Original Article

Negative fluid-attenuated inversion recovery imaging identifies acute ischemic stroke at 3 hours or less†

  1. Götz Thomalla MD1,*,
  2. Philipp Rossbach MSt1,
  3. Michael Rosenkranz MD1,
  4. Susanne Siemonsen MD2,
  5. Anna Krützelmann MD1,
  6. Jens Fiehler MD2,
  7. Christian Gerloff MD1

Article first published online: 20 MAR 2009

DOI: 10.1002/ana.21651

Issue

Annals of Neurology

Annals of Neurology

Volume 65, Issue 6, pages 724–732, June 2009

Additional Information

How to Cite

Thomalla, G., Rossbach, P., Rosenkranz, M., Siemonsen, S., Krützelmann, A., Fiehler, J. and Gerloff, C. (2009), Negative fluid-attenuated inversion recovery imaging identifies acute ischemic stroke at 3 hours or less. Annals of Neurology, 65: 724–732. doi: 10.1002/ana.21651

Author Information

  1. 1

    Department of Neurology, Center for Clinical Neurosciences, University Medical Center Hamburg, Eppendorf, Hamburg, Germany

  2. 2

    Department of Diagnostic and Interventional Neuroradiology, Diagnostic Center, University Medical Center Hamburg, Eppendorf, Hamburg, Germany

*Kopf- und Neurozentrum, Klinik und Poliklinik für Neurologie, Universitätsklinikum Hamburg-Eppendorf, Martinistrasse 52, D-20246 Hamburg, Germany

  1. †

    Potential conflict of interest: Nothing to report.

Publication History

  1. Issue published online: 25 JUN 2009
  2. Article first published online: 20 MAR 2009
  3. Accepted manuscript online: 20 MAR 2009 12:00AM EST
  4. Manuscript Accepted: 16 JAN 2009
  5. Manuscript Revised: 8 JAN 2009
  6. Manuscript Received: 13 NOV 2008

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Abstract

Objective

o evaluate the use of fluid-attenuated inversion recovery (FLAIR) imaging as surrogate marker of lesion age within the first 6 hours of ischemic stroke.

Methods

e analyzed FLAIR and diffusion-weighted imaging (DWI) sequences performed within 6 hours of symptom onset in 120 consecutive patients with ischemic stroke with known symptom onset. The visibility of acute ischemic lesions on FLAIR images was judged in two steps (on FLAIR alone and with knowledge of DWI) and compared with DWI.

Results

egative FLAIR in the case of positive DWI allocated ischemic lesions to a time window 3 hours or less with a high specificity (0.93) and a high positive predictive value (0.94), whereas sensitivity (0.48) and negative predictive value (0.43) were low. Lesion visibility on FLAIR images alone (35.6%) and with knowledge of DWI (62.5%) was lower than on DWI (97.1%). The sensitivity of FLAIR increased with increasing time from symptom onset from 27.0/50.0% ≤ 3 hours to 56.7/93.3% after 3 to 6 hours (FLAIR alone/with knowledge of DWI). Multivariate regression analysis spotted longer time from symptom onset and larger size of the ischemic lesion as independent predictors of lesion visibility on FLAIR images.

Interpretation

“mismatch” between positive DWI and negative FLAIR allows the identification of patients that are highly likely to be within the 3-hour time window. Within the first 6 hours of stroke, the sensitivity of FLAIR sequences for acute ischemic lesions increases with time from symptom onset elapsing, approximating 100% after 3 to 6 hours. Ann Neurol 2009;65:724–732

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