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Follow-up infarct volume on fluid attenuated inversion recovery (FLAIR) imaging in distal medium vessel occlusions: the role of cerebral blood volume index

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Abstract

Background

Distal medium vessel occlusions (DMVOs) contribute substantially to the incidence of acute ischemic strokes (AIS) and pose distinct challenges in clinical management and prognosis. Neuroimaging techniques, such as Fluid Attenuation Inversion Recovery (FLAIR) imaging and cerebral blood volume (CBV) index derived from perfusion imaging, have significantly improved our ability to assess the impact of strokes and predict their outcomes. The primary objective of this study was to investigate relationship between follow-up infarct volume (FIV) as assessed by FLAIR imaging in patients with DMVOs.

Methods

This prospectively collected, retrospective reviewed cohort study included patients from two comprehensive stroke centers within the Johns Hopkins Medical Enterprise, spanning August 2018–October 2022. The cohort consisted of adults with AIS attributable to DMVO. Detailed imaging analyses were conducted, encompassing non-contrast CT, CT angiography (CTA), CT perfusion (CTP), and FLAIR imaging. Univariable and multivariable linear regression models were employed to assess the association between different factors and FIV.

Results

The study included 79 patients with DMVO stroke with a median age of 69 years (IQR, 62–77 years), and 57% (n = 45) were female. There was a negative correlation between the CBV index and FIV in a univariable linear regression analysis (Beta =  – 16; 95% CI,  – 23 to  – 8.3; p < 0.001) and a multivariable linear regression model (Beta =  – 9.1 per 0.1 change; 95% CI,  – 15 to  – 2.7; p = 0.006). Diabetes was independently associated with larger FIV (Beta = 46; 95% CI, 16 to 75; p = 0.003). Additionally, a higher baseline ASPECTS was associated with lower FIV (Beta =  – 30; 95% CI,  – 41 to  – 20; p < 0.001).

Conclusion

Our findings underscore the CBV index as an independent association with FIV in DMVOs, which highlights the critical role of collateral circulation in determining stroke outcomes in this patient population. In addition, our study confirms a negative association of ASPECTS with FLAIR FIV and identifies diabetes as independent factor associated with larger FIV. These insights pave the way for further large-scale, prospective studies to corroborate these findings, thereby refining the strategies for stroke prognostication and management.

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Authors and Affiliations

  1. Department of Radiology, Division of Neuroradiology, Johns Hopkins Medical Center, Baltimore, MD, USA

    Hamza Salim, Dhairya A. Lakhani, Aneri Balar, Meisam Hoseinyazdi, Licia Luna, Francis Deng, Nathan Z. Hyson, Janet Mei & Vivek Yedavalli

  2. Neuroendovascular Program, Massachusetts General Hospital, Harvard University, Boston, MA, USA

    Hamza Salim & Adam A. Dmytriw

  3. Department of Neurosurgery and Interventional Neuroradiology, Louisiana State University, Baton Rouge, LA, USA

    Basel Musmar & Nimer Adeeb

  4. Neurovascular Centre, Departments of Medical Imaging and Neurosurgery, St. Michael’s Hospital, Toronto, ON, Canada

    Adam A. Dmytriw

  5. Department of Diagnostic and Interventional Neuroradiology, Erasme University Hospital, Brussels, Belgium

    Adrien Guenego

  6. Department of Radiology, Neuroendovascular Program, University Medical Center, Münster, Germany

    Tobias D. Faizy

  7. Department of Interventional Neuroradiology, Stanford Medical Center, Palo Alto, CA, USA

    Jeremy J. Heit

  8. Department of Neurology, Stanford Medical Center, Palo Alto, CA, USA

    Gregory W. Albers

  9. Department of Neurology, Johns Hopkins Medical Center, Baltimore, MD, USA

    Victor C. Urrutia, Raf Llinas, Elisabeth B. Marsh & Argye E. Hillis

  10. University of California San Francisco, San Francisco, CA, USA

    Kambiz Nael

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  1. Hamza Salim
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Correspondence to Vivek Yedavalli.

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Salim, H., Lakhani, D.A., Balar, A. et al. Follow-up infarct volume on fluid attenuated inversion recovery (FLAIR) imaging in distal medium vessel occlusions: the role of cerebral blood volume index. J Neurol (2024). https://doi.org/10.1007/s00415-024-12279-3

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