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Observational Study
. 2025 Mar;20(3):310-318.
doi: 10.1177/17474930241289235. Epub 2024 Oct 21.

Early penumbral FLAIR changes predict tissue fate in patients with large vessel occlusions

Lauranne Scheldeman  1   2   3 , Pierre Seners  3   4   5 , Anke Wouters  1   2   6 , Patrick Dupont  7   8 , Soren Christensen  3 , Michael Mlynash  3 , Caroline Arquizan  9 , Adrien Ter Schiphorst  9 , Vincent Costalat  10 , Hilde Henon  11 , Martin Bretzner  12 , Jean-François Albucher  13 , Christophe Cognard  14 , Jean-Marc Olivot  15 , Jeremy J Heit  3 , Gregory W Albers  3 , Maarten G Lansberg  3 , Robin Lemmens  1   2
Affiliations
Observational Study

Early penumbral FLAIR changes predict tissue fate in patients with large vessel occlusions

Lauranne Scheldeman et al. Int J Stroke. 2025 Mar.

Abstract

Background: In patients with an acute ischemic stroke, the penumbra is defined as ischemic tissue that remains salvageable when reperfusion occurs. However, the expected clinical recovery congruent with penumbral salvage is not always observed.

Aims: We aimed to determine whether the magnetic resonance imaging (MRI)-defined penumbra includes irreversible neuronal loss that impedes expected clinical recovery after reperfusion.

Methods: In the prospective French Acute Multimodal Imaging Study to Select Patients for Mechanical Thrombectomy (FRAME) and an observational cohort of patients with large vessel occlusions undergoing endovascular treatment, we quantified penumbral integrity by fluid-attenuated inversion recovery (FLAIR) changes. We studied the influence of recanalization status on the evolution of penumbral FLAIR changes and studied penumbral FLAIR changes as predictor of tissue fate and functional outcome on the 90-day modified Rankin Scale (mRS).

Results: Recanalization status did not modify the evolution of rFLAIR signal intensity (SI) over time in the total cohort, but was associated with lower SI in the FRAME subset (b = -0.06, p for interaction = 0.04). Median rFLAIR SI was higher at baseline in the subsequently infarcted penumbra compared to the salvaged (ratio = 1.07, standard deviation (SD) = 0.07 vs 1.03, SD = 0.06 p < 0.0001, n = 150). The severity and extent of rFLAIR SI changes did not predict 90-day functional outcome in univariate (p = 0.09) and multivariate logistic regression (p = 0.4).

Conclusions: Recanalization status did not influence the evolution of penumbral FLAIR changes. FLAIR SI changes in the baseline penumbra were associated with tissue fate, but not functional outcome.

Keywords: Endovascular treatment; ischemic stroke; magnetic resonance imaging; outcome; penumbra; vasogenic edema.

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Conflict of interest statement

Declaration of conflicting interestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: L.S. reports grants from Research Foundation Flanders and the Belgian American Educational Foundation during the conduct of the study; other (congress participation) from Daiichi Sankyo outside the submitted work. R.L. has no personal disclosures, but reports consultancy fees paid to the institution from iSchemaView and Boehringer Ingelheim. J.-M.O. reports consultancy fees from Abbvie, Acticor, and Bioxodes and speaker fees from Boehringer Ingelheim and Bristol Myers Squibb. C.C. reports consultant for MicroVention, Medtronic, Stryker, Cerenovus, and MIVI. J.J.H. is a consultant for Medtronic and MicroVention and is a member of the medical and scientific advisory board for iSchemaView.

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