Published Online
on May 10, 2007

A more recent version of this article appeared on June 1, 2007

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Submitted on December 12, 2006
Accepted on January 6, 2007

Evaluation of the Clinical-Diffusion and Perfusion-Diffusion Mismatch Models in DEFUSE

Maarten G. Lansberg MD, PhD^*; Vincent N. Thijs MD, PhD; Scott Hamilton PhD; Gottfried Schlaug MD; Roland Bammer PhD; Stephanie Kemp BS; Gregory W. Albers MD; on behalf of the DEFUSE Investigators

From Stanford Stroke Center, Stanford University Medical Center, Palo Alto, Calif (M.G.L., S.H., R.B., S.K., G.W.A.); Department of Neurology, University Hospitals of Leuven, Belgium (V.N.T.); Department of Neurology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston Mass (G.S.).

^* To whom correspondence should be addressed. E-mail: Lansberg{at}stanford.edu.

Background and Purpose--The perfusion-diffusion mismatch (PDM) model has been proposed as a tool to select acute stroke patients who are most likely to benefit from reperfusion therapy. The clinical-diffusion mismatch (CDM) model is an alternative method that is technically less challenging because it does not require perfusion-weighted imaging. This study is an evaluation of these 2 models in the DEFUSE dataset.

Methods--DEFUSE is an open-label multicenter study in which acute stroke patients were treated with intravenous tPA between 3 and 6 hours after symptoms onset and an MRI was obtained before and 3 to 6 hours after treatment. Presence of PDM and CDM was determined for each patient.

Results--Based on conventional predefined mismatch criteria, PDM was present in 54% of the DEFUSE population and CDM in 62%. There was no agreement beyond chance between the 2 mismatch models (kappa 0.07). The presence of PDM was associated with an increased chance of favorable clinical response after reperfusion (OR, 5.4; P=0.039). Reperfusion was not associated with a significant increase in the rate of favorable clinical response in patients with CDM (OR, 2.2; P=0.34). Using optimized mismatch criteria, determined retrospectively based on DEFUSE data, the OR for favorable clinical response was 70 (P=0.001) for PDM and 5.1 (P=0.066) for CDM.

Conclusion--The PDM model appears to be more accurate than the CDM model for selecting patients who are likely to benefit from reperfusion therapy in the 3- to 6-hour time window.

Key words: acute treatment • diffusion-weighted MRI • ischemic stroke • outcome • plasminogen activator • perfusion-weighted MRI • reperfusion

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Mismatch and Defuse: Harvesting the Riches of Multicenter Neuroimaging-Based Stroke Studies

Chelsea S. Kidwell and Steven Warach
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