Hypoperfusion intensity ratio is associated with follow-up infarct volume in medium vessel occlusions: A multicenter multinational study

Vivek Yedavalli¹, Hamza Adel Salim², Dhairya Lakhani³, Basel Musmar⁴, Nimer Adeeb⁵, Davide Simonato⁶, Yan-Lin Li⁶, Orabi Hajjeh⁷, Muhammed Amir Essibayi⁸, Nils Henninger⁷, Sri Hari Sundararajan⁹, Anna Luisa Kühn¹⁰, Jane Khalife¹¹, Sherief Ghozy¹², Luca Scarcia¹³, Leonard Ll Yeo¹⁴, Benjamin Yq Tan¹⁵, Robert W Regenhardt¹⁶, Jeremy J Heit¹⁷, Aymeric Rouchaud¹⁸, Jens Fiehler¹⁹, Sunil Sheth²⁰, Ajit S Puri¹⁰, Christian Dyzmann²¹, Marco Colasurdo²², Leonardo Renieri²³, João Pedro Filipe²⁴, Pablo Harker²⁵, Răzvan Alexandru Radu²⁶, Mohamad Abdalkader²⁷, Piers Klein²⁷, Takahiro Ota²⁸, Ashkan Mowla²⁹, Kareem El Naamani⁴, Pascal Jabbour⁴, Arundhati Biswas³⁰, Frédéric Clarençon³¹, James E Siegler¹¹, Thanh N Nguyen²⁷, Ricardo Varela³², Amanda Baker⁸, David Altschul⁸, Nestor R Gonzalez³³, Markus A Möhlenbruch³⁴, Vincent Costalat²⁶, Benjamin Gory³⁵, Christian Paul Stracke³⁶, Constantin Hecker³⁷, Gaultier Marnat³⁸, Hamza Shaikh¹¹, Christoph J Griessenauer³⁷, David S Liebeskind³⁹, Alessandro Pedicelli⁴⁰, Andrea M Alexandre⁴⁰, Tobias D Faizy⁴¹, Illario Tancredi⁴², Erwah Kalsoum¹³, Boris Lubicz⁴³, Aman B Patel¹⁶, Maurizio Fuschi⁶, Max Wintermark⁴⁴, Adrien Guenego⁴³, Adam A Dmytriw⁴⁵; MAD MT Investigators

Collaborators, Affiliations

Collaborators

MAD MT Investigators:
Abdelaziz Amllay⁴, Achala Vagal⁴⁶, Adrien Ter Schiphorst⁴⁷, Ajith J Thomas⁴⁸, Anil Gopinathan¹⁴, Anne Dusart⁴², Carolina Capirossi²³, Charbel Mounayer¹⁸, Charlotte Weyland³⁴, Cheng-Yang Hsieh⁴⁹, Christopher J Stapleton⁵, Erwah Kalsoum¹³, Flavio Bellante⁴², Géraud Forestier¹⁸, Hamza Shaikh¹¹, Hugo H Cuellar-Saenz⁵, Iacopo Valente⁴⁰, Igor Sibon⁵⁰, James D Rabinov⁵, Jérôme Berge³⁸, Jessica Jesser³⁴, Juan Carlos Martinez-Gutierrez²⁰, Kevin Premat³¹, Lina Chervak⁴⁶, Lukas Meyer¹⁹, Mahmoud Elhorany³¹, Miguel Quintero-Consuegra³³, Mohammad Ali Aziz-Sultan⁵¹, Monika Killer-Oberpfalzer³⁷, Peter T Kan⁵², Priyank Khandelwal⁹, Ramanathan Kadirvel⁴⁸, Robert Fahed⁵³, Sergio Salazar-Marioni²⁰, Shogo Dofuku²⁸, Simona Nedelcu⁷, Stavropoula I Tjoumakaris⁴, Suzana Saleme¹⁸, Xavier Barreau³⁸, Yasmin Aziz²⁵

Affiliations

¹ Department of Radiology, Division of Neuroradiology, Johns Hopkins Medical Center, Baltimore, MD, USA. Electronic address: vyedava1@jhmi.edu.
² Department of Radiology, Division of Neuroradiology, Johns Hopkins Medical Center, Baltimore, MD, USA; Department of Neuroradiology, MD Anderson Medical Center, Houston, TX 77030, USA. Electronic address: Hamza.sleeem@gmail.com.
³ Department of Radiology, Division of Neuroradiology, Johns Hopkins Medical Center, Baltimore, MD, USA; Department of Neuroradiology, Rockefeller Neuroscience Institute, West Virginia University, Morgantown, WV 26505, USA.
⁴ Department of Neurosurgery, Thomas Jefferson University, Philadelphia, PA, USA.
⁵ Department of Neurosurgery and Interventional Neuroradiology, Louisiana State University, LA, USA.
⁶ Department of Neuroradiology, Oxford University Hospitals NHS Foundation Trust, Nuffield Departments of Clinical Neurosciences and Surgical Sciences, University of Oxford, UK.
⁷ Department of Neurology, University of Massachusetts Chan Medical School, Worcester, MA, USA.
⁸ Department of Neurological Surgery and Montefiore-Einstein Cerebrovascular Research Lab, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA.
⁹ Department of Endovascular Neurosurgery and Neuroradiology NJMS, Newark, NJ, USA.
¹⁰ Division of Neurointerventional Radiology, Department of Radiology, University of Massachusetts Medical Center, Worcester, MA, USA.
¹¹ Cooper Neurological Institute, Cooper University Hospital, Cooper Medical School of Rowen University, Camden, NJ, USA.
¹² Nuffield Department of Primary Care Health Sciences and Department for Continuing Education (EBHC Program), University of Oxford, Oxford, UK.
¹³ Department of Neuroradiology, Henri Mondor Hospital, Creteil, France.
¹⁴ Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore.
¹⁵ Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Division of Neurology, Department of Medicine, National University Hospital, Singapore.
¹⁶ Neuroendovascular Program, Massachusetts General Hospital & Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
¹⁷ Department of Interventional Neuroradiology, Stanford Medical Center, Palo Alto, CA, USA.
¹⁸ University Hospital of Limoges, Neuroradiology Department, Dupuytren, Université de Limoges, XLIM CNRS, UMR 7252, France.
¹⁹ Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
²⁰ Department of Neurology, UTHealth McGovern Medical School, Houston, TX, USA.
²¹ Neuroradiology Department, Sana Kliniken, Lübeck GmbH, Lübeck, Germany.
²² Department of Interventional Radiology, Oregon Health and Science University, Portland, OR 97239, USA.
²³ Interventistica Neurovascolare, Ospedale Careggi di Firenze, Florence, Italy.
²⁴ Department of Diagnostic and Interventional Neuroradiology, Centro Hospitalar Universitário Do Porto, Porto, Portugal.
²⁵ Department of Neurology, University of Cincinnati Medical Center, Cincinnati, OH, USA.
²⁶ Department of Neuroradiology, Gui de Chauliac Hospital, Montpellier University Medical Center, France.
²⁷ Departments of Radiology & Neurology, Boston Medical Center, Boston, MA, USA.
²⁸ Department of Neurosurgery, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan.
²⁹ Division of Stroke and Endovascular Neurosurgery, Department of Neurological Surgery, Keck School of Medicine, University of Southern California (USC), 1200 North State St, Suite 3300, Los Angeles, CA, USA.
³⁰ Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, NY, USA.
³¹ Department of Neuroradiology, Pitié-Salpêtrière Hospital, Paris, France; GRC BioFast, Sorbonne University, Paris VI, USA.
³² Department of Neurology, Centro Hospitalar Universitário Do Porto, Porto, Portugal.
³³ Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, USA.
³⁴ Sektion Vaskuläre und Interventionelle Neuroradiologie, Universitätsklinikum Heidelberg, Heidelberg, Germany.
³⁵ Department of Interventional Neuroradiology, Nancy University Hospital, Nancy, France; INSERM U1254, IADI, Université de Lorraine, 54511 Vandoeuvre-les-Nancy, France.
³⁶ Department of Radiology, Interventional Neuroradiology Section, University Medical Center Münster, Germany.
³⁷ Departments of Neurology & Neurosurgery, Christian Doppler Clinic, Paracelsus Medical University Salzburg, Austria.
³⁸ Interventional Neuroradiology Department, Bordeaux University Hospital, Bordeaux, France.
³⁹ UCLA Stroke Center and Department of Neurology Department, UCLA, Los Angeles, CA, USA.
⁴⁰ UOSA Neuroradiologia Interventistica, Fondazione Policlinico Universitario A. Gemelli IRCCS Roma, Italy.
⁴¹ Department of Radiology, Neuroendovascular Program, University Medical Center Münster, Germany.
⁴² Department of Neurology, Hôpital Civil Marie Curie, Charleroi, Belgium.
⁴³ Department of Diagnostic and Interventional Neuroradiology, Erasme University Hospital, Brussels, Belgium.
⁴⁴ Department of Neuroradiology, MD Anderson Medical Center, Houston, TX 77030, USA.
⁴⁵ Department of Neuroradiology, Oxford University Hospitals NHS Foundation Trust, Nuffield Departments of Clinical Neurosciences and Surgical Sciences, University of Oxford, UK; Neuroendovascular Program, Massachusetts General Hospital & Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA. Electronic address: admytriw@mgh.harvard.edu.
⁴⁶ Department of Neurology and Radiology, University of Cincinnati, USA.
⁴⁷ Department of Neurology, Gui de Chauliac Hospital, Montpellier University Medical Center, France.
⁴⁸ Departments of Neurological Surgery & Radiology, Mayo Clinic, Rochester, MN, USA.
⁴⁹ Neurology Department, Sin-Lau Hospital, Tainan, Taiwan, ROC.
⁵⁰ Neurology Department, Bordeaux University Hospital, Bordeaux, France.
⁵¹ Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston MA, USA.
⁵² Department of Neurosurgery, University of Texas Medical Branch, Galveston, TX, USA.
⁵³ Department of Medicine, Division of Neurology, The Ottawa Hospital, Ottawa Hospital Research Institute and University of Ottawa, Ottawa, Ontario, Canada.

PMID: 40829981
DOI: 10.1016/j.neurot.2025.e00713

Free article

Hypoperfusion intensity ratio is associated with follow-up infarct volume in medium vessel occlusions: A multicenter multinational study

Vivek Yedavalli et al. Neurotherapeutics. 2025.

Free article

. 2025 Aug 18:e00713.

doi: 10.1016/j.neurot.2025.e00713. Online ahead of print.

Authors

Collaborators

MAD MT Investigators:
Abdelaziz Amllay⁴, Achala Vagal⁴⁶, Adrien Ter Schiphorst⁴⁷, Ajith J Thomas⁴⁸, Anil Gopinathan¹⁴, Anne Dusart⁴², Carolina Capirossi²³, Charbel Mounayer¹⁸, Charlotte Weyland³⁴, Cheng-Yang Hsieh⁴⁹, Christopher J Stapleton⁵, Erwah Kalsoum¹³, Flavio Bellante⁴², Géraud Forestier¹⁸, Hamza Shaikh¹¹, Hugo H Cuellar-Saenz⁵, Iacopo Valente⁴⁰, Igor Sibon⁵⁰, James D Rabinov⁵, Jérôme Berge³⁸, Jessica Jesser³⁴, Juan Carlos Martinez-Gutierrez²⁰, Kevin Premat³¹, Lina Chervak⁴⁶, Lukas Meyer¹⁹, Mahmoud Elhorany³¹, Miguel Quintero-Consuegra³³, Mohammad Ali Aziz-Sultan⁵¹, Monika Killer-Oberpfalzer³⁷, Peter T Kan⁵², Priyank Khandelwal⁹, Ramanathan Kadirvel⁴⁸, Robert Fahed⁵³, Sergio Salazar-Marioni²⁰, Shogo Dofuku²⁸, Simona Nedelcu⁷, Stavropoula I Tjoumakaris⁴, Suzana Saleme¹⁸, Xavier Barreau³⁸, Yasmin Aziz²⁵

Affiliations

¹ Department of Radiology, Division of Neuroradiology, Johns Hopkins Medical Center, Baltimore, MD, USA. Electronic address: vyedava1@jhmi.edu.
² Department of Radiology, Division of Neuroradiology, Johns Hopkins Medical Center, Baltimore, MD, USA; Department of Neuroradiology, MD Anderson Medical Center, Houston, TX 77030, USA. Electronic address: Hamza.sleeem@gmail.com.
³ Department of Radiology, Division of Neuroradiology, Johns Hopkins Medical Center, Baltimore, MD, USA; Department of Neuroradiology, Rockefeller Neuroscience Institute, West Virginia University, Morgantown, WV 26505, USA.
⁴ Department of Neurosurgery, Thomas Jefferson University, Philadelphia, PA, USA.
⁵ Department of Neurosurgery and Interventional Neuroradiology, Louisiana State University, LA, USA.
⁶ Department of Neuroradiology, Oxford University Hospitals NHS Foundation Trust, Nuffield Departments of Clinical Neurosciences and Surgical Sciences, University of Oxford, UK.
⁷ Department of Neurology, University of Massachusetts Chan Medical School, Worcester, MA, USA.
⁸ Department of Neurological Surgery and Montefiore-Einstein Cerebrovascular Research Lab, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA.
⁹ Department of Endovascular Neurosurgery and Neuroradiology NJMS, Newark, NJ, USA.
¹⁰ Division of Neurointerventional Radiology, Department of Radiology, University of Massachusetts Medical Center, Worcester, MA, USA.
¹¹ Cooper Neurological Institute, Cooper University Hospital, Cooper Medical School of Rowen University, Camden, NJ, USA.
¹² Nuffield Department of Primary Care Health Sciences and Department for Continuing Education (EBHC Program), University of Oxford, Oxford, UK.
¹³ Department of Neuroradiology, Henri Mondor Hospital, Creteil, France.
¹⁴ Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore.
¹⁵ Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Division of Neurology, Department of Medicine, National University Hospital, Singapore.
¹⁶ Neuroendovascular Program, Massachusetts General Hospital & Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
¹⁷ Department of Interventional Neuroradiology, Stanford Medical Center, Palo Alto, CA, USA.
¹⁸ University Hospital of Limoges, Neuroradiology Department, Dupuytren, Université de Limoges, XLIM CNRS, UMR 7252, France.
¹⁹ Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
²⁰ Department of Neurology, UTHealth McGovern Medical School, Houston, TX, USA.
²¹ Neuroradiology Department, Sana Kliniken, Lübeck GmbH, Lübeck, Germany.
²² Department of Interventional Radiology, Oregon Health and Science University, Portland, OR 97239, USA.
²³ Interventistica Neurovascolare, Ospedale Careggi di Firenze, Florence, Italy.
²⁴ Department of Diagnostic and Interventional Neuroradiology, Centro Hospitalar Universitário Do Porto, Porto, Portugal.
²⁵ Department of Neurology, University of Cincinnati Medical Center, Cincinnati, OH, USA.
²⁶ Department of Neuroradiology, Gui de Chauliac Hospital, Montpellier University Medical Center, France.
²⁷ Departments of Radiology & Neurology, Boston Medical Center, Boston, MA, USA.
²⁸ Department of Neurosurgery, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan.
²⁹ Division of Stroke and Endovascular Neurosurgery, Department of Neurological Surgery, Keck School of Medicine, University of Southern California (USC), 1200 North State St, Suite 3300, Los Angeles, CA, USA.
³⁰ Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, NY, USA.
³¹ Department of Neuroradiology, Pitié-Salpêtrière Hospital, Paris, France; GRC BioFast, Sorbonne University, Paris VI, USA.
³² Department of Neurology, Centro Hospitalar Universitário Do Porto, Porto, Portugal.
³³ Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, USA.
³⁴ Sektion Vaskuläre und Interventionelle Neuroradiologie, Universitätsklinikum Heidelberg, Heidelberg, Germany.
³⁵ Department of Interventional Neuroradiology, Nancy University Hospital, Nancy, France; INSERM U1254, IADI, Université de Lorraine, 54511 Vandoeuvre-les-Nancy, France.
³⁶ Department of Radiology, Interventional Neuroradiology Section, University Medical Center Münster, Germany.
³⁷ Departments of Neurology & Neurosurgery, Christian Doppler Clinic, Paracelsus Medical University Salzburg, Austria.
³⁸ Interventional Neuroradiology Department, Bordeaux University Hospital, Bordeaux, France.
³⁹ UCLA Stroke Center and Department of Neurology Department, UCLA, Los Angeles, CA, USA.
⁴⁰ UOSA Neuroradiologia Interventistica, Fondazione Policlinico Universitario A. Gemelli IRCCS Roma, Italy.
⁴¹ Department of Radiology, Neuroendovascular Program, University Medical Center Münster, Germany.
⁴² Department of Neurology, Hôpital Civil Marie Curie, Charleroi, Belgium.
⁴³ Department of Diagnostic and Interventional Neuroradiology, Erasme University Hospital, Brussels, Belgium.
⁴⁴ Department of Neuroradiology, MD Anderson Medical Center, Houston, TX 77030, USA.
⁴⁵ Department of Neuroradiology, Oxford University Hospitals NHS Foundation Trust, Nuffield Departments of Clinical Neurosciences and Surgical Sciences, University of Oxford, UK; Neuroendovascular Program, Massachusetts General Hospital & Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA. Electronic address: admytriw@mgh.harvard.edu.
⁴⁶ Department of Neurology and Radiology, University of Cincinnati, USA.
⁴⁷ Department of Neurology, Gui de Chauliac Hospital, Montpellier University Medical Center, France.
⁴⁸ Departments of Neurological Surgery & Radiology, Mayo Clinic, Rochester, MN, USA.
⁴⁹ Neurology Department, Sin-Lau Hospital, Tainan, Taiwan, ROC.
⁵⁰ Neurology Department, Bordeaux University Hospital, Bordeaux, France.
⁵¹ Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston MA, USA.
⁵² Department of Neurosurgery, University of Texas Medical Branch, Galveston, TX, USA.
⁵³ Department of Medicine, Division of Neurology, The Ottawa Hospital, Ottawa Hospital Research Institute and University of Ottawa, Ottawa, Ontario, Canada.

PMID: 40829981
DOI: 10.1016/j.neurot.2025.e00713

Abstract

Medium vessel occlusion (MeVO) contributes significantly to acute ischemic stroke (AIS). The hypoperfusion intensity ratio (HIR), reflecting collateral circulation via the ratio of Tmax >10s to Tmax >6s volumes, predicts infarct progression in large-vessel occlusions but is unstudied in MeVOs. In this multicenter, multinational retrospective study, we evaluated consecutive patients with MeVO who underwent mechanical thrombectomy with or without intravenous thrombolysis. Inclusion required available follow-up imaging and pretreatment CT perfusion. Follow-up infarct volume (FIV) was measured on CT or MRI 12-36 h post-procedure. Univariable and multivariable linear regression models were used to identify predictors of FIV, with HIR as the primary variable of interest. Among 147 patients (median age 75 years, 57 % female), univariable analysis showed HIR was significantly associated with larger FIV (β = 80 mL; p < 0.001). After adjusting for confounders, HIR remained independently associated with FIV (β = 40 mL; p < 0.001). Tmax >10 s showed the strongest correlation with FIV (r = 0.56; p < 0.001). These findings suggest that higher HIR correlates with larger infarct volumes, underscoring the prognostic role of collateral failure in MeVO and highlighting HIR as a potential imaging marker to guide treatment and outcome prediction.

Keywords: Acute Ischemic Stroke; CT Perfusion (CTP); Collateral Circulation; Distal Occlusions; Follow-Up Infarct Volume (FIV); Hypoperfusion Intensity Ratio (HIR); Mechanical Thrombectomy; Medium Vessel Occlusion (MeVO); Stroke Ou; Tmax Thresholds.

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Conflict of interest statement

Declaration of competing interest Dr. Regenhardt serves on a DSMB for a trial sponsored by Rapid Medical, serves as site PI for studies sponsored by Penumbra and Microvention, and receives stroke research grant funding from the National Institutes of Health, Society of Vascular and Interventional Neurology, and Heitman Stroke Foundation. Dr. Guenego reports consultancy for Rapid Medical and Phenox, not directly related to the present work. Dr. Clarençon reports conflicts of interest with Medtronic, Balt Extrusion (consultant), ClinSearch (core lab), Penumbra, Stryker (payment for reading) and Artedrone (Board); all not directly related to the present work. Dr. Henninger received support from W81XWH-19-PRARP-RPA form the CDMRP/DoD, NS131756 and U24NS113844 from the NINDS, and NR020231 from the NINR and received compensation from Myrobalan, Inc. and General Dynamics during the conduct of this study unrelated to this work. Dr. Liebeskind is consultant as Imaging Core Lab to Cerenovus, Genentech, Medtronic, Stryker, Rapid Medical. Dr. Yeo reports Advisory work for AstraZeneca, Substantial support from NMRC Singapore and is a medical advisor for See-mode, Cortiro and Sunbird Bio, with equity in Ceroflo. All unrelated to the present work. Dr. Griessenauer reports a proctoring agreement with Medtronic and research funding by Penumbra. Dr. Marnat reports conflicts of interest with Microvention Europe, Stryker Neurovascular, Balt (consulting), Medtronic, Johnson & Johnson and Phenox (paid lectures), all not directly related to the present work. Dr. Puri is a consultant for Medtronic Neurovascular, Stryker Neurovascular, Balt, Q'Apel Medical, Cerenovus, Microvention, Imperative Care, Agile, Merit, CereVasc and Arsenal Medical, he received research grants from NIH, Microvention, Cerenovus, Medtronic Neurovascular and Stryker Neurovascular, and holds stocks in InNeuroCo, Agile, Perfuze, Galaxy and NTI. Dr. Tjoumakaris is a consultant for Medtronic and Microvention (funds paid to institution, not personally). Dr. Jabbour is a consultant for Medtronic, Microvention and Cerus. Tobias Faizy was funded by the Else-Kröner-Fresenius-Stiftung (EKFS): Project Number: 2023_EKES.02. Dr. Siegler has served as a consultant for AstraZeneca, Bayer, and Novartis; has received research funding from the National Institutes of Health (R61NS135583, R01NS114632), Viz.ai, Philips, and Medtronic; compensation from the American Heart Association for editorial services; serves on the Editorial Board for Neurology and Stroke: Vascular and Interventional Neurology. Dr.Nguyen reports Associate Editor of Stroke; Advisory board of Brainomix, Aruna Bio; Speaker for Genentech, Kaneka; consulting for Medtronic.

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Hypoperfusion intensity ratio is associated with follow-up infarct volume in medium vessel occlusions: A multicenter multinational study

Collaborators

Affiliations

Hypoperfusion intensity ratio is associated with follow-up infarct volume in medium vessel occlusions: A multicenter multinational study

Authors

Collaborators

Affiliations

Abstract

Conflict of interest statement

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