Malik M Adil1, Marie Luby2, John K Lynch3, Amie W Hsia4, Chandni P Kalaria5, Zurab Nadareishvili6, Lawrence L Latour7, Richard Leigh8. 1. National Institute of Neurological Disorders and Stroke, National Institutes of Health, Building 10, B1D733 MSC 1063, 10 Center Drive, Bethesda, United States; Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, United States. 2. National Institute of Neurological Disorders and Stroke, National Institutes of Health, Building 10, B1D733 MSC 1063, 10 Center Drive, Bethesda, United States. Electronic address: lubym@ninds.nih.gov. 3. National Institute of Neurological Disorders and Stroke, National Institutes of Health, Building 10, B1D733 MSC 1063, 10 Center Drive, Bethesda, United States. Electronic address: lynchj@ninds.nih.gov. 4. National Institute of Neurological Disorders and Stroke, National Institutes of Health, Building 10, B1D733 MSC 1063, 10 Center Drive, Bethesda, United States; MedStar Washington Hospital Center, Washington, DC, United States. Electronic address: hsiaa@ninds.nih.gov. 5. National Institute of Neurological Disorders and Stroke, National Institutes of Health, Building 10, B1D733 MSC 1063, 10 Center Drive, Bethesda, United States; MedStar Washington Hospital Center, Washington, DC, United States. Electronic address: Chandni.P.Kalaria@medstar.net. 6. National Institute of Neurological Disorders and Stroke, National Institutes of Health, Building 10, B1D733 MSC 1063, 10 Center Drive, Bethesda, United States; Department of Neurology, The George Washington University School of Medicine and Health Sciences, Washington, DC, United States. 7. National Institute of Neurological Disorders and Stroke, National Institutes of Health, Building 10, B1D733 MSC 1063, 10 Center Drive, Bethesda, United States. Electronic address: LatourL@ninds.nih.gov. 8. National Institute of Neurological Disorders and Stroke, National Institutes of Health, Building 10, B1D733 MSC 1063, 10 Center Drive, Bethesda, United States; Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, United States. Electronic address: richard.leigh@nih.gov.
Abstract
BACKGROUND: Treatment of FLAIR-negative stroke in patients presenting in an unknown time window has been shown to be safe and effective. However, implementation can be challenging due to the need for hyper-acute MRI screening. The purpose of this study was to review the routine application of this practice outside of a clinical trial. METHODS: Patients presenting from 3/1/16 to 8/22/18 in a time window <4.5 h from symptom discovery but >4.5 h from last known normal were included if they had a hyper-acute MRI performed. Quantitative assessment based on the MR WITNESS trial and qualitative assessment based on the WAKE-UP trial were used to grade the FLAIR images. The MR WITNESS trial used a quantitative assessment of FLAIR change where the fractional increase in signal change had to be <1.15, whereas the WAKE-UP trial used a visual assessment requiring the absence of marked FLAIR signal changes. RESULTS: During the study period, 136 stroke patients presented and were imaged in the specified time window. Of these, 17 (12.5%) received IV tPA. Three patients had hemorrhage on 24-h MRI follow up; none had an increase in NIHSS ≥4. Of the 119 patients who were screened but not treated, 18 (15%) were eligible based on FLAIR quantitative assessment and 55 (46%) were eligible based on qualitative assessment. In all cases where patients were not treated, there was an identifiable exclusion based on trial criteria. During the study period, IV tPA utilization was increased by 5.6% due to screening and treating patients with unknown onset stroke. CONCLUSIONS: Screening stroke patients in an unknown time window with MRI is practical in a real-world setting and increases IV tPA utilization. Published by Elsevier Inc.
BACKGROUND: Treatment of FLAIR-negative stroke in patients presenting in an unknown time window has been shown to be safe and effective. However, implementation can be challenging due to the need for hyper-acute MRI screening. The purpose of this study was to review the routine application of this practice outside of a clinical trial. METHODS: Patients presenting from 3/1/16 to 8/22/18 in a time window <4.5 h from symptom discovery but >4.5 h from last known normal were included if they had a hyper-acute MRI performed. Quantitative assessment based on the MR WITNESS trial and qualitative assessment based on the WAKE-UP trial were used to grade the FLAIR images. The MR WITNESS trial used a quantitative assessment of FLAIR change where the fractional increase in signal change had to be <1.15, whereas the WAKE-UP trial used a visual assessment requiring the absence of marked FLAIR signal changes. RESULTS: During the study period, 136 stroke patients presented and were imaged in the specified time window. Of these, 17 (12.5%) received IV tPA. Three patients had hemorrhage on 24-h MRI follow up; none had an increase in NIHSS ≥4. Of the 119 patients who were screened but not treated, 18 (15%) were eligible based on FLAIR quantitative assessment and 55 (46%) were eligible based on qualitative assessment. In all cases where patients were not treated, there was an identifiable exclusion based on trial criteria. During the study period, IV tPA utilization was increased by 5.6% due to screening and treating patients with unknown onset stroke. CONCLUSIONS: Screening stroke patients in an unknown time window with MRI is practical in a real-world setting and increases IV tPA utilization. Published by Elsevier Inc.
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