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Research ArticleORIGINAL RESEARCH

Adoption of the T2-FLAIR Mismatch Sign Among Radiologists: How Well Are We Doing?

F. Eymen Ucisik, Shekhar Khanpara, B. Berksu Ozkara, Ziyi Li, Rasha Alfattal, Samir A. Dagher, Max Wintermark and Gregory N. Fuller
American Journal of Neuroradiology April 2025, ajnr.A8783; DOI: https://doi.org/10.3174/ajnr.A8783
F. Eymen Ucisik
From the Department of Neuroradiology (F.E.U., S.K., B.B.O., S.A.D., M.W., G.N.F.), Department of Biostatistics (Z.L.), Department of Anatomic Pathology (R.A., G.N.F.) at the University of Texas MD Anderson Cancer Center, Houston, TX; Department of Diagnostic, Molecular and Interventional Radiology (B.B.O.) at the Icahn School of Medicine at Mount Sinai, New York, NY; Department of Pathology (G.N.F.) at the University of Texas Medical Branch, Galveston, TX.
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Shekhar Khanpara
From the Department of Neuroradiology (F.E.U., S.K., B.B.O., S.A.D., M.W., G.N.F.), Department of Biostatistics (Z.L.), Department of Anatomic Pathology (R.A., G.N.F.) at the University of Texas MD Anderson Cancer Center, Houston, TX; Department of Diagnostic, Molecular and Interventional Radiology (B.B.O.) at the Icahn School of Medicine at Mount Sinai, New York, NY; Department of Pathology (G.N.F.) at the University of Texas Medical Branch, Galveston, TX.
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B. Berksu Ozkara
From the Department of Neuroradiology (F.E.U., S.K., B.B.O., S.A.D., M.W., G.N.F.), Department of Biostatistics (Z.L.), Department of Anatomic Pathology (R.A., G.N.F.) at the University of Texas MD Anderson Cancer Center, Houston, TX; Department of Diagnostic, Molecular and Interventional Radiology (B.B.O.) at the Icahn School of Medicine at Mount Sinai, New York, NY; Department of Pathology (G.N.F.) at the University of Texas Medical Branch, Galveston, TX.
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Ziyi Li
From the Department of Neuroradiology (F.E.U., S.K., B.B.O., S.A.D., M.W., G.N.F.), Department of Biostatistics (Z.L.), Department of Anatomic Pathology (R.A., G.N.F.) at the University of Texas MD Anderson Cancer Center, Houston, TX; Department of Diagnostic, Molecular and Interventional Radiology (B.B.O.) at the Icahn School of Medicine at Mount Sinai, New York, NY; Department of Pathology (G.N.F.) at the University of Texas Medical Branch, Galveston, TX.
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Rasha Alfattal
From the Department of Neuroradiology (F.E.U., S.K., B.B.O., S.A.D., M.W., G.N.F.), Department of Biostatistics (Z.L.), Department of Anatomic Pathology (R.A., G.N.F.) at the University of Texas MD Anderson Cancer Center, Houston, TX; Department of Diagnostic, Molecular and Interventional Radiology (B.B.O.) at the Icahn School of Medicine at Mount Sinai, New York, NY; Department of Pathology (G.N.F.) at the University of Texas Medical Branch, Galveston, TX.
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Samir A. Dagher
From the Department of Neuroradiology (F.E.U., S.K., B.B.O., S.A.D., M.W., G.N.F.), Department of Biostatistics (Z.L.), Department of Anatomic Pathology (R.A., G.N.F.) at the University of Texas MD Anderson Cancer Center, Houston, TX; Department of Diagnostic, Molecular and Interventional Radiology (B.B.O.) at the Icahn School of Medicine at Mount Sinai, New York, NY; Department of Pathology (G.N.F.) at the University of Texas Medical Branch, Galveston, TX.
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Max Wintermark
From the Department of Neuroradiology (F.E.U., S.K., B.B.O., S.A.D., M.W., G.N.F.), Department of Biostatistics (Z.L.), Department of Anatomic Pathology (R.A., G.N.F.) at the University of Texas MD Anderson Cancer Center, Houston, TX; Department of Diagnostic, Molecular and Interventional Radiology (B.B.O.) at the Icahn School of Medicine at Mount Sinai, New York, NY; Department of Pathology (G.N.F.) at the University of Texas Medical Branch, Galveston, TX.
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Gregory N. Fuller
From the Department of Neuroradiology (F.E.U., S.K., B.B.O., S.A.D., M.W., G.N.F.), Department of Biostatistics (Z.L.), Department of Anatomic Pathology (R.A., G.N.F.) at the University of Texas MD Anderson Cancer Center, Houston, TX; Department of Diagnostic, Molecular and Interventional Radiology (B.B.O.) at the Icahn School of Medicine at Mount Sinai, New York, NY; Department of Pathology (G.N.F.) at the University of Texas Medical Branch, Galveston, TX.
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ABSTRACT

BACKGROUND AND PURPOSE: The classic T2-FLAIR mismatch sign is a highly specific MRI feature that can aid in preoperative diagnosis of IDH-mutant 1p/19q noncodeleted gliomas and affect surgical planning. This study aimed to assess the real-world utilization of the T2-FLAIR mismatch sign in clinical practice, and to explore the frequencies of classic-and partial T2-FLAIR mismatch within the IDH-mutant 1p/19q noncodeleted glioma population stratified by tumor grade.

MATERIALS AND METHODS: This retrospective cohort study from a dedicated cancer referral center included 251 patients with IDH-mutant astrocytoma diagnosed between 2017 and 2022. Pathology reports were reviewed for eligibility for the WHO 2021 diagnostic criteria. Preoperative MR imaging studies were analyzed by two neuroradiologists for the mismatch and enhancement status. MRI reports were assessed for mismatch status reporting frequency, and neuroradiology fellowship status of the dictating radiologist.

RESULTS: 286 preoperative MRIs (212 from outside facilities and 74 in-house) were available from 251 patients with 251 tumors. Of these, 22.3% exhibited classic T2-FLAIR mismatch, 29.8% partial mismatch, and 47.8% no mismatch. Mismatch status significantly differed between WHO grades 2 and 4, but not between grades 2 and 3. Male sex was significantly associated with higher grade. Radiologist reporting rates for the classic mismatch sign were low overall (21.6%), but higher for the dedicated cancer center category (43.3%) compared to other hospital categories (0–10.3%). The reporting rate was also significantly higher for radiologists with neuroradiology fellowship training compared to those without (25.0% vs 0.0%). A statistically significant upward trend in the reporting rate was observed over the years.

CONCLUSIONS: The T2-FLAIR mismatch sign is underutilized, particularly in institutions that are not specialized cancer centers. Raising awareness of the T2-FLAIR mismatch sign could enhance preoperative diagnosis of IDH-mutant astrocytoma. Additionally, while the classic mismatch sign is more common in lower-grade IDH-mutant gliomas, it remains relevant in higher-grade tumors.

ABBREVIATIONS: IDH = Isocitrate dehydrogenase; WHO = World Health Organization.

Footnotes

  • The authors declare no relevant conflicts of interest.

  • © 2025 by American Journal of Neuroradiology

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Accepted Manuscript
F. Eymen Ucisik, Shekhar Khanpara, B. Berksu Ozkara, Ziyi Li, Rasha Alfattal, Samir A. Dagher, Max Wintermark, Gregory N. Fuller
Adoption of the T2-FLAIR Mismatch Sign Among Radiologists: How Well Are We Doing?
American Journal of Neuroradiology Apr 2025, ajnr.A8783; DOI: 10.3174/ajnr.A8783

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Accepted Manuscript
Adoption of the T2-FLAIR Mismatch Sign Among Radiologists: How Well Are We Doing?
F. Eymen Ucisik, Shekhar Khanpara, B. Berksu Ozkara, Ziyi Li, Rasha Alfattal, Samir A. Dagher, Max Wintermark, Gregory N. Fuller
American Journal of Neuroradiology Apr 2025, ajnr.A8783; DOI: 10.3174/ajnr.A8783
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Print ISSN: 0195-6108 Online ISSN: 1936-959X

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