Research tagged [radiology]

DWI-FLAIR Mismatch and Large Vessel Occlusion in Wake-Up Stroke: A Synthesis of Expert Opinion and Evidence from a Clinical Case Discussion

Background: Wake-up stroke (WUS) presents a significant challenge in acute ischemic stroke management due to unknown symptom onset time, complicating eligibility for time-sensitive reperfusion therapies. Imaging-based selection, particularly diffusion-weighted imaging (DWI) and fluid-attenuated inversion recovery (FLAIR) mismatch, has expanded treatment windows for intravenous thrombolysis (IVT), while advanced perfusion imaging guides mechanical thrombectomy (MT) in large vessel occlusion (LVO). This paper synthesizes expert clinical decision-making in a complex WUS case with DWI-FLAIR mismatch and LVO, integrating current evidence. Methods: This academic paper formalizes a clinical Q&A discussion from the tachyDx platform, involving two verified stroke neurologists and receiving 96 community peer votes. The discussion centered on a 67-year-old female with WUS, left hemiplegia, NIHSS 14, right M1 occlusion, DWI-FLAIR mismatch, and a large penumbra on CT perfusion. Results: Both experts advocated for immediate bridging IVT followed by MT. Divergence arose in IVT dosing: one expert recommended standard 0.9 mg/kg alteplase, citing potential for maximum thrombolytic effect in LVO, while the other preferred 0.6 mg/kg, aligning with regional protocols and improved safety profiles. Both acknowledged the role of good collaterals in delaying FLAIR changes, supporting the validity of the DWI-FLAIR mismatch. The patient achieved TICI 2c reperfusion and significant neurological improvement. Conclusions: This case highlights the evolving consensus on aggressive reperfusion strategies for WUS with favorable imaging. It underscores the ongoing debate regarding optimal IVT dosing in the context of bridging therapy for LVO, emphasizing the need for individualized treatment guided by comprehensive imaging and patient-specific factors.