Association of distal hyperintense vessel sign and recurrent stroke in patients with symptomatic intracranial stenosis

Objective: The distal hyperintense vessel sign (DHV) on fluid-attenuated inversion recovery magnetic resonance image (MRI) is an imaging biomarker of slow lepto-meningeal collateral flow in the presence of large artery stenosis or occlusion reflect-ing impaired cerebral hemodynamics. In this study, we aim to investigate the significance of the DHV sign in patients with symptomatic > 70% intracranial ath-erosclerotic stenosis. Methods: We retrospectively reviewed patients with ischemic stroke or transient ischemic attack admitted to a single center from January 2010 to December 2017. Patients were included if they had symptomatic > 70% atheroscle-rotic stenosis of the intracranial internal carotid artery or middle cerebral artery. The presence of the DHV sign was evaluated by blinded neuroradiologist and vas-cular neurologists. Recurrent ischemic stroke in the vascular territory of symptom-atic intracranial artery was defined as new neurological deficits with associated neuroimaging findings during the follow up period. Results: A total of 109 patients were included in the study, of which 55 had DHV sign. Average duration of follow up was 297 +/- 326 days. Four patients were lost during follow up. Patients with the DHV sign had a higher rate of recurrent ischemic stroke (38%), compared to patients without the DHV sign (17%; p=0.018). In multivariate regression analysis, the presence of DHV sign was an independent predictor of recurrent ischemic stroke. A DHV score of > 2 had a 63% sensitivity and 69% specificity for recurrent ischemic stroke. Interpretation: In patients with severe symptomatic intracranial atherosclerotic stenosis, those with a DHV sign on MRI are at higher risk of recurrent ischemic stroke.