ReviewJournal of thrombosis and thrombolysis2026
DWI-FLAIR mismatch versus perfusion-based selection for extended window thrombolysis in acute ischemic stroke: a meta-analysis of randomized controlled trials.
Review in Journal of thrombosis and thrombolysis, 2026. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Not yet cited in PubMed.
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Abstract
To compare efficacy and safety outcomes of DWI-FLAIR mismatch versus CT/MR perfusion-based selection for intravenous thrombolysis (IVT) in extended-window acute ischemic stroke (AIS), we performed a systematic review and meta-analysis of randomized controlled trials enrolling adults with acute ischemic stroke treated with imaging-selected IVT beyond 4.5 h from last known well or with unknown onset. Trials using DWI-FLAIR mismatch or CT/MR perfusion selection were included. Outcomes were excellent functional outcome, functional independence, symptomatic intracranial hemorrhage (sICH), parenchymal hematoma, major bleeding, and mortality. Random-effects pairwise meta-analysis and Bucher-type indirect comparison were performed. Eight randomized trials including 2,546 patients were analyzed. Compared with best medical treatment, IVT improved excellent functional outcome (mRS 0-1: RR 1.27, 95% CI 1.14-1.40) and functional independence (mRS 0-2: RR 1.15, 95% CI 1.07-1.23), but increased sICH (RR 5.21, 95% CI 2.25-12.04). In imaging-stratified analyses, functional outcome RRs favored IVT in both perfusion-based and DWI-FLAIR mismatch-selected trials, with wider confidence intervals in the DWI-FLAIR subgroup. Hemorrhagic risk was increased with intravenous thrombolysis in both imaging subgroups, but subgroup interaction testing and a Bucher-type indirect comparison did not detect a statistically significant between-paradigm difference; the indirect comparison re-expresses the subgroup contrast rather than adding independent evidence. In AIS patients not planned for routine endovascular therapy, imaging-selected IVT beyond 4.5 h was associated with improved functional outcomes but increased sICH risk. No definitive superiority or equivalence was established between imaging strategies; imaging choice should be guided by clinical context, time window, EVT eligibility, local workflow, and patient-level factors.
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