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February 27, 2024


Quantifying FHV-ASPECTS may prove useful in selecting patients for endovascular treatment, TKTKTK told NVX.


The presence of fluid-attenuated inversion recovery hyperintense vessels (FHVs) on MRI may be used as a surrogate marker for collateral status without use of catheter angiography or vascular imaging, according to a multicenter study. Moreover, these imaging findings portend better 3-month outcomes.

“FHV has been well observed and well documented, but our understanding of what this finding represents remains poor,” Sunil Sheth, MD (McGovern Medical School at UTHealth, Houston, and Memorial Hermann-Texas Medical Center), who was not involved in the research, told Neurovascular Exchange. “The authors in this study examine a large cohort of patients, all with comparable strokes and all with high quality MRI prior to endovascular treatment, to address the question of the clinical significance of FHV.”

Alexander H. Nave, MD (Universitätsmedizin Berlin, Germany), and colleagues analyzed data on 116 patients with M1 middle cerebral artery (MCA) occlusions who underwent MRI prior to endovascular therapy at one of three hospitals in Germany between January 2007 and June 2016. They quantified FHV using an FHV-Alberta Stroke Program Early CT Score (ASPECTS) rating system, with their results published online February 19, 2018, ahead of print in Stoke.

Patients’ median age was 74, and their median National Institutes of Health Stroke Scale (NIHSS) score was 14. Median FHV-ASPECTS was 2 (IQR 1-3). Good collateral status on baseline angiography, defined as an American Society of Interventional and Therapeutic Neuroradiology grade 3-4, was more frequently observed in patients with an FHV-ASPECTS ≤ 2. Similarly, good clinical outcome, based on 3-month mRS score, was also more commonly seen in this group of patients.

Association Between Collateral Status and Clinical Outcome on FHV-ASPECTS



(n = 75)


(n = 41)

P Value

Good Collateral Status




Median 3-Month mRS (IQR)

2 (0-5)

4 (3-6)



Multiple regression analyses revealed that having a FHV-ASPECTS ≤ 2 was independently associated with having a 90-day mRS of 0-2, with an adjusted odds ratio of 5.3 (95% CI, 1.5-18.2).

“The connection between improved collaterals on angiography and improved clinical outcome has been cemented through numerous previous studies,” Sheth pointed out. “This study of FHV now gives us information on collateral status without . . . the need for catheter angiography [or] any vascular imaging.”

Based on the link between low FHV-ASPECTs and good functional outcome at 3 months, the researchers say, “FHV-ASPECTS might be a valuable guide for future patient selection for endovascular therapy, especially when conventional angiography or contrast-based vascular imaging is not accessible.”

But collateral status as a means for selecting patients “remains controversial,” Seth noted. “Specifically, the concept of excluding a patient from treatment who might otherwise be a candidate on the basis of collateral status is challenging.” He said that the ultimate decision to treat patients endovascularly will continue to be based on current criteria, such as extent of infarct at the time of presentation and location of occlusion.

In addition, how generalizable the findings are remains an open question, he pointed out. “Emergent MRI for patients who present with acute ischemic stroke is currently performed in a small subset of all patients,” Seth said. “The authors themselves note that only 16% of patients with M1 occlusions qualified for this study. As such, there is not only bias in the findings, but the applicability of these results to a general population is limited.”

He recommended that the findings be “built upon by a more detailed study examining why certain patients have good collaterals/FHV and others don’t. In this study, the authors found no relationship between FHV and age and other risk factors, . . . so further work is needed to better identify why some patients but not others present with robust collaterals and what steps can be taken to augment collaterals in patients with poor flow.”



Nave AH, Kufner A, Bücke P, et al. Hyperintense vessels, collateralization, and functional outcome in patients with stroke receiving endovascular treatment. Stroke. 2018;Epub ahead of print.



Nave and Sheth report no relevant conflicts of interest.