Perfusion/Diffusion Mismatch Is Valid and Should Be Used for Selecting Delayed Interventions
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REVIEW ARTICLE
Perfusion/Diffusion Mismatch Is Valid and Should Be Used for Selecting Delayed Interventions Stephen Davis & Bruce Campbell & Soren Christensen & Henry Ma & Patricia Desmond & Mark Parsons & Christopher Levi & Christopher Bladin & P. Alan Barber & Geoffrey Donnan
Received: 27 March 2012 / Accepted: 29 March 2012 / Published online: 18 April 2012 # Springer Science+Business Media, LLC 2012
Abstract The mismatch between a larger perfusion lesion and smaller diffusion lesion on magnetic resonance imaging is a validated signal of the ischemic penumbra, namely the region at risk in acute ischemic stroke that is critically hypoperfused and the target of reperfusion therapies. Clinical trials have shown strong correlations between reperfusion in mismatch patients and improved clinical outcomes. Attenuation of infarct growth is associated with reperfusion and corresponding clinical gains. Using computed S. Davis (*) : B. Campbell : S. Christensen : P. Desmond Department of Medicine, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Melbourne, Victoria, 3050, Australia e-mail: [email protected] S. Davis : B. Campbell : S. Christensen : P. Desmond Departments of Medicine and Radiology, Royal Melbourne Hospital, University of Melbourne, Parkville, Melbourne, Victoria, Australia H. Ma : G. Donnan Florey Neuroscience Institutes and University of Melbourne, Carlton South 3053, Australia C. Bladin Department of Neurosciences, Box Hill Hospital, Eastern Health, Monash University, Melbourne, Australia M. Parsons : C. Levi Priority Research Centre for Translational Neuroscience and Mental Health, University of Newcastle and Hunter Medical Research Institute, Newcastle, Australia P. A. Barber Centre for Brain Research, University of Auckland, Auckland, New Zealand
tomography perfusion, the mismatch between relative cerebral blood flow or cerebral blood volume and perfusion delay is a comparable penumbral marker. Automated techniques allow rapid quantitative assessment of mismatch with thresholding to exclude benign oligemia. The penumbra is often present beyond the current 4.5-h time window, defined for the use of intravenous tPA. Treatment beyond this time point remains investigational. Although the efficacy of thrombolysis in mismatch patients requires further validation in randomized trials, there is now sufficient evidence to recommend that advanced neuroimaging of mismatch should be used for selection of delayed therapies in phase 3 trials. Keywords MRI . Mismatch . Ischemic penumbra . Stroke . Therapy
Background Despite a plethora of clinical trials over several decades, there remains one licensed drug therapy for acute ischemic stroke, namely intravenous tissue plasminogen activator (tPA) [1]. This therapy is clinically proven, with a time window of 4.5 h, based on a series of phase 3 trials and meta-analyses [1, 2]. Currently, clinical guidelines for patients treated with IV tPA within 4.5 h use similar clinical eligibility to the initial NINDS trial in 1995, i
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