FLAIR Vascular Hyperintensities/DWI Mismatch Predicts Penumbra in Proximal Middle Cerebral Artery Occlusion

BACKGROUND: Perfusion imaging used to select patients for extended-window stroke therapy is not widely available. We investigated whether fluid-attenuated inversion recovery vascular hyperintensities (FVHs) on routine magnetic resonance imaging could serve as a reliable surrogate for perfusion imaging by predicting the mismatch between hypoperfused tissue volume (perfusion-weighted imaging [PWI]) and infarct core volume (diffusion-weighted imaging [DWI]) in patients with proximal middle cerebral artery occlusion. METHODS: ratio and the true PWI/DWI mismatch and analyzed its association with 24-hour and 3-month outcomes. Predictive performance for the PWI/DWI ratio was tested using the area under the curve-receiver operating characteristic curve. Two thresholds were evaluated-the cohort median PWI/DWI ratio and PWI/DWI ≥1.8 with mismatch >15 mL in patients imaged ≥6 hours after onset-and sensitivity, specificity, positive and negative predictive value with 95% CIs were calculated. RESULTS: =0.002). CONCLUSIONS: ratio is a potential surrogate imaging marker of perfusion-diffusion mismatch in patients with proximal middle cerebral artery occlusion. It may offer a practical and widely accessible alternative to perfusion imaging for identifying candidates for reperfusion therapy beyond the standard time window.