Abstract Introduction In Acute Ischemic Stroke (AIS), mismatch between Diffusion-Weighted Imaging (DWI) and Fluid-Attenuated Inversion-Recovery (FLAIR) helps identify patients who can benefit from thrombolysis when stroke onset time is unknown (15% of AIS). However, visual assessment has suboptimal observer agreement. Our study aims to develop and validate a Deep-Learning model for predicting DWI-FLAIR mismatch using solely DWI data. Patients and methods This retrospective study included AIS patients from ETIS registry (derivation cohort, 2018–2024) and WAKE-UP trial (validation cohort, 2012–2017). DWI-FLAIR mismatch was rated visually. We trained a model to predict manually-labeled FLAIR visible areas (FVA) matching the DWI lesion on baseline and early follow-up MRIs, using only DWI as input. FVA-index was defined as the volume of predicted regions. Area under the ROC curve (AUC) and optimal FVA-index cutoff to predict DWI-FLAIR mismatch in the derivation cohort were computed. Validation was performed using baseline MRIs of the validation cohort. Results The derivation cohort included 3605 MRIs in 2922 patients and the validation cohort 844 MRIs in 844 patients. FVA-index demonstrated strong predictive value for DWI-FLAIR mismatch in baseline MRIs from the derivation (n = 2453, AUC = 0.85, 95%CI: 0.84–0.87) and validation cohort (n = 844, AUC = 0.86, 95%CI: 0.84–0.89). With an optimal FVA-index cutoff at 0.5, we obtained a kappa of 0.54 (95%CI: 0.48–0.59), 70% sensitivity (378/537, 95%CI: 66–74%) and 88% specificity (269/307, 95%CI: 83–91%) in the validation cohort. Discussion and conclusion The model accurately predicts DWI-FLAIR mismatch in AIS patients with unknown stroke onset. It could aid readers when visual rating is challenging, or FLAIR unavailable.
Benzakoun et al. (2026) studied this question.