors.lastname: Costalat
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D020520:Brain Infarction / Q000175:diagnosis* / Q000188:drug therapy*; D003131:Combined Modality Therapy; D038524:Diffusion Magnetic Resonance Imaging / Q000379:methods*; D005260:Female; D006801:Humans; D007089:Image Enhancement / Q000379:methods*; D007090:Image Interpretation, Computer-Assisted / Q000379:methods*; D008297:Male; D008875:Middle Aged; D011379:Prognosis; D012189:Retrospective Studies; D017131:Thrombectomy / Q000379:methods*; D015912:Thrombolytic Therapy / Q000379:methods*; D055815:Young Adult