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FLAIR Vascular Hyperintensities as a Surrogate of Collaterals in Acute Stroke: DWI Matters
L Legrand1,2, A Le Berre3,2, P Seners4
1From the Institute of Psychiatry and Neuroscience of Paris (L.L., A.L.B., J.B., W.B.H., C.P., O.N., J.-C.B., G.T., C. Oppenheim), Université Paris Cité, Institut National de la Santé et de la Recherche Médicale U1266, Federation Hospitalo-Universitaire NeuroVasc, Paris, France l.legrand@ghu-paris.fr.
Background And Purpose:
FLAIR vascular hyperintensities are thought to represent leptomeningeal collaterals in acute ischemic stroke. However, whether all-FLAIR vascular hyperintensities or FLAIR vascular hyperintensities-DWI mismatch, ie, FLAIR vascular hyperintensities beyond the DWI lesion, best reflects collaterals remains debated. We aimed to compare the value of FLAIR vascular hyperintensities-DWI mismatch versus all-FLAIR vascular hyperintensities for collateral assessment using PWI-derived collateral flow maps as a reference.
Materials And Methods:
We retrospectively reviewed the registries of 6 large stroke centers and included all patients with acute stroke with anterior circulation large-vessel occlusion who underwent MR imaging with PWI before thrombectomy. Collateral status was graded from 1 to 4 on PWI-derived collateral flow maps and dichotomized into good (grades 3-4) and poor (grades 1-2). The extent of all-FLAIR vascular hyperintensities and FLAIR vascular hyperintensities-DWI mismatch was assessed on the 7 cortical ASPECTS regions, ranging from 0 (absence) to 7 (extensive), and associations with good collaterals were compared using receiver operating characteristic curves.
Results:
Of the 209 included patients, 133 (64%) and 76 (36%) had good and poor collaterals, respectively. All-FLAIR vascular hyperintensity extent was similar between collateral groups (P = .76). Conversely, FLAIR vascular hyperintensities-DWI mismatch extent was significantly higher in patients with good compared with poor collaterals (P < .001). The area under the curve was 0.80 (95% CI, 0.74-0.87) for FLAIR vascular hyperintensities-DWI mismatch and 0.52 (95% CI, 0.44-0.60) for all-FLAIR vascular hyperintensities (P < .001 for the comparison), to predict good collaterals. Variables independently associated with good collaterals were smaller DWI lesion volume (P < .001) and larger FLAIR vascular hyperintensities-DWI mismatch (P = .02).
Conclusions:
In acute ischemic stroke with large-vessel occlusion, the extent of FLAIR vascular hyperintensities does not reliably reflect collateral status unless one accounts for DWI.
