European Radiology

, Volume 29, Issue 5, pp 2624–2631 | Cite as

Validation of overestimation ratio and TL-SVS as imaging biomarker of cardioembolic stroke and time from onset to MRI

  • Romain BourcierEmail author
  • Laurence Legrand
  • Sébastien Soize
  • Julien Labreuche
  • Marine Beaumont
  • Hubert Desal
  • Imad Derraz
  • Serge Bracard
  • Catherine Oppenheim
  • Olivier Naggara
  • on behalf of the THRACE investigators



We aimed to determine in the “THRACE” trial, the clinical and MRI technical parameters associated with the two-layered susceptibility vessel sign (TL-SVS) and the overestimation ratio (overR).

Materials and methods

Patients with pre-treatment brain gradient echo (GRE) sequence and an etiological work-up were identified. Two readers reviewed TL-SVS, i.e., a SVS with a linear low-intense signal core surrounded by a higher intensity and measured the overR as the width of SVS divided by the width of the artery. Binomial and ordinal logistic regression respectively tested the association between TL-SVS and quartiles of overR with patient characteristics, cardioembolic stroke (CES), time from onset to imaging, and GRE sequence parameters (inter slice gap, slice thickness, echo time, flip angle, voxel size, and field strength).


Among 258 included patients, 102 patients were examined by 3 Tesla MRI and 156 by 1.5 Tesla MRI. Intra- and inter-reader agreements for quartiles of overR and TL-SVS were good to excellent. The median overR was 1.59 (IQR, 1.30 to 1.86). TL-SVS was present in 101 patients (39.2%, 95%CI, 33.1 to 45.1%). In multivariate analysis, only CES was associated with overR quartiles (OR, 1.83; 95%CI, 1.11 to 2.99), and every 60 min increase from onset to MRI time was associated with TL-SVS (OR, 1.72; 95%CI, 1.10 to 2.67). MRI technical parameters were statistically associated with neither overR nor TL-SVS.


Independent of GRE sequence parameters, an increased overR was associated to CES, while the TL-SVS is independently related to a longer time from onset to MRI.

Key Points

• An imaging biomarker would be useful to predict the etiology of stroke in order to adapt secondary prevention of stroke.

• The two-layered susceptibility vessel sign and the overestimation ratio are paramagnetic effect derived markers that vary according to the MRI machines and sequence parameters.

• Independent of sequence parameters, an increased overestimation ratio was associated to cardioembolic stroke, while the two-layered susceptibility vessel sign is independently related to a longer time from onset to MRI.


Thrombosis Embolism Magnetic resonance imaging Stroke Biomarkers 



Acute ischemic stroke patients with large vessel occlusion


Cardioembolic stroke


Gradient echo


Overestimation ratio


Susceptibility-weighted imaging


THRombectomie des Artères CErebrales


Two-layered susceptibility vessel sign



This study was funded by the French Ministry for Health as part of its 2009 STIC program for the support of costly innovations (grant number 2009 A00753-54).

Compliance with ethical standards


The scientific guarantor of this publication is Hubert Desal, head of the Department of Neuroradiology, University Hospital of Nantes France.

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

J. Labreuche from the Centre Hospitalier Regional Universitaire de Lille, Biostatistics, Lille, Hauts-de-France, France, kindly provided statistical advice for this manuscript.

Informed consent

Before randomization, written informed consent was obtained from all patients or their legal representatives.

Ethical approval

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


• Prospective

• Diagnostic or prognostic study

• Multicenter study


The trial steering committee attests to the integrity of the trial, the fidelity of this report to the study protocol, and the completeness and accuracy of the reported data.

Supplementary material

330_2018_5835_MOESM1_ESM.docx (20 kb)
ESM 1 (DOCX 20 kb)


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Copyright information

© European Society of Radiology 2018

Authors and Affiliations

  • Romain Bourcier
    • 1
    Email author
  • Laurence Legrand
    • 2
  • Sébastien Soize
    • 3
    • 4
  • Julien Labreuche
    • 5
  • Marine Beaumont
    • 6
  • Hubert Desal
    • 1
  • Imad Derraz
    • 7
  • Serge Bracard
    • 8
  • Catherine Oppenheim
    • 2
  • Olivier Naggara
    • 2
    • 9
  • on behalf of the THRACE investigators
  1. 1.Department of Diagnostic and Interventional NeuroradiologyGuillaume et René Laennec University HospitalNantesFrance
  2. 2.Department of NeuroradiologyUniversité Paris-Descartes. INSERM U894, Sainte-Anne HospitalParisFrance
  3. 3.Department of Diagnostic and Interventional NeuroradiologyUniversity Hospital of ReimsReimsFrance
  4. 4.INSERM UMR-S 1237 Physiopathology and imaging of neurological disordersUniversité Caen NormandieCaenFrance
  5. 5.Centre Hospitalier Regional Universitaire de Lille, BiostatisticsLilleFrance
  6. 6.CIC1433, INSERM, IADI, U1254Université de Lorraine, INSERM, CHRU de Nancy CIC-IT NancyNancyFrance
  7. 7.Department of Diagnostic and Interventional NeuroradiologyHopital Gui de ChauillacMontpellierFrance
  8. 8.Department of Diagnostic and Interventional NeuroradiologyUniversity Hospital of NancyNancyFrance
  9. 9.Pediatric Radiology Department, Necker Enfants MaladesParisFrance

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