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In large-vessel occlusion acute ischemic stroke (LVO-AIS), CCD may result from hemodynamic impairment, structural injury, or both. From a blood-oxygenation-level-dependent cerebrovascular reactivity (BOLD-CVR) imaging database, we identified patients with anterior-circulation LVO-AIS who underwent BOLD-CVR MRI within 7 days of symptom onset. Patients were stratified into those with persistent occlusion (non-endovascular thrombectomy, non-EVT) and those imaged after successful reperfusion (EVT). CCD was defined by a cerebellar asymmetry index\u2009&gt;\u200912%. Associations between CCD and imaging markers of structural injury (infarct lesion volume) and hemodynamic impairment (steal phenomenon volume) as well as associations with 90-day functional outcome were assessed using logistic regression models. Sensitivity analyses included multiple imputation and best-\/worst-case scenarios for missing outcomes. Seventy-nine patients were included (23 EVT, 56 non-EVT). CCD was present in 35% of EVT and 41% of non-EVT patients. In non-EVT patients, CCD was independently associated with larger steal phenomenon volumes (adjusted OR 1.99; 95% CI 1.12\u20133.73), but not infarct size. In EVT patients, CCD was associated with larger infarct lesions (adjusted OR 5.75; 95% CI 1.41\u201368.92) but not steal phenomenon volume. CCD predicted poorer 90-day outcome only in non-EVT patients in complete-case analysis, but this association was not robust in sensitivity analyses. CCD in acute LVO-AIS reflects different mechanisms depending on occlusion status: hemodynamic impairment under persistent occlusion and structural injury after reperfusion. BOLD-CVR imaging provides insight into CCD, though larger studies are needed to clarify its prognostic value.<\/jats:p>","DOI":"10.1007\/s12311-026-02014-1","type":"journal-article","created":{"date-parts":[[2026,5,6]],"date-time":"2026-05-06T23:46:39Z","timestamp":1778111199000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":2,"title":["Deciphering Crossed Cerebellar Diaschisis in Patients with Large-Vessel Occlusion Acute Ischemic Stroke using BOLD Cerebrovascular Reactivity"],"prefix":"10.1007","volume":"25","author":[{"given":"Jacopo","family":"Bellomo","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Vittorio","family":"Stumpo","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Christiaan Hendrik Bas","family":"van Niftrik","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Susanne","family":"Wegener","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Andreas","family":"Luft","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Zsolt","family":"Kulcsar","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Luca","family":"Regli","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jorn","family":"Fierstra","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Martina","family":"Seb\u00f6k","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2026,5,7]]},"reference":[{"issue":"4","key":"2014_CR1","doi-asserted-by":"publisher","first-page":"1190","DOI":"10.1002\/jmri.27410","volume":"53","author":"M Seb\u00f6k","year":"2021","unstructured":"Seb\u00f6k M, van Niftrik CHB, Piccirelli M, et al. 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