Collateral circulation assessment within the 4.5 h time window in patients with and without DWI/FLAIR MRI mismatch

The aim of the present study was to assess the association between collateral status and DWI-FLAIR mismatch in patients with acute ischemic stroke within the 4.5 h time-window.

We analysed DWI, FLAIR, and PWI data in patients within 4.5 h after symptom onset from the I-KNOW European database. Collateral flow maps were graded by analyzing contrast 'staining' extent over the early, mid and late perfusion phases. ADC values, DWI lesion volume, and normalised perfusion parameters (CBV,Tmax) within DWI lesions were determined. Visibility of parenchymal hyperintensivty on FLAIR was evaluated ("FLAIR positive"), and DWI-FLAIR mismatch was assessed. Spontaneously reperfused regions were defined as voxels with Tmax <6 s within the DWI lesion. Final infarct size was assessed on day-30 FLAIR images.

Of the 168 patients included in I-KNOW database, 87 were eligible for this study. DWI-FLAIR mismatch was present in 69 patients. There was no difference between poor and good collaterals status according to age, sex, baseline NIHSS score, time to MRI and DWI lesion volume. Collateral status was significantly better in the FLAIR positive group (p = .001). Patients with poor collaterals had significantly increased Tmax (p = .005). Baseline DWI lesion volume and final lesion volume were significantly smaller in patients with good collateral status (p < .001 and 0.01, respectively).

We found that patients with early FLAIR lesion visibility have a better collateral status. This finding has implications for the management of stroke patients with unknown time-of-onset, and more widely should be considered in the current context of extending the therapeutic window.