Background: Vascular hyperintensities of brain-supplying arteries on stroke FLAIR MRI are common and represent slow flow or stasis. FLAIR vascular hyperintensities (FVH) are discussed as an independent marker for cerebral hypoperfusion, but the impact on infarct size and clinical outcome in acute stroke patients is controversial. This study evaluates the association of FVH with infarct morphology, clinical stroke severity and infarct growth in patients with symptomatic internal carotid artery (ICA) or middle cerebral artery (MCA) occlusion. Methods: MR images of 84 patients [median age 73 years (IQR 65–80), 56.0% male, median NIHSS 7 (IQR 3–13)] with acute stroke due to symptomatic ICA or MCA occlusion or stenosis were reviewed. Vessel occlusions were identified by MRA time of flight and graded with the TIMI score. Diffusion and perfusion deficit volumes on admission and FLAIR lesion volumes on discharge were assessed. The presence and number of FVH were evaluated according to MCA-ASPECT areas, and associations with MR volumes, morphology of infarction, recanalization status, presence of white matter disease and hemorrhagical transformation as well as with stroke severity (NIHSS), stroke etiology and thrombolysis rate were analyzed. Results: FVH were detectable in 75 (89.3%) patients. The median number of FVH was 4 (IQR 2–7). Patients with FVH >4 presented with more severe strokes due to NIHSS (p = 0.021), had larger initial DWI lesions (p = 0.008), perfusion deficits (p = 0.001) and mismatch volumes/ratios (p = 0.005). The final infarct volume was larger (p = 0.005), and hemorrhagic transformation was more frequent (p = 0.029) in these patients. Conclusions: The presence of FVH indicates larger ischemic areas in brain parenchyma predominantly caused by proximal anterior circulation vessel occlusion. A high count of FVH might be a further surrogate marker for initial ischemic mismatch and stroke severity.

Toyoda K, Ida M, Fukuda K: Fluid-attenuated inversion recovery intraarterial signal: an early sign of hyperacute cerebral ischemia. AJNR Am J Neuroradiol 2001;22:1021–1029.
Sanossian N, Saver JL, Alger JR, Kim D, Duckwiler GR, Jahan R, Vinuela F, Ovbiagele B, Liebeskind DS: Angiography reveals that fluid-attenuated inversion recovery vascular hyperintensities are due to slow flow, not thrombus. AJNR Am J Neuroradiol 2009;30:564–568.
Assouline E, Benziane K, Reizine D, Guichard JP, Pico F, Merland JJ, Bousser MG, Chabriat H: Intra-arterial thrombus visualized on T2* gradient echo imaging in acute ischemic stroke. Cerebrovasc Dis 2005;20:6–11.
Lee KY, Latour LL, Luby M, Hsia AW, Merino JG, Warach S: Distal hyperintense vessels on FLAIR: an MRI marker for collateral circulation in acute stroke? Neurology 2009;72:1134–1139.
Schellinger PD, Chalela JA, Kang DW, Latour LL, Warach S: Diagnostic and prognostic value of early MR imaging vessel signs in hyperacute stroke patients imaged <3 h and treated with recombinant tissue plasminogen activator. AJNR Am J Neuroradiol 2005;26:618–624.
Cosnard G, Duprez T, Grandin C, Smith AM, Munier T, Peeters A: Fast FLAIR sequence for detecting major vascular abnormalities during the hyperacute phase of stroke: a comparison with MR angiography. Neuroradiology 1999;41:342–346.
Kamran S, Bates V, Bakshi R, Wright P, Kinkel W, Miletich R: Significance of hyperintense vessels on FLAIR MRI in acute stroke. Neurology 2000;55:265–269.
Hotter B, Pittl S, Ebinger M, Oepen G, Jegzentis K, Kudo K, Rozanski M, Schmidt WU, Brunecker P, Xu C, Martus P, Endres M, Jungehulsing GJ, Villringer A, Fiebach JB: Prospective study on the mismatch concept in acute stroke patients within the first 24 h after symptom onset – 1,000 plus study. BMC Neurol 2009;9:60.
Muir KW, Weir CJ, Murray GD, Povey C, Lees KR: Comparison of neurological scales and scoring systems for acute stroke prognosis. Stroke 1996;27:1817–1820.
Adams HP Jr, Bendixen BH, Kappelle LJ, Biller J, Love BB, Gordon DL, Marsh EE 3rd: Classification of subtype of acute ischemic stroke. Definitions for use in a multicenter clinical trial. TOAST. Trial of Org 10172 in Acute Stroke Treatment. Stroke 1993;24:35–41.
The thrombolysis in myocardial infarction (TIMI) trial. Phase I findings. TIMI study group. N Engl J Med 1985;312:932–936.
Khatri P, Neff J, Broderick JP, Khoury JC, Carrozzella J, Tomsick T: Revascularization end points in stroke interventional trials: recanalization versus reperfusion in IMS-I. Stroke 2005;36:2400–2403.
Ebinger M, Brunecker P, Jungehulsing GJ, Malzahn U, Kunze C, Endres M, Fiebach JB: Reliable perfusion maps in stroke MRI using arterial input functions derived from distal middle cerebral artery branches. Stroke 2010;41:95–101.
Berger C, Fiorelli M, Steiner T, Schabitz WR, Bozzao L, Bluhmki E, Hacke W, von Kummer R: Hemorrhagic transformation of ischemic brain tissue: asymptomatic or symptomatic? Stroke 2001;32:1330–1335.
Fiorelli M, Bastianello S, von Kummer R, del Zoppo GJ, Larrue V, Lesaffre E, Ringleb AP, Lorenzano S, Manelfe C, Bozzao L: Hemorrhagic transformation within 36 hours of a cerebral infarct: relationships with early clinical deterioration and 3-month outcome in the European Cooperative Acute Stroke Study I (Ecass I) cohort. Stroke 1999;30:2280–2284.
Wahlund LO, Barkhof F, Fazekas F, Bronge L, Augustin M, Sjogren M, Wallin A, Ader H, Leys D, Pantoni L, Pasquier F, Erkinjuntti T, Scheltens P: A new rating scale for age-related white matter changes applicable to MRI and CT. Stroke 2001;32:1318–1322.
Pexman JH, Barber PA, Hill MD, Sevick RJ, Demchuk AM, Hudon ME, Hu WY, Buchan AM: Use of the Alberta Stroke Program Early CT Score (ASPECTS) for assessing CT scans in patients with acute stroke. AJNR Am J Neuroradiol 2001;22:1534–1542.
Tomanek AI, Coutts SB, Demchuk AM, Hudon ME, Morrish WE, Sevick RJ, Simon JE, Frayne R, Buchan AM, Hill MD: MR angiography compared to conventional selective angiography in acute stroke. Can J Neurol Sci 2006;33:58–62.
Ozsarlak O, Van Goethem JW, Maes M, Parizel PM: MR angiography of the intracranial vessels: technical aspects and clinical applications. Neuroradiology 2004;46:955–972.
Galinovic I, Ostwaldt AC, Soemmer C, Bros H, Hotter B, Brunecker P, Schmidt WU, Jungehulsing J, Fiebach JB: Search for a map and threshold in perfusion MRI to accurately predict tissue fate: a protocol for assessing lesion growth in patients with persistent vessel occlusion. Cerebrovasc Dis 2011;32:186–193.
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