Focal T2 and FLAIR hyperintensities within the infarcted area: A suitable marker for patient selection for treatment?

Julia Meisterernst,Julia Meisterernst,Monika Buehlmann,Pascal P Klinger-Gratz,Urs Fischer,Urs Fischer,Lars Leidolt,Pascal P Klinger-Gratz,Monika Buehlmann,Simon Jung,Simon Jung,Rebekka Kurmann,Matthias F Lang,Rebekka Kurmann,Jan Gralla,Jan Gralla,Mirjam R Heldner,Mirjam R Heldner,Heinrich P Mattle,Lars Leidolt,Pascal P Klinger-Gratz,Marcel Arnold,Marcel Arnold,Pasquale Mordasini,Pasquale Mordasini,Gerhard Schroth,Marie-Luise Mono,Marwan El-Koussy,Marwan El-Koussy,Marie-Luise Mono,Heinrich P Mattle,Pascal P Klinger-Gratz,Gerhard Schroth,Jens Minnerup

doi:10.1371/journal.pone.0185158

Julia Meisterernst, Julia Meisterernst + Show 32 more

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https://doi.org/10.1371/journal.pone.0185158

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Abstract

Background and purposeSome authors use FLAIR imaging to select patients for stroke treatment. However, the effect of hyperintensity on FLAIR images on outcome and bleeding has been addressed in only few studies with conflicting results.Methods466 patients with anterior circulation strokes were included in this study. They all were examined with MRI before intravenous or endovascular treatment. Baseline data and 3 months outcome were recorded prospectively. Focal T2 and FLAIR hyperintensities within the ischemic lesion were evaluated by two raters, and the PROACT II classification was applied to assess bleeding complications on follow up imaging. Logistic regression analysis was used to determine predictors of bleeding complications and outcome and to analyze the influence of T2 or FLAIR hyperintensity on outcome.ResultsFocal hyperintensities were found in 142 of 307 (46.3%) patients with T2 weighted imaging and in 89 of 159 (56%) patients with FLAIR imaging. Hyperintensity in the basal ganglia, especially in the lentiform nucleus, on T2 weighted imaging was the only independent predictor of any bleeding after reperfusion treatment (33.8% in patients with vs. 18.2% in those without; p = 0.003) and there was a non-significant trend for more bleedings in patients with FLAIR hyperintensity within the basal ganglia (p = 0.069). However, there was no association of hyperintensity on T2 weighted or FLAIR images and symptomatic bleeding or worse outcome.ConclusionOur results question the assumption that T2 or FLAIR hyperintensities within the ischemic lesion should be used to exclude patients from reperfusion therapy, especially not from endovascular treatment.

Highlights

Focal hyperintensities on T2 weighted spin echo or fluid-attenuated inversion recovery (FLAIR) imaging in the region of diffusion restriction on diffusion weighted imaging (DWI) have been identified as a tissue marker of the ischemic lesion age
Hyperintensity in the basal ganglia, especially in the lentiform nucleus, on T2 weighted imaging was the only independent predictor of any bleeding after reperfusion treatment (33.8% in patients with vs. 18.2% in those without; p = 0.003) and there was a non-significant trend for more bleedings in patients with FLAIR hyperintensity within the basal ganglia (p = 0.069)
There was no association of hyperintensity on T2 weighted or FLAIR images and symptomatic bleeding or worse outcome

Summary

Introduction

Focal hyperintensities on T2 weighted spin echo or fluid-attenuated inversion recovery (FLAIR) imaging in the region of diffusion restriction on diffusion weighted imaging (DWI) have been identified as a tissue marker of the ischemic lesion age Such hyperintensities are regarded as a new tool to select stroke patients with unknown symptom onset for treatment with intravenous thrombolysis (IVT).[1,2,3,4,5,6] Reperfusion therapy based on mismatch between DWI and FLAIR images, i.e. no FLAIR hyperintensity within the DWI lesion, has been shown to be feasible and safe when symptom onset of stroke is unknown.[7, 8]. The effect of hyperintensity on FLAIR images on outcome and bleeding has been addressed in only few studies with conflicting results

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