title: Clinical-Radiological Parameters Improve the Prediction of the Thrombolysis Time Window by Both MRI Signal Intensities and DWI-FLAIR Mismatch.
abstract: With regard to acute stroke, patients with unknown time from stroke onset are not eligible for thrombolysis. Quantitative diffusion weighted imaging (DWI) and fluid attenuated inversion recovery (FLAIR) MRI relative signal intensity (rSI) biomarkers have been introduced to predict eligibility for thrombolysis, but have shown heterogeneous results in the past. In the present work, we investigated whether the inclusion of easily obtainable clinical-radiological parameters would improve the prediction of the thrombolysis time window by rSIs and compared their performance to the visual DWI-FLAIR mismatch.
  
  
  
  In a retrospective study, patients from 2 centers with proven stroke with onset <12 h were included. The DWI lesion was segmented and overlaid on ADC and FLAIR images. rSI mean and SD, were calculated as follows: (mean ROI value/mean value of the unaffected hemisphere). Additionally, the visual DWI-FLAIR mismatch was evaluated. Prediction of the thrombolysis time window was evaluated by the area-under-the-curve (AUC) derived from receiver operating characteristic (ROC) curve analysis. Factors such as the association of age, National Institutes of Health Stroke Scale, MRI field strength, lesion size, vessel occlusion and Wahlund-Score with rSI were investigated and the models were adjusted and stratified accordingly.
  
  
  
  In 82 patients, the unadjusted rSI measures DWI-mean and -SD showed the highest AUCs (AUC 0.86-0.87). Adjustment for clinical-radiological covariates significantly improved the performance of FLAIR-mean (0.91) and DWI-SD (0.91). The best prediction results based on the AUC were found for the final stratified and adjusted models of DWI-SD (0.94) and FLAIR-mean (0.96) and a multivariable DWI-FLAIR model (0.95). The adjusted visual DWI-FLAIR mismatch did not perform in a significantly worse manner (0.89). ADC-rSIs showed fair performance in all models.
  
  
  
  Quantitative DWI and FLAIR MRI biomarkers as well as the visual DWI-FLAIR mismatch provide excellent prediction of eligibility for thrombolysis in acute stroke, when easily obtainable clinical-radiological parameters are included in the prediction models.
authors.affiliation: Max-Planck-Institute for Neurological Research, Cologne, Germany.
authors.forename: Vince Istvan
authors.initials: VI
authors.lastname: Madai
authors.forename: Carla N
authors.initials: CN
authors.lastname: Wood
authors.forename: Ivana
authors.initials: I
authors.lastname: Galinovic
authors.forename: Ulrike
authors.initials: U
authors.lastname: Grittner
authors.forename: Sophie K
authors.initials: SK
authors.lastname: Piper
authors.forename: Gajanan S
authors.initials: GS
authors.lastname: Revankar
authors.forename: Steve Z
authors.initials: SZ
authors.lastname: Martin
authors.forename: Olivier
authors.initials: O
authors.lastname: Zaro-Weber
authors.forename: Walter
authors.initials: W
authors.lastname: Moeller-Hartmann
authors.forename: Federico C
authors.initials: FC
authors.lastname: von Samson-Himmelstjerna
authors.forename: Wolf-Dieter
authors.initials: WD
authors.lastname: Heiss
authors.forename: Martin
authors.initials: M
authors.lastname: Ebinger
authors.forename: Jochen B
authors.initials: JB
authors.lastname: Fiebach
authors.forename: Jan
authors.initials: J
authors.lastname: Sobesky
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D019540:Area Under Curve; D002560:Cerebrovascular Circulation; D016009:Chi-Square Distribution; D000066491:Clinical Decision-Making; D038524:Diffusion Magnetic Resonance Imaging; D004334:Drug Administration Schedule; D005260:Female; D005343:Fibrinolytic Agents / Q000008:administration & dosage*; D005858:Germany; D006801:Humans; D007090:Image Interpretation, Computer-Assisted; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D018579:Patient Selection; D011237:Predictive Value of Tests; D012372:ROC Curve; D012189:Retrospective Studies; D020521:Stroke / Q000000981:diagnostic imaging* / Q000188:drug therapy / Q000503:physiopathology; D015912:Thrombolytic Therapy; D013997:Time Factors; D061665:Time-to-Treatment
chemical_list: D005343:Fibrinolytic Agents