title: Does Diffusion Lesion Volume Above 70 mL Preclude Favorable Outcome Despite Post-Thrombolysis Recanalization?
abstract: OBJECTIVE
  Whether to withhold recanalization treatment when the diffusion-weighted imaging (DWI) lesion exceeds a given volume is unsettled. Our aim was to assess the impact of recanalization on outcome in patients with baseline DWI lesion ≥70 mL (DWI≥70 mL) treated ≤4.5 hours from onset. We hypothesized that recanalization is beneficial in a sizeable fraction of these patients and that this is associated with a larger DWI lesion reversal.
  
  
  METHODS
  We analyzed 267 consecutive patients treated with intravenous recombinant tissue-type plasminogen activator for middle cerebral artery territory stroke in whom an occlusion was present on magnetic resonance angiography and 24-hour recanalization and 90-day clinical outcome could be assessed. After stratification relative to the 70-mL DWI lesion cut point, we calculated the odds ratio for recanalization of the primary arterial occlusive lesion (AOL score ≥2) to predict favorable outcome (modified Rankin scale score ≤2). DWI lesion reversal was compared between recanalizers with DWI≥70 mL with favorable and unfavorable outcomes.
  
  
  RESULTS
  Median (interquartile range) DWI lesion volume was 22 mL (10-60), and median onset time to imaging was 116 minutes (86-151). Twelve (22%) of the 54 patients with DWI≥70 mL experienced favorable outcome, of which 9 had recanalized. In patients with DWI≥70 mL, recanalization was significantly associated with favorable outcome after adjustment for age and National Institutes of Health Stroke Scale (odds ratio =4.72 [1.09-20.32]; P=0.0375). Among recanalizers with DWI≥70 mL, absolute and relative DWI reversal volumes were larger in those with favorable as compared with unfavorable outcome (18.8 mL [12.2-47.6] versus 8.5 mL [4.3-31.1]; P=0.17; and 19.6% [10.9-62.8] versus 8.7% [3.9-16.5], respectively; P=0.049).
  
  
  CONCLUSIONS
  Patients with DWI lesion volume ≥70 mL can benefit from recanalization after intravenous recombinant tissue-type plasminogen activator. This may partly reflect a larger amount of DWI lesion reversal.
authors.affiliation: From the Departments of Radiology (M.T., S.C., L.L., M.E., P.R., S.L., O.N., J.-F.M., C.O.) and Neurology (G.T., P.S., J.-L.M., J.-C.B.), Université Paris Descartes Sorbonne Paris Cité, Centre de Psychiatrie et Neurosciences, INSERM S894, DHU Neurovasc, Centre Hospitalier Sainte-Anne, Paris, France.
authors.forename: Marie
authors.initials: M
authors.lastname: Tisserand
authors.affiliation: From the Departments of Radiology (M.T., S.C., L.L., M.E., P.R., S.L., O.N., J.-F.M., C.O.) and Neurology (G.T., P.S., J.-L.M., J.-C.B.), Université Paris Descartes Sorbonne Paris Cité, Centre de Psychiatrie et Neurosciences, INSERM S894, DHU Neurovasc, Centre Hospitalier Sainte-Anne, Paris, France.
authors.forename: Guillaume
authors.initials: G
authors.lastname: Turc
authors.affiliation: From the Departments of Radiology (M.T., S.C., L.L., M.E., P.R., S.L., O.N., J.-F.M., C.O.) and Neurology (G.T., P.S., J.-L.M., J.-C.B.), Université Paris Descartes Sorbonne Paris Cité, Centre de Psychiatrie et Neurosciences, INSERM S894, DHU Neurovasc, Centre Hospitalier Sainte-Anne, Paris, France.
authors.forename: Sylvain
authors.initials: S
authors.lastname: Charron
authors.affiliation: From the Departments of Radiology (M.T., S.C., L.L., M.E., P.R., S.L., O.N., J.-F.M., C.O.) and Neurology (G.T., P.S., J.-L.M., J.-C.B.), Université Paris Descartes Sorbonne Paris Cité, Centre de Psychiatrie et Neurosciences, INSERM S894, DHU Neurovasc, Centre Hospitalier Sainte-Anne, Paris, France.
authors.forename: Laurence
authors.initials: L
authors.lastname: Legrand
authors.affiliation: From the Departments of Radiology (M.T., S.C., L.L., M.E., P.R., S.L., O.N., J.-F.M., C.O.) and Neurology (G.T., P.S., J.-L.M., J.-C.B.), Université Paris Descartes Sorbonne Paris Cité, Centre de Psychiatrie et Neurosciences, INSERM S894, DHU Neurovasc, Centre Hospitalier Sainte-Anne, Paris, France.
authors.forename: Myriam
authors.initials: M
authors.lastname: Edjlali
authors.affiliation: From the Departments of Radiology (M.T., S.C., L.L., M.E., P.R., S.L., O.N., J.-F.M., C.O.) and Neurology (G.T., P.S., J.-L.M., J.-C.B.), Université Paris Descartes Sorbonne Paris Cité, Centre de Psychiatrie et Neurosciences, INSERM S894, DHU Neurovasc, Centre Hospitalier Sainte-Anne, Paris, France.
authors.forename: Pierre
authors.initials: P
authors.lastname: Seners
authors.affiliation: From the Departments of Radiology (M.T., S.C., L.L., M.E., P.R., S.L., O.N., J.-F.M., C.O.) and Neurology (G.T., P.S., J.-L.M., J.-C.B.), Université Paris Descartes Sorbonne Paris Cité, Centre de Psychiatrie et Neurosciences, INSERM S894, DHU Neurovasc, Centre Hospitalier Sainte-Anne, Paris, France.
authors.forename: Pauline
authors.initials: P
authors.lastname: Roca
authors.affiliation: From the Departments of Radiology (M.T., S.C., L.L., M.E., P.R., S.L., O.N., J.-F.M., C.O.) and Neurology (G.T., P.S., J.-L.M., J.-C.B.), Université Paris Descartes Sorbonne Paris Cité, Centre de Psychiatrie et Neurosciences, INSERM S894, DHU Neurovasc, Centre Hospitalier Sainte-Anne, Paris, France.
authors.forename: Stéphanie
authors.initials: S
authors.lastname: Lion
authors.affiliation: From the Departments of Radiology (M.T., S.C., L.L., M.E., P.R., S.L., O.N., J.-F.M., C.O.) and Neurology (G.T., P.S., J.-L.M., J.-C.B.), Université Paris Descartes Sorbonne Paris Cité, Centre de Psychiatrie et Neurosciences, INSERM S894, DHU Neurovasc, Centre Hospitalier Sainte-Anne, Paris, France.
authors.forename: Olivier
authors.initials: O
authors.lastname: Naggara
authors.affiliation: From the Departments of Radiology (M.T., S.C., L.L., M.E., P.R., S.L., O.N., J.-F.M., C.O.) and Neurology (G.T., P.S., J.-L.M., J.-C.B.), Université Paris Descartes Sorbonne Paris Cité, Centre de Psychiatrie et Neurosciences, INSERM S894, DHU Neurovasc, Centre Hospitalier Sainte-Anne, Paris, France.
authors.forename: Jean-Louis
authors.initials: JL
authors.lastname: Mas
authors.affiliation: From the Departments of Radiology (M.T., S.C., L.L., M.E., P.R., S.L., O.N., J.-F.M., C.O.) and Neurology (G.T., P.S., J.-L.M., J.-C.B.), Université Paris Descartes Sorbonne Paris Cité, Centre de Psychiatrie et Neurosciences, INSERM S894, DHU Neurovasc, Centre Hospitalier Sainte-Anne, Paris, France.
authors.forename: Jean-François
authors.initials: JF
authors.lastname: Méder
authors.affiliation: From the Departments of Radiology (M.T., S.C., L.L., M.E., P.R., S.L., O.N., J.-F.M., C.O.) and Neurology (G.T., P.S., J.-L.M., J.-C.B.), Université Paris Descartes Sorbonne Paris Cité, Centre de Psychiatrie et Neurosciences, INSERM S894, DHU Neurovasc, Centre Hospitalier Sainte-Anne, Paris, France.
authors.forename: Jean-Claude
authors.initials: JC
authors.lastname: Baron
authors.affiliation: From the Departments of Radiology (M.T., S.C., L.L., M.E., P.R., S.L., O.N., J.-F.M., C.O.) and Neurology (G.T., P.S., J.-L.M., J.-C.B.), Université Paris Descartes Sorbonne Paris Cité, Centre de Psychiatrie et Neurosciences, INSERM S894, DHU Neurovasc, Centre Hospitalier Sainte-Anne, Paris, France. c.oppenheim@ch-sainte-anne.fr.
authors.forename: Catherine
authors.initials: C
authors.lastname: Oppenheim
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001921:Brain / Q000473:pathology*; D002545:Brain Ischemia / Q000188:drug therapy / Q000473:pathology*; D005260:Female; D005343:Fibrinolytic Agents / Q000627:therapeutic use*; D006801:Humans; D008279:Magnetic Resonance Imaging; D008297:Male; D008875:Middle Aged; D011379:Prognosis; D020521:Stroke / Q000188:drug therapy / Q000473:pathology*; D015912:Thrombolytic Therapy; D010959:Tissue Plasminogen Activator / Q000627:therapeutic use*; D016896:Treatment Outcome
chemical_list: D005343:Fibrinolytic Agents; D010959:Tissue Plasminogen Activator
keywords: MRI; acute stroke; diffusion-weighted imaging; ischemia; thrombolysis