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BACKGROUND: Few studies with a limited number of patients focused on the outcomes of patients with diffusion-weighted imaging (DWI)-negative acute ischemic stroke (AIS) after intravenous thrombolysis (IVT) and/or endovascular treatment (EVT). METHODS: This retrospective observational, single-center study included all consecutive patients admitted for AIS involving the anterior circulation and treated with IVT and/or EVT between January 1, 2015 and December 31, 2023. The collected data were used to identify the characteristics of patients with negative DWI and to compare outcomes in patients with negative and positive DWI. RESULTS: Among the 1210 patients included, 47 (3.9%) had negative (DWI-negative group) and 1163 had increased DWI signal (DWI-positive group). In the DWI-negative group, the mean age was 69 years (SD=19.4), 55.3% were men, and 27 (57.4%) had a large vessel occlusion. Thirty eight (80.9%) were treated with IVT alone, 7 (14.9%) with EVT alone, and 2 (4.3%) with both. Fluid attenuated inversion recovery (FLAIR) sequences were the most sensitive to detect predictive factors of cerebral ischemia, such as vessel thrombosis and the spaghetti sign that were found in 68.1% and 83%, of patients, respectively. Oxyhemoglobin-sensitive (T2*) and susceptibility-weighted angiography (SWAN) sequences were less sensitive: vessel thrombosis and the brush sign were detected in 55.3% and 19.1% of patients, respectively. Comparison of the two DWI groups showed that M2 occlusion was more frequent (31.9% vs 13%, p<0.001) and M1 occlusion rarer (19.1% vs 36%, p<0.02) in the DWI-negative than DWI-positive group. At admission, the median National Institutes of Health Stroke Scale score was lower in the DWI-negative than DWI-positive group (2 vs 6, p=0.0001), but the median symptom onset-to-MRI time was similar in both groups (108 vs 111 min, p=0.88). CONCLUSIONS: In patients with DWI-negative AIS, symptoms are less severe. Large vessel occlusions, notably in the M2 segment, are more distal at the expense of the M1 segment of MCA. The spaghetti sign remains the most predictive feature of AIS that should be specifically searched in the absence of DWI lesions.
RESUMO
INTRODUCTION: Too few patients benefit from endovascular therapy (EVT) in large vessel occlusion acute stroke (LVOS), and various acute stroke care paradigms are currently investigated to reduce these inequalities in health access. We aimed to investigate whether newly set-up thrombectomy-capable stroke centers (TSC) offered a safe, effective and cost-effective procedure. PATIENTS AND METHODS: This French retrospective study compared the outcomes of LVOS patients with an indication for EVT and treated at the Perpignan hospital before on-site thrombectomy was available (Primary stroke center), and after formation of local radiology team for neurointervention (TSC). Primary endpoints were 3-months functional outcomes, assessed by the modified Rankin scale. Various safety endpoints for ischemic and hemorragic procedural complications were assessed. We conducted a medico-economic analysis to estimate the cost-benefit of becoming a TSC for the hospital. RESULTS: The differences between 422 patients in the PSC and 266 in the TSC were adjusted by the means of weighted logistic regression. Patients treated in the TSC had higher odds of excellent functional outcome (aOR 1.77 [1.16-2.72], p = 0.008), with no significant differences in the rates of procedural complications. The TSC setting shortened onset-to-reperfusion times by 144 min (95% CI [131-155]; p < 0.0001), and was cost-effective after 21 treated LVOS patients. On-site thrombectomy saves 10.825 per patient for the hospital. DISCUSSION: Our results demonstrate that the TSC setting improves functional outcomes and reduces intra-hospital costs in LVOS patients. TSCs could play a major public health role in acute stroke care and access to EVT.