Quantitative Signal Intensity in Fluid-Attenuated Inversion Recovery and Treatment Effect in the WAKE-UP Trial

Research output: Contribution to journalJournal articleResearchpeer-review

  • Bastian Cheng
  • Florent Boutitie
  • Alina Nickel
  • Anke Wouters
  • Tae-Hee Cho
  • Martin Ebinger
  • Matthias Endres
  • Jochen B Fiebach
  • Jens Fiehler
  • Ivana Galinovic
  • Josep Puig
  • Vincent Thijs
  • Robin Lemmens
  • Keith W Muir
  • Norbert Nighoghossian
  • Salvador Pedraza
  • Claus Z Simonsen
  • Christian Gerloff
  • Götz Thomalla
  • WAKE-UP (Efficacy and Safety of MRI-Based Thrombolysis inWake-Up Stroke Trial) investigators and administrative staff are as follows:
  • Götz Thomalla
  • Christian Gerloff
  • Amir Golsari
  • Marstrand, Jacob Rørbech
  • Karen Lehrmann Ægidius
  • Meden, Per
  • Iversen, Helle Klingenberg
  • David Gorriz
  • Stefan Oberndorfer
  • Elisabeth Prohaska

Background and Purpose- Relative signal intensity of acute ischemic stroke lesions in fluid-attenuated inversion recovery (fluid-attenuated inversion recovery relative signal intensity [FLAIR-rSI]) magnetic resonance imaging is associated with time elapsed since stroke onset with higher intensities signifying longer time intervals. In the randomized controlled WAKE-UP trial (Efficacy and Safety of MRI-Based Thrombolysis in Wake-Up Stroke Trial), intravenous alteplase was effective in patients with unknown onset stroke selected by visual assessment of diffusion weighted imaging fluid-attenuated inversion recovery mismatch, that is, in those with no marked fluid-attenuated inversion recovery hyperintensity in the region of the acute diffusion weighted imaging lesion. In this post hoc analysis, we investigated whether quantitatively measured FLAIR-rSI modifies treatment effect of intravenous alteplase. Methods- FLAIR-rSI of stroke lesions was measured relative to signal intensity in a mirrored region in the contralesional hemisphere. The relationship between FLAIR-rSI and treatment effect on functional outcome assessed by the modified Rankin Scale (mRS) after 90 days was analyzed by binary logistic regression using different end points, that is, favorable outcome defined as mRS score of 0 to 1, independent outcome defined as mRS score of 0 to 2, ordinal analysis of mRS scores (shift analysis). All models were adjusted for National Institutes of Health Stroke Scale at symptom onset and stroke lesion volume. Results- FLAIR-rSI was successfully quantified in stroke lesions in 433 patients (86% of 503 patients included in WAKE-UP). Mean FLAIR-rSI was 1.06 (SD, 0.09). Interaction of FLAIR-rSI and treatment effect was not significant for mRS score of 0 to 1 (P=0.169) and shift analysis (P=0.086) but reached significance for mRS score of 0 to 2 (P=0.004). We observed a smooth continuing trend of decreasing treatment effects in relation to clinical end points with increasing FLAIR-rSI. Conclusions- In patients in whom no marked parenchymal fluid-attenuated inversion recovery hyperintensity was detected by visual judgement in the WAKE-UP trial, higher FLAIR-rSI of diffusion weighted imaging lesions was associated with decreased treatment effects of intravenous thrombolysis. This parallels the known association of treatment effect and elapsing time of stroke onset.

Original languageEnglish
Issue number1
Pages (from-to)209-215
Publication statusPublished - 2020

    Research areas

  • Acute Disease, Aged, Brain Ischemia/diagnostic imaging, Diffusion Magnetic Resonance Imaging, Double-Blind Method, Female, Humans, Male, Middle Aged, Stroke/diagnostic imaging, Thrombolytic Therapy, Tissue Plasminogen Activator/therapeutic use

ID: 257198131