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Distal hyperintense vessels on FLAIR

An MRI marker for collateral circulation in acute stroke?

From the Section on Stroke Diagnostics and Therapeutics (K.Y.L., L.L.L., M.L., J.G.M., S.W.), National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD; the Washington Hospital Center Stroke Center (A.W.H.), Washington, DC; and the Department of Neurology (K.Y.L.), Yonsei University College of Medicine, Seoul, Korea.

Address correspondence and reprint requests to Dr. Steven Warach, Section on Stroke Diagnostics and Therapeutics, National Institute of Neurological Disorders and Stroke, 10 Center Drive, Room B1D733, Bethesda, MD 20892-1063 warachs{at}ninds.nih.gov

Background: Hyperintense vessels (HV) on fluid-attenuated inversion recovery imaging are frequently observed in acute ischemic stroke patients. However, the exact mechanism and clinical implications of this sign have not yet been clearly defined. The features of HV and its relevance to other imaging factors are presented here.

Methods: Prominence and location of HV were documented in 52 consecutive patients with middle cerebral artery (MCA) territory infarction, before treatment with IV recombinant tissue plasminogen activator. Pretreatment ischemic lesion volume, perfusion lesion volume, and vessel occlusion were determined in addition to recanalization status and ischemic lesion volume on follow-up imaging. NIH Stroke Scale (NIHSS) was used as a measure of clinical severity.

Results: HV distal to arterial occlusion was observed in 73% of patients; more frequent in proximal than distal MCA occlusion patients. Among the 38 patients with proximal MCA occlusion, initial perfusion lesion volume was comparable among patients with different grade distal HV. However, patients with more prominent distal HV had smaller initial, 24-hour, and subacute ischemic lesion volumes and lower initial NIHSS scores.

Conclusions: The presence of distal hyperintense vessels before thrombolytic treatment is associated with large diffusion–perfusion mismatch and smaller subacute ischemic lesion volumes in patients with proximal middle cerebral artery occlusion.

DWI = diffusion-weighted imaging; FLAIR = fluid-attenuated inversion recovery; GRE = gradient recalled echo; HV = hyperintense vessels; MCA = middle cerebral artery; MRA = magnetic resonance angiography; MTT = mean transit time; NIHSS = NIH Stroke Scale; PWI = perfusion-weighted imaging; rt-PA = recombinant tissue plasminogen activator; TE = echo time; TI = inversion time; TIMI = thrombolysis in myocardial infarction; TR = repetition time.

e-Pub ahead of print on February 11, 2009, at www.neurology.org.

Disclosure: The authors report no disclosures.

Received August 3, 2008. Accepted in final form December 29, 2008.