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

Eur Radiol. 2019 Oct;29(10):5567-5576. doi: 10.1007/s00330-019-06094-y. Epub 2019 Mar 22.


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.

Keywords: Collateral circulation; Magnetic resonance imaging; Prognosis; Stroke; Thrombectomy.

Publication types

  • Multicenter Study

MeSH terms

  • Adult
  • Aged
  • Angiography, Digital Subtraction / methods
  • Biomarkers
  • Collateral Circulation / physiology
  • Diffusion Magnetic Resonance Imaging / methods
  • Female
  • Humans
  • Image Interpretation, Computer-Assisted / methods
  • Infarction, Middle Cerebral Artery / diagnostic imaging
  • Infarction, Middle Cerebral Artery / therapy*
  • Magnetic Resonance Angiography / methods
  • Male
  • Middle Aged
  • Patient Selection
  • Prognosis
  • Retrospective Studies
  • Stroke / diagnostic imaging
  • Stroke / therapy*
  • Thrombectomy / methods*
  • Thrombolytic Therapy / methods
  • Treatment Outcome


  • Biomarkers