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The impact of FLAIR vascular hyperintensity on clinical severity and outcome

A retrospective study in stroke patients with proximal middle cerebral artery stenosis or occlusion

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Abstract

Background

The clinical significance of fluid-attenuated inversion recovery vascular hyperintensity (FVH) has not been clarified. The aim of this study was to clarify the effects of FVH on the clinical severity and long-term prognosis of patients with proximal middle cerebral artery (MCA) occlusion or severe stenosis.

Method

Because their clinical and imaging data is not accessible, we excluded the patients being treated with IV thrombolysis or mechanical thrombectomy. Clinical and imaging characteristics were documented in 282 consecutive AIS patients with proximal MCA occlusion or severe stenosis. We assessed clinical severity using the National Institutes of Health Stroke Scale (NIHSS) score and clinical outcomes using mRS scores. The average time interval between symptom onset and imaging was 16–18 h. The FVH score according to FVH-ASPECTS ranged from 0 to 7, based on the numbers of territories where FVH is positive.

Results

FVH was observed in 235 (83.33%) of the AIS patients. The FVH(+) group tended to have more alcoholics (65 [27.66%] vs 6 [12.77%], P = 0.032), a higher NIHSS score on the 7th day (3 [1–6] vs 2 [1–3], P = 0.039), more instances of early neurological deterioration (END) (27 [11.4%] vs 1 [2.12%], P = 0.05), and more patients with MCA occlusion (94 [40.00%] vs 3 [6.38%]). Among the patients with positive FVH, a high FVH score represented severe clinical impairment (higher NIHSS score on admission [P = 0.009] and 7th day since admission [P = 0.02]) and poor clinical outcomes. Spearman’s rank correlations showed that FVH scores were positively correlated with NIHSS scores on admission and NIHSS scores on the 7th day (P = 0.039; P = 0.017, respectively).

Conclusion

In patients with proximal middle cerebral artery (MCA) occlusion or stenosis ≥ 70%, a high FVH score represented severe clinical impairment and poor clinical outcomes. In acute ischemic stroke (AIS) patients with proximal MCA occlusion, a high FVH score represented favorable clinical outcomes.

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References

  1. Cosnard G, Duprez T, Grandin C et al (1999) Fast flair sequence for detecting major vascular abnormalities during the hyperacute phase of stroke: a comparison with mr angiography. Neuroradiology, 41(5):342–346.

  2. Ahn SJ, Lee KY, Ahn SS, Suh H, Kim BS, Lee SK (2016) Can FLAIR hyperintense vessel (FHV) signs be influenced by varying MR parameters and flow velocities? A flow phantom analysis. Acta Radiol 57(5):580–586

    Article  Google Scholar 

  3. Azizyan A, Sanossian N, Mogensen MA, Liebeskind DS (2011) Fluid-attenuated inversion recovery vascular hyperintensities: an important imaging marker for cerebrovascular disease. AJNR Am J Neuroradiol 32(10):1771–1775

    Article  CAS  Google Scholar 

  4. Lee KY, Latour LL, Luby M et al (2009) Distal hyperintense vessels on FLAIR: an MRI marker for collateral circulation in acute stroke?. Neurology 72(13):1134–1139

  5. Huang X, Liu W, Zhu W et al (2012) Distal hyperintense vessels on FLAIR: a prognostic indicator of acute ischemic stroke. Eur Neurol 68(4):214–220

    Article  Google Scholar 

  6. Girot M, Gauvrit J-Y, Cordonnier C et al (2007) Prognostic value of hyperintense vessel signals on fluid-attenuated inversion recovery sequences in acute cerebral ischemia. Eur Neurol 57(2):75–79

    Article  Google Scholar 

  7. Hohenhaus M, Schmidt WU, Brunecker P et al (2012) FLAIR vascular hyperintensities in acute ICA and MCA infarction: a marker for mismatch and stroke severity? Cerebrovasc Dis 34(1):63–69

    Article  CAS  Google Scholar 

  8. Aoki J, Suzuki K, Suda S, Okubo S, Mishina M, Kimura K (2020) Negative-FLAIR vascular hyperintensities serve as a marker of no recanalization during hospitalization in acute stroke. J Clin Neurosci 72:233–237

    Article  Google Scholar 

  9. Cheng B, Ebinger M, Kufner A et al (2012) Hyperintense vessels on acute stroke fluid-attenuated inversion recovery imaging. Stroke. 43(11):2957–2961

    Article  Google Scholar 

  10. Samuels OB, Joseph GJ, Lynn MJ et al (2000) A standardized method for measuring intracranial arterial stenosis. AJNR Am J Neuroradiol 21(4):643–646

    CAS  PubMed  Google Scholar 

  11. Lee SH, Seo KD, Kim JH, Suh SH, Ahn SJ, Lee K-Y (2016) Correlation between hyperintense vessels on FLAIR imaging and arterial circulation time on cerebral angiography. Magn Reson Med Sci 15(1):105–110

    Article  Google Scholar 

  12. Wang Y, Zhou Z, Ding S (2020) FLAIR vascular hyperintensity-DWI mismatch most likely to benefit from recanalization and good outcome after stroke. Medicine (Baltimore) 99(2):e18665

    Article  Google Scholar 

  13. Jiang L, Peng M, Geng W, et al. (2019) FLAIR hyperintensities-DWI mismatch in acute stroke: associations with DWI volume and functional outcome. Brain Imaging Behav

  14. Fazekas F, Chawluk J, Alavi A et al (1987) MR signal abnormalities at 1.5 T in Alzheimer’s dementia and normal aging. Am J Roentgenol 149(2):351–356

    Article  CAS  Google Scholar 

  15. Assouline E, Benziane K, Reizine D et al (2005) Intra-arterial thrombus visualized on T2* gradient echo imaging in acute ischemic stroke. Cerebrovascular Diseases 20(1):6–11.

  16.  Flacke S, Urbach H, Keller E et al (2000). Middle cerebral artery (MCA) susceptibility sign at susceptibility-based perfusion MR imaging: clinical importance and comparison with hyperdense MCA sign at CT. Radiology 215(2):476–482.

  17. Schellinger PD, Chalela JA, Kang DW et al (2005) Diagnostic and prognostic value of early MR imaging vessel signs in hyperacute stroke patients imaged <3 hours and treated with recombinant tissue plasminogen activator. AJNR Am J Neuroradiol 26(3):618–624

    PubMed  Google Scholar 

  18. Kamran S, Bates V, Bakshi R et al (2001) Significance of hyperintense vessels on FLAIR MRI in acute stroke. Neurology 56(9):1248–1249

    Article  Google Scholar 

  19. Essig M, Kummer RV, Egelhof T et al (1996) Vascular MR contrast enhancement in cerebrovascular disease. Ajnr American Journal of Neuroradiology 17(5):887–94

  20. Maeda M, Yamamoto T, Daimon S et al (2001) Arterial hyperintensity on fast fluid-attenuated inversion recovery images: a subtle finding for hyperacute stroke undetected by diffusion-weighted MR imaging. AJNR Am J Neuroradiol 22(4):632–636

    CAS  PubMed  Google Scholar 

  21. Ding B, Chen Y, Jiang H et al (2020) Fluid-Attenuated Inversion Recovery Vascular Hyperintensities in Transient Ischemic Attack within the Anterior Circulation. Biomed Res Int. 2020:7056056. Published 2020 Feb 18. 

  22. Sanossian N, Saver JL, Alger JR et al (2009) Angiography reveals that fluid-attenuated inversion recovery vascular hyperintensities are due to slow flow, Not thrombus. Am J Neuroradiol 30(3):564–568

    Article  CAS  Google Scholar 

  23. Jiang L, Chen YC, Zhang H et al (2019) FLAIR vascular hyperintensity in acute stroke is associated with collateralization and functional outcome. Eur Radiol 29(9):4879–4888

    Article  Google Scholar 

  24. Thomalla G, Cheng B, Ebinger M et al (2011) DWI-FLAIR mismatch for the identification of patients with acute ischaemic stroke within 4.5 h of symptom onset (PRE-FLAIR): a multicentre observational study. Lancet Neurol 10(11):978–986.

  25. Dong X, Nao J (2019) Fluid-attenuated inversion recovery vascular hyperintensities in anterior circulation acute ischemic stroke: associations with cortical brain infarct volume and 90-day prognosis. Neurol Sci 40(8):1675–1682

    Article  Google Scholar 

  26. Olindo S, Chausson N, Joux J et al (2012) Fluid-attenuated inversion recovery vascular hyperintensity: an early predictor of clinical outcome in proximal middle cerebral artery occlusion. Arch Neurol 69(11):1462–1468

  27. Shang WJ, Shu LM, Zhou X, et al (2020) Association of FLAIR vascular hyperintensity and acute MCA stroke outcome changes with the severity of leukoaraiosis [published online ahead of print, 2020 May 6]. Neurol Sci.

  28. Gawlitza M, Gragert J, Quäschling U et al (2014) FLAIR-hyperintense vessel sign, diffusion-perfusion mismatch and infarct growth in acute ischemic stroke without vascular recanalisation therapy. J Neuroradiol 41(4):227–233. 

  29. Pérez de la Ossa N, Hernández-Pérez M, Domènech S et al (2012) Hyperintensity of distal vessels on FLAIR is associated with slow progression of the infarction in acute ischemic stroke. Cerebrovasc Dis 34(5–6):376–384

    Article  Google Scholar 

  30. Nam KW, Kwon HM, Park SW, Lim JS, Han MK, Lee YS (2017) Distal hyperintense vessel sign is associated with neurological deterioration in acute ischaemic stroke. Eur J Neurol 24(4):617–623

    Article  Google Scholar 

  31. Kobayashi J, Uehara T, Toyoda K et al (2013) Clinical significance of fluid-attenuated inversion recovery vascular hyperintensities in transient ischemic attack. Stroke. 44(6):1635–1640

    Article  CAS  Google Scholar 

  32. Inatomi Y, Yonehara T, Hashimoto Y et al (2008) Occlusive vessel signs on MRI as only findings of hyperacute ischemic stroke. J Neurol Sci 268(1–2):187–189. 

  33. Zhou SB, Zhang XM, Gao Y, Yang B, Shen WR (2019) Diffusion-weighted imaging volume and diffusion-weighted imaging volume growth in acute stroke: associations with fluid-attenuated inversion recovery hyperintensities-diffusion-weighted imaging mismatch and functional outcome. Neuroreport. 30(13):875–881

    Article  Google Scholar 

  34. Jiang L, Peng M, Chen H et al (2020) Diffusion-weighted imaging (DWI) ischemic volume is related to FLAIR hyperintensity-DWI mismatch and functional outcome after endovascular therapy. Quant Imaging Med Surg 10(2):356–367

    Article  Google Scholar 

  35. Song L, Lyu C, Shen G et al (2019) Application of FLAIR vascular hyperintensity-DWI mismatch in ischemic stroke depending on semi-quantitative DWI-Alberta Stroke Program Early CT Score. Front Neurol 10:994

    Article  Google Scholar 

  36. Yuan T, Ren G, Hu X et al (2019) Added assessment of middle cerebral artery and atrial fibrillation to FLAIR vascular hyperintensity-DWI mismatch would improve the outcome prediction of acute infarction in patients with acute internal carotid artery occlusion. Neurol Sci 40(12):2617–2624

    Article  Google Scholar 

  37. Legrand L, Turc G, Edjlali M et al (2019) Benefit from revascularization after thrombectomy according to FLAIR vascular hyperintensities-DWI mismatch. Eur Radiol 29(10):5567–5576

    Article  Google Scholar 

  38. Abdel Razek AA, Alvarez H, Bagg S, Refaat S, Castillo M (2014) Imaging spectrum of CNS vasculitis. Radiographics 34:873–894

    Article  Google Scholar 

  39. Abdelrasoul AA, Elsebaie NA, Gamaleldin OA, Khalifa MH, Razek AAKA (2019) Imaging of brain infarctions. J Comput Assist Tomogr 43(3):443–451

    Article  Google Scholar 

  40. Abdel Razek AAK, Talaat M, El-Serougy L, Gaballa G, Abdelsalam M (2019) Clinical applications of arterial spin labeling in brain tumors. J Comput Assist Tomogr 43:525–532

    Article  Google Scholar 

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Authors and Affiliations

  1. Department of Neurology, Shengjing Hospital of China Medical University, Shenyang, China

    Guangshuo Li, Rui Huang & Guorong Bi

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  1. Guangshuo Li
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  2. Rui Huang
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Li, G., Huang, R. & Bi, G. The impact of FLAIR vascular hyperintensity on clinical severity and outcome. Neurol Sci 42, 589–598 (2021). https://doi.org/10.1007/s10072-020-04513-3

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