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Research ArticleBRAIN

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

L. Legrand, M. Tisserand, G. Turc, O. Naggara, M. Edjlali, C. Mellerio, J.-L. Mas, J.-F. Méder, J.-C. Baron and C. Oppenheim
American Journal of Neuroradiology September 2014, DOI: https://doi.org/10.3174/ajnr.A4088
L. Legrand
From the Departments of Radiology (L.L., M.T., O.N., M.E., C.M., J.-F.M., C.O.) and Neurology (G.T., J.-L.M, J.-C.B.), Université Paris Descartes Sorbonne Paris Cité, Centre de Psychiatrie et Neurosciences, Institut National de la Santé et de la Recherche Médicale S894, Centre Hospitalier Sainte-Anne, Paris, France.
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M. Tisserand
From the Departments of Radiology (L.L., M.T., O.N., M.E., C.M., J.-F.M., C.O.) and Neurology (G.T., J.-L.M, J.-C.B.), Université Paris Descartes Sorbonne Paris Cité, Centre de Psychiatrie et Neurosciences, Institut National de la Santé et de la Recherche Médicale S894, Centre Hospitalier Sainte-Anne, Paris, France.
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G. Turc
From the Departments of Radiology (L.L., M.T., O.N., M.E., C.M., J.-F.M., C.O.) and Neurology (G.T., J.-L.M, J.-C.B.), Université Paris Descartes Sorbonne Paris Cité, Centre de Psychiatrie et Neurosciences, Institut National de la Santé et de la Recherche Médicale S894, Centre Hospitalier Sainte-Anne, Paris, France.
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O. Naggara
From the Departments of Radiology (L.L., M.T., O.N., M.E., C.M., J.-F.M., C.O.) and Neurology (G.T., J.-L.M, J.-C.B.), Université Paris Descartes Sorbonne Paris Cité, Centre de Psychiatrie et Neurosciences, Institut National de la Santé et de la Recherche Médicale S894, Centre Hospitalier Sainte-Anne, Paris, France.
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M. Edjlali
From the Departments of Radiology (L.L., M.T., O.N., M.E., C.M., J.-F.M., C.O.) and Neurology (G.T., J.-L.M, J.-C.B.), Université Paris Descartes Sorbonne Paris Cité, Centre de Psychiatrie et Neurosciences, Institut National de la Santé et de la Recherche Médicale S894, Centre Hospitalier Sainte-Anne, Paris, France.
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C. Mellerio
From the Departments of Radiology (L.L., M.T., O.N., M.E., C.M., J.-F.M., C.O.) and Neurology (G.T., J.-L.M, J.-C.B.), Université Paris Descartes Sorbonne Paris Cité, Centre de Psychiatrie et Neurosciences, Institut National de la Santé et de la Recherche Médicale S894, Centre Hospitalier Sainte-Anne, Paris, France.
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J.-L. Mas
From the Departments of Radiology (L.L., M.T., O.N., M.E., C.M., J.-F.M., C.O.) and Neurology (G.T., J.-L.M, J.-C.B.), Université Paris Descartes Sorbonne Paris Cité, Centre de Psychiatrie et Neurosciences, Institut National de la Santé et de la Recherche Médicale S894, Centre Hospitalier Sainte-Anne, Paris, France.
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J.-F. Méder
From the Departments of Radiology (L.L., M.T., O.N., M.E., C.M., J.-F.M., C.O.) and Neurology (G.T., J.-L.M, J.-C.B.), Université Paris Descartes Sorbonne Paris Cité, Centre de Psychiatrie et Neurosciences, Institut National de la Santé et de la Recherche Médicale S894, Centre Hospitalier Sainte-Anne, Paris, France.
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J.-C. Baron
From the Departments of Radiology (L.L., M.T., O.N., M.E., C.M., J.-F.M., C.O.) and Neurology (G.T., J.-L.M, J.-C.B.), Université Paris Descartes Sorbonne Paris Cité, Centre de Psychiatrie et Neurosciences, Institut National de la Santé et de la Recherche Médicale S894, Centre Hospitalier Sainte-Anne, Paris, France.
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C. Oppenheim
From the Departments of Radiology (L.L., M.T., O.N., M.E., C.M., J.-F.M., C.O.) and Neurology (G.T., J.-L.M, J.-C.B.), Université Paris Descartes Sorbonne Paris Cité, Centre de Psychiatrie et Neurosciences, Institut National de la Santé et de la Recherche Médicale S894, Centre Hospitalier Sainte-Anne, Paris, France.
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Abstract

BACKGROUND AND PURPOSE: In acute stroke with proximal artery occlusion, FLAIR vascular hyperintensities observed beyond the boundaries of the cortical lesion on DWI (newly defined “FLAIR vascular hyperintensity–DWI mismatch”) may be a marker of tissue at risk of infarction. Our aim was to compare the occurrence of FLAIR vascular hyperintensity–DWI mismatch relative to that of perfusion-weighted imaging–DWI mismatch in patients with proximal MCA occlusion before IV thrombolysis.

MATERIALS AND METHODS: In 141 consecutive patients with proximal MCA occlusion, 2 independent observers analyzed FLAIR images for the presence of FLAIR vascular hyperintensity–DWI mismatch before IV thrombolysis. PWI-DWI mismatch was defined as Volumehypoperfusion> 1.8 × VolumeDWI, with Volumehypoperfusion > 6 seconds on time to maximum value of the residue function maps in the 94 patients with available PWI. The presence of FLAIR vascular hyperintensity–DWI mismatch, PWI-DWI mismatch, and infarct growth on 24-hour follow-up DWI was compared.

RESULTS: A FLAIR vascular hyperintensity–DWI mismatch was present in 102/141 (72%) patients, with an excellent interobserver reliability (κ = 0.91), and a PWI-DWI mismatch, in 61 of the 94 (65%) patients with available PWI. FLAIR vascular hyperintensity–DWI mismatch predicted PWI-DWI mismatch with a sensitivity of 92% (95% CI, 85%–99%) and a specificity of 64% (95% CI, 47%–80%). Patients with FLAIR vascular hyperintensity–DWI mismatch had smaller initial DWI lesion and larger infarct growth (P < .001) than patients without FLAIR vascular hyperintensity–DWI mismatch, even though their final infarcts remained smaller (P < .001).

CONCLUSIONS: Albeit being moderately specific, probably due to inclusion of oligemic tissue, the FLAIR vascular hyperintensity–DWI mismatch identifies large PWI-DWI mismatch with high sensitivity.

Abbreviations

DWI1
pretreatment lesions on DWI
DWI2
follow-up lesions on DWI
FVH
FLAIR vascular hyperintensity
Tmax
time to maximum value of the residue function
  • © 2015 American Society of Neuroradiology
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Do FLAIR Vascular Hyperintensities beyond the DWI Lesion Represent the Ischemic Penumbra?
L. Legrand, M. Tisserand, G. Turc, O. Naggara, M. Edjlali, C. Mellerio, J.-L. Mas, J.-F. Méder, J.-C. Baron, C. Oppenheim
American Journal of Neuroradiology Sep 2014, DOI: 10.3174/ajnr.A4088

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Do FLAIR Vascular Hyperintensities beyond the DWI Lesion Represent the Ischemic Penumbra?
L. Legrand, M. Tisserand, G. Turc, O. Naggara, M. Edjlali, C. Mellerio, J.-L. Mas, J.-F. Méder, J.-C. Baron, C. Oppenheim
American Journal of Neuroradiology Sep 2014, DOI: 10.3174/ajnr.A4088
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