Do FLAIR Vascular Hyperintensities beyond the DWI Lesion Represent the Ischemic Penumbra?

Legrand, Laurence; Tisserand, Marie; Turc, Guillaume; Naggara, Olivier; Edjlali, Myriam; Mellerio, Charles; Mas, Jean‐Louis; Méder, Jean-François; Baron, Jean‐Claude; Oppenheim, Catherine

doi:10.3174/ajnr.a4088

Cited by 64 publications

(82 citation statements)

References 22 publications

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“…One hundred and sixty-four patients (85 men) met the inclusion criteria (median [interquartile range] age 72 years , admission National Institutes of Health Stroke Scale score 17 [12][13][14][15][16][17][18][19][20][21], and 3-month modified Rankin Scale 3 [1][2][3][4][5] …”

Section: Resultsmentioning

confidence: 99%

“…2,18 PWI was included in the pretreament magnetic resonance whenever feasible with no delay, but was not part of follow-up magnetic resonance. FVH were defined as focal, tubular, or serpentine hyperintensities in the subarachnoid space relative to cerebrospinal fluid 3 and corresponding to typical arterial course.…”

Section: Methodsmentioning

confidence: 99%

“…We have recently proposed an alternative model based on the mismatch between fluidattenuated inversion recovery (FLAIR) vascular hyperintensities (FVH) and DWI to assess the presence of large penumbra. 2 FVH have been reported in 45-100% of stroke patients with intracranial occlusion. [3][4][5][6][7][8][9][10][11][12][13][14][15][16] They represent slow retrograde flow in leptomeningeal collaterals, 4 which maintain some perfusion distal to the occlusion until revascularization.…”

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confidence: 99%

“…Rapidly assessable with the naked eye, this model is simple and reproducible and predicts large PWI-DWI mismatch with excellent sensitivity. 2 We hypothesized that complete recanalization after intravenous tissue-type plasminogen activator would be associated with better outcome in patients with, as compared to those without, FVH-DWI mismatch.…”

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confidence: 99%

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Fluid-Attenuated Inversion Recovery Vascular Hyperintensities–Diffusion-Weighted Imaging Mismatch Identifies Acute Stroke Patients Most Likely to Benefit From Recanalization

Legrand

Tisserand

Turc

et al. 2016

Stroke

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Background and Purpose-Fluid-attenuated inversion recovery vascular hyperintensities (FVH) beyond the boundaries of diffusion-weighted imaging (DWI) lesion (FVH-DWI mismatch) have been proposed as an alternative to perfusionweighted imaging (PWI)-DWI mismatch. We aimed to establish whether FVH-DWI mismatch can identify patients most likely to benefit from recanalization. Methods-FVH-DWI mismatch was assessed in 164 patients with proximal middle cerebral artery occlusion before intravenous thrombolysis. PWI-DWI mismatch (PWI Tmax>6sec /DWI>1.8) was assessed in the 104 patients with available PWI data. We tested the associations between 24-hours complete recanalization on magnetic resonance angiography and 3-month favorable outcome (modified Rankin Scale score ≤2), stratified on FVH-DWI (or PWI-DWI) status. Results-FVH-DWI mismatch was present in 121/164 (74%) patients and recanalization in 50/164 (30%) patients. The odds ratio for favorable outcome with recanalization was 16.2 (95% confidence interval, 5.7-46.5; P<0.0001) in patients with FVH-DWI mismatch and 2.6 (95% confidence interval, 0.6-12.1; P=0.22) in those without FVH-DWI mismatch (P=0.048 for interaction). Recanalization was associated with favorable outcome in patients with PWI-DWI mismatch (odds ratios, 9.9; 95% confidence interval, 3.1-31.3; P=0.0001) and in patients without PWI-DWI mismatch (odds ratios, 7.0; 95% confidence interval, 1.1-44.1; P=0.047), P=0.76 for interaction. Conclusion-The FVH-DWI mismatch may rapidly identify patients with proximal occlusion most likely to benefit from recanalization.

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Section: Resultsmentioning

confidence: 99%

Section: Methodsmentioning

confidence: 99%

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confidence: 99%

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confidence: 99%

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Fluid-Attenuated Inversion Recovery Vascular Hyperintensities–Diffusion-Weighted Imaging Mismatch Identifies Acute Stroke Patients Most Likely to Benefit From Recanalization

Legrand

Tisserand

Turc

et al. 2016

Stroke

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“…7,8 A recent study described DWI-FLAIR mismatch as a potential parameter to consider in stroke selection, but its relevancy and validity are still to be evaluated and proved. 9 CT with all its advantages of being quick, easy to interpret, and widely available produces much less valuable information for acute stroke diagnosis than MR imaging at any stage of stroke onset. Except for imaging time, there is no major advantage of CT over MR imaging.…”

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confidence: 99%

MRI of Acute Stroke: What Went Wrong?

Lövblad¹,

Pereira²

2015

AJNR Am J Neuroradiol

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The news of the recently published trials about the efficacy of intra-arterial interventions for stroke lifted the spirits of all neuroradiologists and the vascular neurology community. [1][2][3][4] Finally, these trials proved our personal experience: Effective early reperfusion of proximal occlusions can save brain parenchyma and improve patient outcomes. Studies were focused on patient selection and fast-treatment workflow to perform interventions as early as possible. In most hospitals, the preferred imaging technique to select patients is CT with CTA and/or CT perfusion, based more on local logistics than on imaging quality or predefined standards. While we are no longer in the era of the early stroke trials, in which imaging with negative findings (ie, CT without hemorrhage) was the indicator for thrombolysis, we are still early in the use of advanced imaging in acute stroke interventions. It seems that just by identifying proximal occlusions, we have improved the selection of patients despite the limitations of CT to demonstrate early definitive lesions in acute stroke. While CT has made great strides in recent years, with perfusion, dual-energy, and other techniques improving and becoming a clear standard, MR imaging techniques seem to have "lost it," at least, in acute stroke.Despite the potential of MR imaging, such as the extreme sensitivity of diffusion techniques, 5,6 its capacity to image the whole brain, and a whole armamentarium of techniques (FLAIR, SWI, MRA, perfusion, and so forth), this potential did not convince most centers to invest in or adapt their workflow to the use of MR imaging over CT. CT evaluation criteria and scores for acute stroke are undisputed. However, their assessment requires experience and can vary considerably among operators. MR imaging is vastly superior in delineating lesion extent, making the differential diagnosis of other conditions, measuring the clot length, and detecting potential "risky" lesions like microbleeds. DWI with or without FLAIR can still demonstrate an early ischemic lesion much better than CT.So, what went wrong with MR imaging in stroke? In the era of the new-generation devices and early and effective reperfusion, has the clear identification of the stroke core lost its importance? One opinion is that use of MR imaging in an emergency setting disturbs the workflow, inhibiting effective treatment. Others might say that without a clear benefit from MR imaging, it is not worth the sacrifice in time to get better image quality. Recent studies have revolutionized the field of acute stroke treatment, but a significant proportion of patients have inadequate reperfusion.1-4 How can we reduce or eliminate the inadequate reperfusion? Can MR imaging-based patient selection be a solution in addition to the improvement of health care systems, prehospital transportation, societal awareness, and hospital workflow improvements?We think that MR imaging can add more information on patient selection for acute stroke and should be the ultimate goal for acute stroke tr...

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