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Benefit from revascularization after thrombectomy according to FLAIR vascular hyperintensities–DWI mismatch

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Abstract

Objectives

We tested whether FLAIR vascular hyperintensities (FVH)–DWI mismatch could identify candidates for thrombectomy most likely to benefit from revascularization.

Methods

We retrospectively reviewed 100 patients with proximal MCA occlusion from 18 stroke centers randomized in the IV-thrombolysis plus mechanical thrombectomy arm of the THRACE trial (2010–2015). We tested the associations between successful revascularization on digital subtraction angiography (modified Thrombolysis in Cerebral Infarction 2b/3) and 3-month favorable outcome (modified Rankin Scale score ≤ 2), stratified on FVH–DWI mismatch status, with secondary analyses adjusted on National Institutes of Health Stroke Scale (NIHSS) and DWI lesion volume.

Results

FVH–DWI mismatch was present in 79% of patients, with a similar prevalence at 1.5 T (80%) and 3 T (78%). Successful revascularization (74%) was more frequent in patients with FVH–DWI mismatch (63/79, 80%) than in patients without (11/21, 52%), p = 0.01. The OR of favorable outcome for revascularization were 15.05 (95% CI 3.12–72.61, p < 0.001) in patients with FVH–DWI mismatch and 0.83 (95% CI 0.15–4.64, p = 0.84) in patients without FVH–DWI mismatch (p = 0.011 for interaction). Similar results were observed after adjustment for NIHSS (OR = 12.73 [95% CI 2.69–60.41, p = 0.001] and 0.96 [95% CI 0.15–6.30, p = 0.96]) or for DWI volume (OR = 12.37 [95% CI 2.76–55.44, p = 0.001] and 0.91 [95% CI 0.16–5.33, p = 0.92]) in patients with and without FVH–DWI mismatch, respectively.

Conclusions

The FVH–DWI mismatch identifies patients likeliest to benefit from revascularization, irrespective of initial DWI lesion volume and clinical stroke severity, and could serve as a useful surrogate marker for penumbral evaluation.

Key Points

• The FVH–DWI mismatch, defined by FLAIR vascular hyperintensities (FVH) located beyond the boundaries of the DWI lesion, is associated with large penumbra.

• Among stroke patients with proximal middle cerebral artery occlusion referred for thrombectomy, those with FVH–DWI mismatch are most likely to benefit from revascularization.

• FVH–DWI mismatch provides an alternative to PWI–DWI mismatch in order to select patients who are candidates for thrombectomy.

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Abbreviations

DSA:

Digital subtraction angiography

FLAIR:

Fluid-attenuated inversion recovery

FVH:

FLAIR vascular hyperintensities

MCA:

Middle cerebral artery

mRS:

Modified Rankin Scale

NIHSS:

National Institutes of Health Stroke Scale

OR:

Odds ratio

PWI:

Perfusion-weighted imaging

THRACE:

THRombectomie des Artères CErébrales (mechanical thrombectomy after intravenous alteplase versus alteplase alone after stroke)

TICI:

Thrombolysis in Cerebral Infarction

References

  1. Goyal M, Menon BK, van Zwam WH et al (2016) Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials. Lancet 387:1723–1731

    Article  Google Scholar 

  2. Powers WJ, Rabinstein AA, Ackerson T et al (2018) 2018 Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 49:e46–e110

    Article  Google Scholar 

  3. Nogueira RG, Jadhav AP, Haussen DC et al (2018) Thrombectomy 6 to 24 hours after stroke with a mismatch between deficit and infarct. N Engl J Med 378:11–21

    Article  Google Scholar 

  4. Albers GW, Marks MP, Kemp S et al (2018) Thrombectomy for stroke at 6 to 16 hours with selection by perfusion imaging. N Engl J Med 378:708–718

    Article  PubMed  PubMed Central  Google Scholar 

  5. 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. AJNR Am J Neuroradiol 30:564–568

    Article  CAS  PubMed  Google Scholar 

  6. Bang OY, Saver JL, Kim SJ et al (2011) Collateral flow predicts response to endovascular therapy for acute ischemic stroke. Stroke 42:693–699

    Article  PubMed  PubMed Central  Google Scholar 

  7. Legrand L, Tisserand M, Turc G et al (2015) Do FLAIR vascular hyperintensities beyond the DWI lesion represent the ischemic penumbra? AJNR Am J Neuroradiol 36:269–274

    Article  CAS  PubMed  Google Scholar 

  8. Legrand L, Tisserand M, Turc G et al (2016) Fluid-attenuated inversion recovery vascular hyperintensities-diffusion-weighted imaging mismatch identifies acute stroke patients most likely to benefit from recanalization. Stroke 47:424–427

    Article  PubMed  Google Scholar 

  9. Bracard S, Ducrocq X, Mas JL et al (2016) Mechanical thrombectomy after intravenous alteplase versus alteplase alone after stroke (THRACE): a randomised controlled trial. Lancet Neurol 15:1138–1147

    Article  CAS  Google Scholar 

  10. Haute Autorité de Santé (2009) Stroke: Early management alert, prehospital phase, initial hospital phase, indications for thrombolysis). Clinical practice guidelines. Available via https://www.hassante.fr/portail/upload/docs/application/pdf/2010-03/stroke_early_management_-_guidelines_-_english_version.pdf. Accessed 28 Jan 2019

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

    Article  CAS  PubMed  Google Scholar 

  12. Gautheron V, Xie Y, Tisserand M et al (2018) Outcome after reperfusion therapies in patients with large baseline diffusion-weighted imaging stroke lesions: a THRACE trial (mechanical thrombectomy after intravenous alteplase versus alteplase alone after stroke) subgroup analysis. Stroke 49:750–753

    Article  PubMed  Google Scholar 

  13. Tomsick T, Broderick J, Carrozella J et al (2008) Revascularization results in the Interventional Management of Stroke II trial. AJNR Am J Neuroradiol 29:582–587

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  14. Labeyrie MA, Turc G, Hess A et al (2012) Diffusion lesion reversal after thrombolysis: a MR correlate of early neurological improvement. Stroke 43:2986–2991

    Article  PubMed  Google Scholar 

  15. Steyerberg EW (2009) Clinical prediction models: a practical approach to development, validation, and updating. Springer, New York

    Book  Google Scholar 

  16. Peduzzi P, Concato J, Feinstein AR et al (1995) Importance of events per independent variable in proportional hazards regression analysis. II. Accuracy and precision of regression estimates. J Clin Epidemiol 48:1503–1510

    Article  CAS  Google Scholar 

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

    Article  PubMed  Google Scholar 

  18. Liu W, Xu G, Yue X et al (2011) Hyperintense vessels on FLAIR: a useful non-invasive method for assessing intracerebral collaterals. Eur J Radiol 80:786–791

    Article  PubMed  Google Scholar 

  19. Nave AH, Kufner A, Bucke P et al (2018) Hyperintense vessels, collateralization, and functional outcome in patients with stroke receiving endovascular treatment. Stroke 49:675–681

    Article  PubMed  Google Scholar 

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

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  21. Liu D, Scalzo F, Rao NM et al (2016) Fluid-attenuated inversion recovery vascular hyperintensity topography, novel imaging marker for revascularization in middle cerebral artery occlusion. Stroke 47:2763–2769

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  22. Mahdjoub E, Turc G, Legrand L et al (2018) Do fluid-attenuated inversion recovery vascular hyperintensities represent good collaterals before reperfusion therapy? AJNR Am J Neuroradiol 39:77–83

    Article  CAS  PubMed  Google Scholar 

  23. 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 69:1462–1468

    Article  PubMed  Google Scholar 

  24. Perez de la Ossa N, Hernandez-Perez M, Domenech S et al (2012) Hyperintensity of distal vessels on FLAIR is associated with slow progression of the infarction in acute ischemic stroke. Cerebrovasc Dis 34:376–384

    Article  CAS  PubMed  Google Scholar 

  25. Verma RK, Gralla J, Klinger-Gratz PP et al (2015) Infarction distribution pattern in acute stroke may predict the extent of leptomeningeal collaterals. PLoS One 10:e0137292

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  26. Bang OY, Saver JL, Buck BH et al (2008) Impact of collateral flow on tissue fate in acute ischaemic stroke. J Neurol Neurosurg Psychiatry 79:625–629

    Article  CAS  PubMed  Google Scholar 

  27. Kaesmacher J, Huber T, Lehm M et al (2017) Isolated striatocapsular infarcts after endovascular treatment of acute proximal middle cerebral artery occlusions: prevalence, enabling factors, and clinical outcome. Front Neurol 8:272

    Article  PubMed  PubMed Central  Google Scholar 

  28. von Kummer R, Hacke W (1992) Safety and efficacy of intravenous tissue plasminogen activator and heparin in acute middle cerebral artery stroke. Stroke 23:646–652

    Article  Google Scholar 

  29. Yoo AJ, Andersson T (2017) Thrombectomy in acute ischemic stroke: challenges to procedural success. J Stroke 19:121–130

    Article  PubMed  PubMed Central  Google Scholar 

  30. Leng X, Fang H, Leung TW et al (2016) Impact of collateral status on successful revascularization in endovascular treatment: a systematic review and meta-analysis. Cerebrovasc Dis 41:27–34

    Article  PubMed  Google Scholar 

  31. Liebeskind DS, Jahan R, Nogueira RG et al (2014) Impact of collaterals on successful revascularization in solitaire FR with the intention for thrombectomy. Stroke 45:2036–2040

    Article  PubMed  PubMed Central  Google Scholar 

  32. Singer OC, Berkefeld J, Nolte CH et al (2015) Collateral vessels in proximal middle cerebral artery occlusion: the ENDOSTROKE study. Radiology 274:851–858

    Article  PubMed  Google Scholar 

  33. Davalos A, Blanco M, Pedraza S et al (2004) The clinical-DWI mismatch: a new diagnostic approach to the brain tissue at risk of infarction. Neurology 62:2187–2192

    Article  CAS  PubMed  Google Scholar 

  34. Kaesmacher J, Dobrocky T, Heldner MR et al (2018) Systematic review and meta-analysis on outcome differences among patients with TICI2b versus TICI3 reperfusions: success revisited. J Neurol Neurosurg Psychiatry 89:910–917

    Article  PubMed  PubMed Central  Google Scholar 

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Acknowledgements

We thank Farhat Benbelkacem and Raphael Petazzoni (Olea Medical) for their help in image post-processing.

Funding

THRACE study was funded by the French Ministry of Health.

Author information

Authors and Affiliations

  1. Department of Neuroradiology, INSERM U1266, Sainte-Anne Hospital, Paris Descartes University, Paris, France

    Laurence Legrand, Myriam Edjlali, Vincent Gautheron, Wagih Ben Hassen, Sylvain Charron, Denis Trystram, Grégoire Boulouis, Joseph Benzakoun, Olivier Naggara & Catherine Oppenheim

  2. Department of Neurology, INSERM U1266, Sainte-Anne Hospital, Paris Descartes University, Paris, France

    Guillaume Turc

  3. Clinical Investigation Centre-Innovative Technology, INSERM U1254, Lorraine University, Lorraine, France

    Marine Beaumont

  4. Department of Neuroradiology, CHU Nantes, Nantes, France

    Romain Bourcier

  5. Department of Neuroradiology, Pitié-Salpêtrière Hospital, Paris, France

    Frédéric Clarençon

  6. Department of Neuroradiology, CHRU Nancy, Nancy, France

    Serge Bracard

Authors
  1. Laurence Legrand
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  2. Guillaume Turc
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  3. Myriam Edjlali
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  4. Marine Beaumont
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  5. Vincent Gautheron
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  6. Wagih Ben Hassen
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  7. Sylvain Charron
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  8. Denis Trystram
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  9. Grégoire Boulouis
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  10. Romain Bourcier
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  11. Joseph Benzakoun
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  12. Olivier Naggara
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  13. Frédéric Clarençon
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  14. Serge Bracard
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  15. Catherine Oppenheim
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Consortia

on behalf of the THRACE Investigators

Corresponding author

Correspondence to Catherine Oppenheim.

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Guarantor

The scientific guarantor of this publication is Catherine Oppenheim.

Conflict of interest

The authors of this manuscript declare no relationships with any companies, whose products or services may be related to the subject matter of the article.

Statistics and biometry

One of the authors (GT) has significant statistical expertise.

Informed consent

Written informed consent was obtained from all subjects (patients) or their legal representatives in the THRACE study.

Ethical approval

The THRACE study was approved by the CPP (Comité de Protection des Personnes) III Nord Est Ethics Committee and the research boards of the participating centers.

Study subjects or cohorts overlap

In addition to the THRACE trial [1], the stroke population studied here has been published previously in the following articles dealing with entirely different scientific questions, respectively cost-effectiveness of thrombectomy in patients with acute ischemic stroke [2], impact of pretreatment lesional volume on clinical outcome and thrombectomy efficacy [3], outcome after reperfusion therapies in patients with large baseline DWI stroke lesions [4], susceptibility vessel sign [5, 6], inter- and intraobserver reliability for angiographic leptomeningeal collateral flow assessment by the American Society of Interventional and Therapeutic Neuroradiology/Society of Interventional Radiology scale [7], imaging features and safety and efficacy of endovascular stroke treatment [8] and Validation of Overestimation Ratio and TL-SVS as imaging biomarker of cardioembolic stroke and time from onset to MRI [9] whereas we focused on FLAIR vascular hyperintensities.

1. Bracard S, Ducrocq X, Mas JL et al. (2016) Mechanical thrombectomy after intravenous alteplase versus alteplase alone after stroke (THRACE): a randomized controlled trial. Lancet Neurol 15(11):1138-1147.

2. Achit H, Soudant M, Hosseini K et al. (2017) Cost-Effectiveness of Thrombectomy in Patients With Acute Ischemic Stroke: The THRACE Randomized Controlled Trial. Stroke 48(10):2843-2847.

3. Xie Y, Oppenheim C, Guillemin F et al. (2018) Pretreatment lesional volume impacts clinical outcome and thrombectomy efficacy. Ann Neurol 83(1):178-185.

4. Gautheron V, Xie Y, Tisserand M et al. (2018) Outcome after reperfusion therapies in patients with large baseline Diffusion-Weighted Imaging stroke lesions: a THRACE trial (mechanical thrombectomy after intravenous alteplase versus alteplase alone after stroke) subgroup analysis. Stroke 49(3):750-753.

5. Bourcier R, Derraz I, Delasalle B et al. (2018) Susceptibility Vessel Sign and Cardioembolic Etiology in the THRACE Trial. Clin Neuroradiol.

6. Bourcier R, Hassen WB, Soize S et al. (2018) Susceptibility vessel sign on MRI predicts better clinical outcome in patients with anterior circulation acute stroke treated with stent retriever as first-line strategy. J Neurointerv Surg.

7. Ben Hassen W, Malley C, Boulouis G et al. (2018) Inter- and intraobserver reliability for angiographic leptomeningeal collateral flow assessment by the American Society of Interventional and Therapeutic Neuroradiology/Society of Interventional Radiology (ASITN/SIR) scale. J Neurointerv Surg.

8. Roman LS, Menon BK, Blasco J et al. (2018) Imaging features and safety and efficacy of endovascular stroke treatment: a meta-analysis of individual patient-level data. Lancet Neurol 17(10):895-904.

9.Bourcier R, Legrand L, Soize S et al. (in press) Clinical and MRI Technical Parameters Related to the Two Layered Susceptibility Vessel Sign and the Overestimation Ratio in the THRACE Trial. European Radiology.

Methodology

• Retrospective review of prospectively acquired data

• Prognostic study/observational

• Multicenter study

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Legrand, L., Turc, G., Edjlali, M. et al. Benefit from revascularization after thrombectomy according to FLAIR vascular hyperintensities–DWI mismatch. Eur Radiol 29, 5567–5576 (2019). https://doi.org/10.1007/s00330-019-06094-y

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