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Adusumilli G, Faizy TD, Christensen S, Mlynash M, Loh Y, Albers GW, Lansberg MG, Fiehler J, Heit JJ. Deep venous outflow as a surrogate for collaterals in late-window patients with successful revascularization from the DEFUSE 3 cohort. Interv Neuroradiol 2024:15910199241276905. [PMID: 39194997 DOI: 10.1177/15910199241276905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/29/2024] Open
Abstract
BACKGROUND Deep venous outflow (VO) may be an important surrogate marker of collateral blood flow in acute ischemic stroke patients with a large vessel occlusion (AIS-LVO). Researchers have yet to determine the relationship between deep VO status in late-window patients and imaging measures of collaterals, which are key in preserving tissue. MATERIALS AND METHODS We performed a multicenter retrospective cohort study on a subset of DEFUSE 3 patients recruited across 38 centers between May 2016 and May 2017 who underwent successful thrombectomy revascularization. Internal cerebral vein opacification was scored on a scale of 0-2. This metric was added to the cortical vein opacification score to derive the comprehensive VO (CVO) score from 0 to 8. Patients were stratified by favorable (ICV+) and unfavorable (ICV-) ICV scores, and similarly CVO+ and CVO-. Analyses comparing outcomes were primarily conducted by Mann-Whitney U and χ2 tests. RESULTS Forty-five patients from DEFUSE 3 were scored and dichotomized into CVO+, CVO-, ICV+, and ICV- categories, with comparable demographics. Hypoperfusion intensity ratio, a marker of tissue level collaterals, was significantly worse in the ICV- and CVO- groups (p = 0.005). ICV- alone was also associated with a larger perfusion lesion (138 ml vs 87 ml; p = 0.023). No significant differences were noted in functional and safety outcomes. CONCLUSIONS Impaired deep venous drainage alone may be a marker of poor tissue level collaterals and a greater degree of affected tissue in AIS-LVO patients presenting in the late-window who subsequently undergo successful revascularization.
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Affiliation(s)
- Gautam Adusumilli
- Department of Radiology, Massachusetts General Hospital, Boston, MA, USA
| | - Tobias D Faizy
- Department of Neuroradiology, University of Hamburg-Eppendorf, Hamburg, Germany
| | | | - Michael Mlynash
- Stanford Stroke Center, Stanford University, Stanford, CA, USA
| | - Yince Loh
- Comprehensive Stroke Center, Swedish Neuroscience Institute, Seattle, WA, USA
| | | | | | - Jens Fiehler
- Department of Neuroradiology, University of Hamburg-Eppendorf, Hamburg, Germany
| | - Jeremy J Heit
- Department of Radiology, Stanford University, Stanford, CA, USA
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Jiang S, Gong C, Huang L, Wang Y, Wang Z, Chen Y, Yuan J, Wang L, Gong S, Tan D, Zhang P, Huang Y, Wen Y, Hu Y, Li Z, Li W, Liu J, Guo J, Chen S, Chen Y, Xu T. The benefit of favorable venous outflow profiles is mediated through the reduced risk of intracranial hemorrhage in acute ischemic stroke patients undergoing endovascular treatment. J Neurointerv Surg 2024:jnis-2024-021826. [PMID: 39043582 DOI: 10.1136/jnis-2024-021826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2024] [Accepted: 06/29/2024] [Indexed: 07/25/2024]
Abstract
BACKGROUND Favorable venous outflow (VO) has been recognized as an independent predictor of excellent clinical outcomes in acute ischemic stroke caused by anterior circulation large vessel occlusion (AIS-LVO) patients who received endovascular treatment (EVT). However, the reasons why VO affects clinical outcomes have not been fully explained. In this study, we aimed to identify the potential mediators of VO affecting prognosis. METHODS We conducted a multicenter retrospective cohort study of consecutive patients with AIS-LVO who underwent EVT. Baseline computed tomographic angiography (CTA) was applied to assess VO by the Cortical Vein Opacification Score (COVES). The primary outcome was functional independence at 90 days (modified Rankin Scale (mRS) score of 0-2). Classifying subtypes of intracranial hemorrhage (ICH) to explore the relationship between ICH subtypes and VO. Multivariate logistic regression and causal mediation analyses were used to evaluate the relationship among VO, functional independence, and potential mediators. RESULTS Among 860 AIS-LVO patients undergoing EVT, a total of 515 patients were included in the present study after strict screening. In multivariate logistic regression analysis, favorable VO profiles (defined as COVES 3-6) were significantly associated with a lower incidence of ICH (24.2% vs 46.9%, adjusted odds ratio (aOR) 0.48, 95% confidence interval (CI) 0.30 to 0.77, P=0.002) and a higher proportion of functional independence (58.9% vs 15.0%, aOR 4.07, 95% CI 2.41 to 6.88, P<0.001). Mediation analysis showed that favorable VO profiles significantly reduced the incidence of parencuymal hematoma (PH) 2 accounting for 8.0% (95% CI 0.9% to 19.0%) of its beneficial effect on functional independence. CONCLUSION This study demonstrated the potential mediating effects of severe ICH for the beneficial effect of favorable VO on clinical prognosis among patients with AIS-LVO who underwent EVT.
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Affiliation(s)
- Shuyu Jiang
- Department of Neurology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Chen Gong
- Department of Neurology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Liping Huang
- Department of Neurology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - You Wang
- Department of Neurology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Zhiyuan Wang
- Department of Neurology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yankun Chen
- Department of Neurology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Jinxian Yuan
- Department of Neurology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Li Wang
- Department of Neurology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Siyin Gong
- Department of Neurology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Dandan Tan
- Department of Neurology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Peng Zhang
- Department of Neurology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yunyi Huang
- Department of Neurology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yuetao Wen
- Department of Neurology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yang Hu
- Department of Neurology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Zhipeng Li
- Department of Neurology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Wenze Li
- Department of Neurology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Jin Liu
- Department of Neurology, Chongqing University Three Gorges Hospital, Chongqing, China
| | - Jing Guo
- Department of Neurology, Chongqing University Three Gorges Hospital, Chongqing, China
| | - Shengli Chen
- Department of Neurology, Chongqing University Three Gorges Hospital, Chongqing, China
| | - Yangmei Chen
- Department of Neurology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Tao Xu
- Department of Neurology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
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Lin Y, Xing Z, Lv S, Yang X, Kang J, Kang N, Wang J, Cao D. Colour-coded collateral and venous outflow patterns in estimating infarct progression and predicting functional independence for stroke patients in late time window. Br J Radiol 2024; 97:1335-1342. [PMID: 38754104 PMCID: PMC11186557 DOI: 10.1093/bjr/tqae104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 06/29/2023] [Accepted: 05/14/2024] [Indexed: 05/18/2024] Open
Abstract
OBJECTIVES To investigate whether cerebral collateral and venous outflow (VO) patterns on colour-coded multi-phase computed tomography angiography (mCTA) can estimate ischaemic core growth rate (IGR) and predict 90-day functional independence for patients with late-presenting acute ischaemic stroke (AIS). METHODS The retrospective analysis included 127 AIS patients with a late time window. All patients underwent baseline mCTA with colour-coded reconstruction and computed tomography perfusion. Both collateral score and VO score on colour-coded mCTA maps were analysed and recorded. The IGR was calculated as ischaemic core volume divided by the time from onset to imaging. A 90-day modified Rankin Scale score of 0-2 was defined as functional independence. Kendall's Tau-b analysis was used for nonparametric correlation analysis. Propensity scores, logistic regressions, and receiver operator characteristic (ROC) curves were applied to construct the prediction model. RESULTS Moderate correlations were found between collateral delay and IGR (Tau-b = -0.554) and between VO and IGR (Tau-b = -0.501). High collateral score (odds ratio = 3.01) and adequate VO (odds ratio = 4.89) remained independent predictors for 90-day functional independence after adjustment. The joint predictive model, which integrated the VO score and clinical features, demonstrated an area under the ROC curve (AUC) of 0.878. The AUCs of collateral score and VO score were 0.836 and 0.883 for outcome prediction after adjustment. CONCLUSIONS Cerebral collateral and VO patterns based on colour-coded mCTA can effectively predict infarct progression and 90-day clinical outcomes, even for AIS patients beyond the routine time window. ADVANCES IN KNOWLEDGE Colour-coded mCTA is a readily understandable post-processing technique for the rapid assessment of collateral circulation and VO status in stroke imaging. A moderate correlation was observed between the characteristics of collateral delay/VO on colour-coded mCTA and IGR in patients with AIS. Both high-quality collateral circulation and "red superficial middle cerebral vein sign" can predict 90-day functional independence even for patients beyond the routine time window.
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Affiliation(s)
- Yu Lin
- Department of Radiology, the First Affiliated Hospital of Fujian Medical University, Fuzhou 350005, China
- Department of Radiology, Zhongshan Hospital Affiliated to Xiamen University, School of Medicine, Xiamen University, Xiamen 361004, China
- Xiamen Radiology Quality Control Center, Zhongshan Hospital Affiliated to Xiamen University, School of Medicine, Xiamen University, Xiamen 361004, China
| | - Zhen Xing
- Department of Radiology, the First Affiliated Hospital of Fujian Medical University, Fuzhou 350005, China
- Department of Radiology, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou 350212, China
| | - Shaomao Lv
- Department of Radiology, Zhongshan Hospital Affiliated to Xiamen University, School of Medicine, Xiamen University, Xiamen 361004, China
- Xiamen Radiology Quality Control Center, Zhongshan Hospital Affiliated to Xiamen University, School of Medicine, Xiamen University, Xiamen 361004, China
- School of Clinical Medicine, Fujian Medical University, Fuzhou 350005, China
- The Third Clinical Medical College, Fujian Medical University, Fuzhou 350005, China
| | - Xiefeng Yang
- Department of Radiology, the First Affiliated Hospital of Fujian Medical University, Fuzhou 350005, China
- Department of Radiology, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou 350212, China
| | - Jianghe Kang
- Department of Radiology, Zhongshan Hospital Affiliated to Xiamen University, School of Medicine, Xiamen University, Xiamen 361004, China
- Xiamen Radiology Quality Control Center, Zhongshan Hospital Affiliated to Xiamen University, School of Medicine, Xiamen University, Xiamen 361004, China
| | - Nannan Kang
- Department of Radiology, Zhongshan Hospital Affiliated to Xiamen University, School of Medicine, Xiamen University, Xiamen 361004, China
| | - Jinan Wang
- Department of Radiology, Zhongshan Hospital Affiliated to Xiamen University, School of Medicine, Xiamen University, Xiamen 361004, China
- Xiamen Radiology Quality Control Center, Zhongshan Hospital Affiliated to Xiamen University, School of Medicine, Xiamen University, Xiamen 361004, China
| | - Dairong Cao
- Department of Radiology, the First Affiliated Hospital of Fujian Medical University, Fuzhou 350005, China
- Department of Radiology, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou 350212, China
- Fujian Provincial Key Laboratory of Precision Medicine for Cancer, the First Affiliated Hospital, Fujian Medical University, Fuzhou 350005, China
- Key Laboratory of Radiation Biology of Fujian Higher Education Institutions, the First Affiliated Hospital, Fujian Medical University, Fuzhou 350005, China
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Li S, Hong L, Yang W, Liu X, Zhang Y, Ling Y, He Z, Wang X, Yue Y, Dong Q, Wang F, Cheng X. The benefit of favorable venous outflow profile is mediated through reduced microvascular dysfunction in acute ischemic stroke. Eur Stroke J 2024; 9:432-440. [PMID: 38291622 PMCID: PMC11318418 DOI: 10.1177/23969873231224573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 12/18/2023] [Indexed: 02/01/2024] Open
Abstract
INTRODUCTIONS Venous outflow (VO) is emerging as a marker of microvascular integrity in acute ischemic stroke. Using hemorrhagic transformation (HT) and infarct growth as mediators, we tested whether a favorable VO profile benefited functional outcome by reducing consequences of microvascular dysfunction. PATIENTS AND METHODS Patients receiving thrombectomy in three comprehensive stroke centers due to acute anterior circulation occlusion were included. VO was assessed semi-quantitatively by the opacification of ipsilateral vein of Labbé, Trolard and superficial middle cerebral vein. HT was graded on follow-up CT. Infarct growth volume (IGV) was the difference of final infarct volume and baseline core volume. The association of VO and functional independence (90-day modified Rankin Scale ⩽ 2) was examined by logistic regression. Mediation analysis was performed among VO, HT or IGV, and functional outcome in patients with or without recanalization, respectively. RESULTS In 242 patients analyzed, VO was strongly correlated with functional independence and VO ⩾ 4 was defined favorable. In 175 patients recanalized, favorable VO was associated with a reduced risk of HT (OR = 0.82, 95% CI 0.71-0.95, p = 0.008), which accounted for 13.1% of the association between VO and favorable outcome. In 67 patients without recanalization, favorable VO was associated with decreased IGV (β = -0.07, 95% CI -0.11 to -0.02, p = 0.007). The association of favorable VO and functional independence was no longer significant (aOR = 4.84, 95% CI 0.87-38.87, p = 0.089) after including IGV in the model, suggesting a complete mediation. DISCUSSION AND CONCLUSION In patients with acute anterior large vessel occlusion, the clinical benefit of VO may be mediated through reduced microvascular dysfunction.
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Affiliation(s)
- Siyuan Li
- Department of Neurology, National Center for Neurological Disorders, Huashan Hospital, Fudan University, Shanghai, China
| | - Lan Hong
- Department of Neurology, National Center for Neurological Disorders, Huashan Hospital, Fudan University, Shanghai, China
| | - Wenhao Yang
- Department of Neurology, Seventh People’s Hospital of Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Xinyu Liu
- Department of Neurology, National Center for Neurological Disorders, Huashan Hospital, Fudan University, Shanghai, China
| | - Yiran Zhang
- Department of Neurology, National Center for Neurological Disorders, Huashan Hospital, Fudan University, Shanghai, China
| | - Yifeng Ling
- Department of Neurology, National Center for Neurological Disorders, Huashan Hospital, Fudan University, Shanghai, China
| | - Zhijiao He
- Department of Neurology, National Center for Neurological Disorders, Huashan Hospital, Fudan University, Shanghai, China
| | - Xinru Wang
- Department of Neurology, National Center for Neurological Disorders, Huashan Hospital, Fudan University, Shanghai, China
| | - Yunhua Yue
- Department of Neurology, Yangpu Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Qiang Dong
- Department of Neurology, National Center for Neurological Disorders, Huashan Hospital, Fudan University, Shanghai, China
| | - Feng Wang
- Department of Neurology, Seventh People’s Hospital of Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Xin Cheng
- Department of Neurology, National Center for Neurological Disorders, Huashan Hospital, Fudan University, Shanghai, China
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Dai L, Sun Z, Jiang J, Wei J, Song X, Chen S, Li Y. Synchronous Superficial Middle Cerebral Vein Outflow Correlates Favorable Tissue Fate After Mechanical Thrombectomy for Acute Ischemic Stroke. Acad Radiol 2024; 31:1548-1557. [PMID: 37541827 DOI: 10.1016/j.acra.2023.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 07/05/2023] [Accepted: 07/05/2023] [Indexed: 08/06/2023]
Abstract
RATIONALE AND OBJECTIVES The purpose of this study was to determine the association between hemispheric synchrony in venous outflow at baseline and tissue fate after mechanical thrombectomy (MT) for acute ischemic stroke (AIS). MATERIALS AND METHODS A two-center retrospective analysis involving AIS patients who underwent MT was performed. The four cortical veins of interest include the superficial middle cerebral vein (SMCV), sphenoparietal sinus (SS), vein of Labbé (VOL), and vein of Trolard (VOT). Baseline computed tomography perfusion data were used to compare the following outflow parameters between the hemispheres: first filling time (△FFT), time to peak (△TTP) and total filling time (△TFT). Synchronous venous outflow was defined as △FFT = 0. Multivariable regression analyses were performed to evaluate the association of venous outflow synchrony with penumbral salvage, infarct growth, and intracranial hemorrhage (ICH) after MT. RESULTS A total of 151 patients (71.4 ± 13.2 years, 65.6% women) were evaluated. Patients with synchronous SMCV outflow demonstrated significantly greater penumbral salvage (41.3 mL vs. 33.1 mL, P = 0.005) and lower infarct growth (9.0 mL vs. 14.4 mL, P = 0.015) compared to those with delayed SMCV outflow. Higher △FFTSMCV (β = -1.44, P = 0.013) and △TTPSMCV (β = -0.996, P = 0.003) significantly associated with lower penumbral salvage, while higher △FFTSMCV significantly associated with larger infarct growth (β = 1.09, P = 0.005) and increased risk of ICH (odds ratio [OR] = 1.519, P = 0.047). CONCLUSION Synchronous SMCV outflow is an independent predictor of favorable tissue outcome and low ICH risk, and thereby carries the potential as an auxiliary radiological marker aiding the treatment planning of AIS patients.
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Affiliation(s)
- Lisong Dai
- Institute of Diagnostic and Interventional Radiology, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai 200233, China (L.D., Z.S., J.J., X.S., S.C., Y.L.)
| | - Zheng Sun
- Institute of Diagnostic and Interventional Radiology, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai 200233, China (L.D., Z.S., J.J., X.S., S.C., Y.L.)
| | - Jingxuan Jiang
- Institute of Diagnostic and Interventional Radiology, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai 200233, China (L.D., Z.S., J.J., X.S., S.C., Y.L.); Department of Radiology, Affiliated Hospital of Nantong University, Nantong, Jiangsu, China (J.J.)
| | - Jianyong Wei
- Clinical Research Center, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China (J.W.)
| | - Xinyu Song
- Institute of Diagnostic and Interventional Radiology, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai 200233, China (L.D., Z.S., J.J., X.S., S.C., Y.L.)
| | - Shen Chen
- Institute of Diagnostic and Interventional Radiology, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai 200233, China (L.D., Z.S., J.J., X.S., S.C., Y.L.)
| | - Yuehua Li
- Institute of Diagnostic and Interventional Radiology, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai 200233, China (L.D., Z.S., J.J., X.S., S.C., Y.L.).
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Wang H, Shen P, Yu X, Shang Y, Xu J, Chen X, Tan M, Lin L, Parsons M, Zhang S, Geng Y. Asymmetric deep cerebral venous filling predicts poor outcome of acute basilar artery occlusion after endovascular treatment. CNS Neurosci Ther 2024; 30:e14513. [PMID: 37953498 PMCID: PMC11017399 DOI: 10.1111/cns.14513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 10/04/2023] [Accepted: 10/09/2023] [Indexed: 11/14/2023] Open
Abstract
OBJECTIVE To explore the relationship between asymmetric deep cerebral venous (ADCV) filling and poor outcomes after endovascular treatment (EVT) in patients with acute basilar artery occlusion (ABAO). METHODS ABAO patients were selected from a prospectively collected data at our center. The DCV filling was evaluated using computed tomography perfusion (CTP)-derived reconstructed 4D-DSA or mean venous map. ADCV filling was defined as the internal cerebral vein (ICV), thalamostriate vein (TSV), or basal vein of Rosenthal (BVR) presence of ipsilateral filling defects or delayed opacification compared to the contralateral side. Poor prognosis was defined as a modified Rankin scale score >3 at the 90-day follow-up. RESULTS A total of 90 patients were enrolled in the study, with a median Glasgow Coma Scale of 6, 46 (51.1%) showed ADCV filling, 59 (65.6%) had a poor prognosis, and 27 (30.7%) had malignant cerebellar edema (MCE). Multivariate adjusted analysis revealed significant associations between asymmetric TSV and poor prognosis (odds ratio, 9.091, p = 0.006); asymmetric BVR (OR, 9.232, p = 0.001) and asymmetric ICV (OR, 4.028, p = 0.041) were significantly associated with MCE. CONCLUSION Preoperative ADCV filling is an independent influencing factor for the poor outcome after EVT in ABAO patients.
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Affiliation(s)
- Huiyuan Wang
- Center for Rehabilitation Medicine, Department of NeurologyZhejiang Provincial People's Hospital (Affiliated People's Hospital, Hangzhou Medical College)HangzhouChina
- School of Clinical Medicine, Graduate SchoolBengbu Medical CollegeBengbuChina
| | - Panpan Shen
- Center for Rehabilitation Medicine, Department of NeurologyZhejiang Provincial People's Hospital (Affiliated People's Hospital, Hangzhou Medical College)HangzhouChina
- The Second Clinical Medical CollegeZhejiang Traditional Chinese Medicine UniversityHangzhouChina
| | - Xinyue Yu
- Alberta InstituteWenzhou Medical UniversityWenzhouChina
| | - Yafei Shang
- Center for Rehabilitation Medicine, Department of NeurologyZhejiang Provincial People's Hospital (Affiliated People's Hospital, Hangzhou Medical College)HangzhouChina
- School of Clinical Medicine, Graduate SchoolBengbu Medical CollegeBengbuChina
| | - Jie Xu
- Center for Rehabilitation Medicine, Department of NeurologyZhejiang Provincial People's Hospital (Affiliated People's Hospital, Hangzhou Medical College)HangzhouChina
- The Second Clinical Medical CollegeZhejiang Traditional Chinese Medicine UniversityHangzhouChina
| | - Xinyi Chen
- Center for Rehabilitation Medicine, Department of NeurologyZhejiang Provincial People's Hospital (Affiliated People's Hospital, Hangzhou Medical College)HangzhouChina
- The Second Clinical Medical CollegeZhejiang Traditional Chinese Medicine UniversityHangzhouChina
| | - Mingming Tan
- Department of Quality ManagementZhejiang Provincial People's HospitalHangzhouChina
| | - Longting Lin
- School of Medicine and Public HealthUniversity of NewcastleNew South WalesNewcastleAustralia
| | - Mark Parsons
- Department of Neurology, Liverpool HospitalUniversity of New South WalesNew South WalesSydneyAustralia
| | - Sheng Zhang
- Center for Rehabilitation Medicine, Department of NeurologyZhejiang Provincial People's Hospital (Affiliated People's Hospital, Hangzhou Medical College)HangzhouChina
| | - Yu Geng
- Center for Rehabilitation Medicine, Department of NeurologyZhejiang Provincial People's Hospital (Affiliated People's Hospital, Hangzhou Medical College)HangzhouChina
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7
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Yedavalli VS, Koneru M, Hoseinyazdi M, Greene C, Lakhani DA, Xu R, Luna LP, Caplan JM, Dmytriw AA, Guenego A, Heit JJ, Albers GW, Wintermark M, Gonzalez LF, Urrutia VC, Huang J, Nael K, Leigh R, Marsh EB, Hillis AE, Llinas RH. Prolonged venous transit on perfusion imaging is associated with higher odds of mortality in successfully reperfused patients with large vessel occlusion stroke. J Neurointerv Surg 2024:jnis-2024-021488. [PMID: 38471762 DOI: 10.1136/jnis-2024-021488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2024] [Accepted: 03/02/2024] [Indexed: 03/14/2024]
Abstract
BACKGROUND Poor venous outflow (VO) profiles are associated with unfavorable outcomes in patients with acute ischemic stroke caused by large vessel occlusion (AIS-LVO), despite achieving successful reperfusion. The objective of this study is to assess the association between mortality and prolonged venous transit (PVT), a novel visual qualitative VO marker on CT perfusion (CTP) time to maximum (Tmax) maps. METHODS We performed a retrospective analysis of prospectively collected data from consecutive adult patients with AIS-LVO with successful reperfusion (modified Thrombolysis in Cerebral Infarction 2b/2c/3). PVT+ was defined as Tmax ≥10 s timing on CTP Tmax maps in at least one of the following: superior sagittal sinus (proximal venous drainage) and/or torcula (deep venous drainage). PVT- was defined as lacking this in both regions. The primary outcome was mortality at 90 days. In a 1:1 propensity score-matched cohort, regressions were performed to determine the effect of PVT on 90-day mortality. RESULTS In 127 patients of median (IQR) age 71 (64-81) years, mortality occurred in a significantly greater proportion of PVT+ patients than PVT- patients (32.5% vs 12.6%, P=0.01). This significant difference persisted after matching (P=0.03). PVT+ was associated with a significantly increased likelihood of 90-day mortality (OR 1.22 (95% CI 1.02 to 1.46), P=0.03) in the matched cohort. CONCLUSIONS PVT+ was significantly associated with 90-day mortality despite successful reperfusion therapy in patients with AIS-LVO. PVT is a simple VO profile marker with potential as an adjunctive metric during acute evaluation of AIS-LVO patients. Future studies will expand our understanding of using PVT in the evaluation of patients with AIS-LVO.
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Affiliation(s)
- Vivek S Yedavalli
- Department of Radiology and Radiological Sciences, The Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Manisha Koneru
- Department of Radiology, Cooper Medical School of Rowan University, Camden, New Jersey, USA
| | - Meisam Hoseinyazdi
- Department of Radiology and Radiological Sciences, The Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Cynthia Greene
- Department of Radiology and Radiological Sciences, The Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Dhairya A Lakhani
- Department of Radiology and Radiological Sciences, The Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Risheng Xu
- Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Licia P Luna
- Department of Radiology and Radiological Sciences, The Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Justin M Caplan
- Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Adam A Dmytriw
- Neuroendovascular Program, Massachusetts General Hospital, Boston, Massachusetts, USA
- Neuroradiology and Neurointervention, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Adrien Guenego
- Interventional Neuroradiology Department, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
| | - Jeremy J Heit
- Department of Radiology, Stanford University School of Medicine, Stanford, California, USA
- Radiology, Stanford University, Palo Alto, California, USA
| | - Gregory W Albers
- Department of Radiology, Stanford University School of Medicine, Stanford, California, USA
- Neurology, Stanford University, Palo Alto, California, USA
| | - Max Wintermark
- The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - L Fernando Gonzalez
- Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - Judy Huang
- Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Kambiz Nael
- Department of Radiology, University of California San Francisco, San Francisco, California, USA
| | - Richard Leigh
- Neurology, Johns Hopkins Medicine, Baltimore, Maryland, USA
| | | | - Argye E Hillis
- Neurology, Johns Hopkins Medicine, Baltimore, Maryland, USA
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Pham J, Ng FC. Novel advanced imaging techniques for cerebral oedema. Front Neurol 2024; 15:1321424. [PMID: 38356883 PMCID: PMC10865379 DOI: 10.3389/fneur.2024.1321424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2023] [Accepted: 01/09/2024] [Indexed: 02/16/2024] Open
Abstract
Cerebral oedema following acute ischemic infarction has been correlated with poor functional outcomes and is the driving mechanism of malignant infarction. Measurements of midline shift and qualitative assessment for herniation are currently the main CT indicators for cerebral oedema but have limited sensitivity for small cortical infarcts and are typically a delayed sign. In contrast, diffusion-weighted (DWI) or T2-weighted magnetic resonance imaging (MRI) are highly sensitive but are significantly less accessible. Due to the need for early quantification of cerebral oedema, several novel imaging biomarkers have been proposed. Based on neuroanatomical shift secondary to space-occupying oedema, measures such as relative hemispheric volume and cerebrospinal fluid displacement are correlated with poor outcomes. In contrast, other imaging biometrics, such as net water uptake, T2 relaxometry and blood brain barrier permeability, reflect intrinsic tissue changes from the influx of fluid into the ischemic region. This review aims to discuss quantification of cerebral oedema using current and developing advanced imaging techniques, and their role in predicting clinical outcomes.
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Affiliation(s)
- Jenny Pham
- Department of Radiology, Royal Melbourne Hospital, Parkville, VIC, Australia
| | - Felix C. Ng
- Department of Neurology, Royal Melbourne Hospital, Parkville, VIC, Australia
- Department of Neurology, Austin Health, Heidelberg, VIC, Australia
- Department of Medicine at Royal Melbourne Hospital, Melbourne Brain Centre, University of Melbourne, Parkville, VIC, Australia
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9
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Li X, Lin L, Zhang J, Fan Y, Xing S, Jiang L, Yang Z, Zhao J, Li J. Microvascular dysfunction associated with unfavorable venous outflow in acute ischemic stroke patients. J Cereb Blood Flow Metab 2023; 43:106-115. [PMID: 36967711 PMCID: PMC10638995 DOI: 10.1177/0271678x231165606] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Revised: 02/23/2023] [Accepted: 03/05/2023] [Indexed: 06/18/2023]
Abstract
Unfavorable venous outflow (VO) is associated with cerebral edema, which represents microvascular dysfunction. This study estimated the relationship between VO and microvascular function in acute ischemic stroke patients. We retrospectively included 102 MCA/ICA occluded patients with anterior circulation infarction who underwent reperfusion therapy between July 2017 and April 2022. Unfavorable VO was defined as a cortical vein opacification score of 0-3 and favorable VO as that of 4-6. The clinical characteristics, collateral status, microvascular integrity, and outcomes were compared between patients with favorable and unfavorable VO. Multivariate analysis and receiver operator characteristic (ROC) analysis were used. The patients with unfavorable VO had higher extravascular-extracellular volume fraction (Ve) in the infarct core and a lower percentage of robust arterial collateral circulation. ROC analysis revealed that Ve in the infarct core predicts unfavorable VO (AUC = 0.67, sensitivity = 65.08%, specificity = 69.23%). The higher Ve in the infarct core (odds ratio = 1.011, 95% CI = 1.000-1.021, P = 0.046) and poor arterial collateral flow (odds ratio = 0.102, 95% CI = 0.032-0.327, P < 0.001) were independent predictors of unfavorable VO. This suggests that microvascular dysfunction may be one of the mechanisms underlying impaired VO.
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Affiliation(s)
- Xiaoshuang Li
- Department of Neurology, The First Affiliated Hospital, Sun Yat-Sen University, Guangdong Provincial Key Laboratory of Diagnosis and Treatment of Major Neurological Diseases, National Key Clinical Department and Key Discipline of Neurology, Guangzhou, China
| | - Liping Lin
- Department of Radiology, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Jian Zhang
- Department of Neurology, The First Affiliated Hospital, Sun Yat-Sen University, Guangdong Provincial Key Laboratory of Diagnosis and Treatment of Major Neurological Diseases, National Key Clinical Department and Key Discipline of Neurology, Guangzhou, China
| | - Yuhua Fan
- Department of Neurology, The First Affiliated Hospital, Sun Yat-Sen University, Guangdong Provincial Key Laboratory of Diagnosis and Treatment of Major Neurological Diseases, National Key Clinical Department and Key Discipline of Neurology, Guangzhou, China
| | - Shihui Xing
- Department of Neurology, The First Affiliated Hospital, Sun Yat-Sen University, Guangdong Provincial Key Laboratory of Diagnosis and Treatment of Major Neurological Diseases, National Key Clinical Department and Key Discipline of Neurology, Guangzhou, China
| | - Li Jiang
- Department of Radiology, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Zhiyun Yang
- Department of Radiology, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Jing Zhao
- Department of Radiology, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Jingjing Li
- Department of Neurology, The First Affiliated Hospital, Sun Yat-Sen University, Guangdong Provincial Key Laboratory of Diagnosis and Treatment of Major Neurological Diseases, National Key Clinical Department and Key Discipline of Neurology, Guangzhou, China
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10
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Guo Y, Li P, Boltze J. Recent advances in mechanistic, therapeutic, and diagnostic research of cerebrovascular diseases: updates from brain & BrainPET 2022. J Cereb Blood Flow Metab 2023; 43:4-7. [PMID: 37589500 PMCID: PMC10638987 DOI: 10.1177/0271678x231183290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 06/02/2023] [Accepted: 06/03/2023] [Indexed: 08/18/2023]
Abstract
Cerebrovascular dysfunction and diseases are major causes of mortality, morbidity, and poor quality of patient life. Despite the enormous socioeconomic burden imposed by these conditions, therapeutic options remain scarce. However, rigorous preclinical and clinical research has augmented our mechanistic understanding of cerebrovascular diseases and underlying pathophysiological processes, and there is some optimism that novel therapeutic strategies may be developed in the next decade. This special collection comprises preclinical and clinical studies from investigators who presented their work at the Brain & BrainPET 2022 conference. It highlights recent research on cerebrovascular disease mechanisms, diagnosis, and treatments. A focus is set on cerebroprotective strategies during acute and chronic cerebral ischemia and predicting stroke risk and unfavorable outcomes. The special collection also sheds light on emerging novel treatment targets and management strategies in the pursuit of better clinical outcomes for patients with cerebrovascular diseases.
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Affiliation(s)
- Yunlu Guo
- Department of Anesthesiology, Key Laboratory of the Ministry of Education of Anesthesia Medicine, Clinical Research Center, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Peiying Li
- Department of Anesthesiology, Key Laboratory of the Ministry of Education of Anesthesia Medicine, Clinical Research Center, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Johannes Boltze
- School of Life Sciences, University of Warwick, Coventry, UK
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11
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Dodd WS, Dayton O, Lucke-Wold B, Reitano C, Sorrentino Z, Busl KM. Decrease in cortical vein opacification predicts outcome after aneurysmal subarachnoid hemorrhage. J Neurointerv Surg 2023; 15:1105-1110. [PMID: 36456184 DOI: 10.1136/jnis-2022-019578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 11/20/2022] [Indexed: 12/05/2022]
Abstract
BACKGROUND The pathophysiology of brain injury after aneurysmal subarachnoid hemorrhage (aSAH) remains incompletely understood. Cerebral venous flow patterns may be a marker of hemodynamic disruptions after aneurysm rupture. We hypothesized that a decrease in venous filling after aSAH would predict cerebral ischemia and poor outcome. OBJECTIVE To examine the hypotheses that venous filling as measured by the cortical venous opacification score (COVES) would (1) decrease after aSAH and (2) that decreased COVES would be associated with higher rates of hydrocephalus, vasospasm, delayed cerebral iscemia (DCI), and poor functional evaluation at outcome. METHODS In this retrospective observational cohort study of consecutive patients with aSAH admitted to our tertiary care center between 2016 and 2018, we measured the COVES at admission and at subsequent CT angiography (CTA). We collected clinical variables and compared hydrocephalus, vasospasm, DCI, and outcome at discharge in patients with decrease in COVES with patients with stable COVES. RESULTS A total of 22 patients were included in the analysis. COVES decreased from first CTA to second CTA in 11 (50%) patients, by an average of 1.1 points (P=0.01). Patients whose COVES decreased between admission and follow-up imaging were more likely to develop DCI (58% vs 0%, P=0.03) and have a poor outcome at discharge (100% vs 55%, P=0.03) than patients who had no change in COVES. aSAH severity was not associated with initial COVES, and there was no association between change in COVES and development of hydrocephalus or vasospasm. CONCLUSIONS Development of decreased venous filling on CTA is associated with poor outcome after aSAH. This association suggests that venous hemodynamics may be reflective of, or contribute to, the pathophysiological mechanisms of brain injury after aSAH. Larger prospective studies are necessary to substantiate our findings.
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Affiliation(s)
- William S Dodd
- College of Medicine, University of Florida, Gainesville, Florida, USA
| | - Orrin Dayton
- Department of Radiology, University of Florida, Gainesville, Florida, USA
| | - Brandon Lucke-Wold
- Department of Neurosurgery, University of Florida, Gainesville, Florida, USA
| | - Christian Reitano
- Department of Radiology, University of Florida, Gainesville, Florida, USA
| | - Zachary Sorrentino
- Department of Neurosurgery, University of Florida, Gainesville, Florida, USA
| | - Katharina M Busl
- Department of Neurosurgery, University of Florida, Gainesville, Florida, USA
- Department of Neurology, University of Florida, Gainesville, Florida, USA
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12
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Chu Y, Yin ZX, Ni WJ, Lu SS, Shi HB, Liu S, Wu FY, Xu XQ. Prognostic Value of Venous Outflow Profiles on Multiphase CT Angiography for the Patients with Acute Ischemic Stroke After Endovascular Thrombectomy. Transl Stroke Res 2023:10.1007/s12975-023-01187-9. [PMID: 37667134 DOI: 10.1007/s12975-023-01187-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 07/14/2023] [Accepted: 08/07/2023] [Indexed: 09/06/2023]
Abstract
To evaluate the prognostic value of venous outflow (VO) profiles evaluated on multiphase CTA (mCTA) for the patients with acute ischemic stroke (AIS) after endovascular thrombectomy (EVT). We retrospectively collected 150 patients with AIS who underwent pre-treatment CT perfusion (CTP) evaluation and subsequent EVT from April 2018 to April 2022. Three-phases (peak arterial phase, peak venous phase, late venous phase) CTA was reconstructed from CTP raw data, and VO was evaluated on three-phases CTA, respectively. Favorable VO was regarded as a cortical vein opacification score of 3-6, and unfavorable VO as a score of 0-2. Good outcome was defined as modified Rankin Scale score of 0-2 at 90 days after EVT. Multivariate logistic regression analysis was performed to explore the predictors of good outcome. Prognostic value was assessed and compared using receiver operating characteristic (ROC) curves and Delong test. We found that good outcome was achieved in 85 (56.7%) patients. Among the mCTA-derived VO profiles, only favorable peak venous phase VO was found to be independently associated with good outcome (P < 0.001). After integrating favorable peak venous phase VO with lower post-treatment National Institute of Health Stroke Scale score at 24 hours, successful recanalization and favorable hypoperfusion intensity ratio, the predictive ability for a good outcome was significantly improved than before (area under the ROC curve; 0.947 vs 0.881; P = 0.002). This study supports that favorable peak venous VO profiles on mCTA might be a promising biomarker in predicting the good outcome in patients with AIS after EVT.
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Affiliation(s)
- Yue Chu
- Department of Radiology, The First Affiliated Hospital of Nanjing Medical University, No. 300, Guangzhou Rd, Nanjing, China
| | - Zi-Xin Yin
- Department of Radiology, The First Affiliated Hospital of Nanjing Medical University, No. 300, Guangzhou Rd, Nanjing, China
| | - Wen-Jing Ni
- Department of Radiology, The First Affiliated Hospital of Nanjing Medical University, No. 300, Guangzhou Rd, Nanjing, China
| | - Shan-Shan Lu
- Department of Radiology, The First Affiliated Hospital of Nanjing Medical University, No. 300, Guangzhou Rd, Nanjing, China
| | - Hai-Bin Shi
- Department of Interventional Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Sheng Liu
- Department of Interventional Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Fei-Yun Wu
- Department of Radiology, The First Affiliated Hospital of Nanjing Medical University, No. 300, Guangzhou Rd, Nanjing, China
| | - Xiao-Quan Xu
- Department of Radiology, The First Affiliated Hospital of Nanjing Medical University, No. 300, Guangzhou Rd, Nanjing, China.
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13
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Wang J, Li J, Liu J, Wu J, Gu S, Yao Y, Luo T, Huang C, Huang F, Li Y. Significant Slowed Cortical Venous Blood Flow in Patients with Acute Ischemic Stroke with Large Vessel Occlusion Suggests Poor Collateral Circulation and Prognosis. Acad Radiol 2023; 30:1896-1903. [PMID: 36543687 DOI: 10.1016/j.acra.2022.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 12/02/2022] [Indexed: 12/24/2022]
Abstract
RATIONALE AND OBJECTIVES To investigate the change of cortical venous flow in acute ischemic stroke patients with large vessel occlusion (LVO-AIS) and its clinical value. MATERIALS AND METHODS Baseline whole-brain 4D-CTA/CTP and clinical data of LVO-AIS and a control group were collected from June 2020 to October 2021. Venous inflow time (VIT), venous peak time (VPT), and venous outflow time (VOT) were analyzed on both sides of patients and normal controls. The VIT/VPT/VOT were statistically described and compared between the patient group and normal controls, then, in patients with different collateral circulation and prognoses. Next, the correlation between cortical venous drainage time and collateral circulation grading was analyzed. Finally, logistic regression analysis was used to explore the relationship between the three venous times and prognosis, and receiver operating characteristic (ROC) curves were plotted to assess the value of delayed cortical venous imaging in predicting prognosis. RESULTS 149 LVO-AIS and 73 normal controls were collected. VIT, VPT, and VOT were significantly delayed on the affected side in the patient group compared with the healthy side (p<0.05) and the controls (p<0.05); VIT and VPT were also significantly delayed on the healthy side of patients compared with the controls (p<0.05). Delayed VIT and VPT on the affected side in the patient group were more significant in patients with poor collateral circulation (p<0.05), and VIT and VPT on the affected side in the patient group were negatively correlated with arterial collateral scores. VIT and VPT were significantly delayed in both sides of patients in the poor prognosis group compared with the good prognosis group (p<0.05). logistic regression showed that patients' affected VPT, arterial collateral scores, and NIHSS were independent predictors of poor prognosis, with an accuracy of 79.6% in predicting poor prognosis. The affected VPT and NIHSS were independent predictors of poor prognosis for patients presenting within 24 hours, with an accuracy of 79.6% in predicting poor prognosis. CONCLUSION Cortical venous flow was significantly slowed in both sides of LVO-AIS patients. delayed ipsilateral VPT in LVO-AIS patients can be used as an imaging indicator to determine poor collateral circulation and predict poor prognosis.
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Affiliation(s)
- Jingjie Wang
- Department of Radiology, the First Affiliated Hospital of Chongqing Medical University, Chongqing, P.R.China
| | - Jing Li
- Department of Radiology, the First Affiliated Hospital of Chongqing Medical University, Chongqing, P.R.China; Medical Imaging Center, Central Hospital of Shaoyang, Shaoyang, HN, P.R.China
| | - Jiayang Liu
- Department of Radiology, the First Affiliated Hospital of Chongqing Medical University, Chongqing, P.R.China
| | - Jiajing Wu
- Department of Radiology, NO.958th Hospital of PLA Army, Chongqing, P.R. China
| | - Sirun Gu
- Department of Radiology, the First Affiliated Hospital of Chongqing Medical University, Chongqing, P.R.China
| | - Yunzhuo Yao
- Department of Radiology, the First Affiliated Hospital of Chongqing Medical University, Chongqing, P.R.China
| | - Tianyou Luo
- Department of Radiology, the First Affiliated Hospital of Chongqing Medical University, Chongqing, P.R.China
| | - Cheng Huang
- Department of Neurology, the First Affiliated Hospital of Chongqing Medical University, Chongqing, P.R. China
| | - Fusen Huang
- Department of Anesthesiology, the First Affiliated Hospital of Chongqing Medical University, Chongqing, P.R. China.
| | - Yongmei Li
- Department of Radiology, the First Affiliated Hospital of Chongqing Medical University, Chongqing, P.R.China
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14
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Heitkamp C, Winkelmeier L, Heit JJ, Albers GW, Lansberg MG, Wintermark M, Broocks G, van Horn N, Kniep HC, Sporns PB, Zeleňák K, Fiehler J, Faizy TD. Unfavorable cerebral venous outflow is associated with futile recanalization in acute ischemic stroke patients. Eur J Neurol 2023; 30:2684-2692. [PMID: 37243906 DOI: 10.1111/ene.15898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Revised: 05/11/2023] [Accepted: 05/24/2023] [Indexed: 05/29/2023]
Abstract
BACKGROUND AND PURPOSE Mechanical thrombectomy (MT) has proven to be the standard of care for patients with acute ischemic stroke due to large vessel occlusion (AIS-LVO). However, high revascularization rates do not necessarily result in favorable functional outcomes. We aimed to investigate imaging biomarkers associated with futile recanalization, defined as unfavorable functional outcome despite successful recanalization in AIS-LVO patients. METHODS A retrospective multicenter cohort study was made of AIS-LVO patients treated by MT. Successful recanalization was defined as modified Thrombolysis in Cerebral Infarction score of 2b-3. A modified Rankin Scale score of 3-6 at 90 days was defined as unfavorable functional outcome. Cortical Vein Opacification Score (COVES) was used to assess venous outflow (VO), and the Tan scale was utilized to determine pial arterial collaterals on admission computed tomography angiography (CTA). Unfavorable VO was defined as COVES ≤ 2. Multivariable regression analysis was performed to investigate vascular imaging factors associated with futile recanalization. RESULTS Among 539 patients in whom successful recanalization was achieved, unfavorable functional outcome was observed in 59% of patients. Fifty-eight percent of patients had unfavorable VO, and 31% exhibited poor pial arterial collaterals. In multivariable regression, unfavorable VO was a strong predictor (adjusted odds ratio = 4.79, 95% confidence interval = 2.48-9.23) of unfavorable functional outcome despite successful recanalization. CONCLUSIONS We observe that unfavorable VO on admission CTA is a strong predictor of unfavorable functional outcomes despite successful vessel recanalization in AIS-LVO patients. Assessment of VO profiles could help as a pretreatment imaging biomarker to determine patients at risk for futile recanalization.
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Affiliation(s)
- Christian Heitkamp
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Laurens Winkelmeier
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jeremy J Heit
- Department of Radiology, Stanford University School of Medicine, Stanford, California, USA
| | - Gregory W Albers
- Department of Neurology, Stanford University School of Medicine, Stanford, California, USA
| | - Maarten G Lansberg
- Department of Neurology, Stanford University School of Medicine, Stanford, California, USA
| | - Max Wintermark
- Department of Neuroradiology, University of Texas MD Anderson Cancer Center, Children's Cancer Hospital, Houston, Texas, USA
| | - Gabriel Broocks
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Noel van Horn
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Helge C Kniep
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Peter B Sporns
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Department of Neuroradiology, University Hospital Basel, Basel, Switzerland
- Department of Radiology and Neuroradiology, Stadtspital Zürich, Zurich, Switzerland
| | - Kamil Zeleňák
- Department of Radiology, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovakia
| | - Jens Fiehler
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Tobias D Faizy
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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15
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Gao J, Zhang L, Lin J, Yang J, Yao M, Cheng Z, Cai X, Huang L. Stroke recurrence is associated with unfavorable intracranial venous outflow in patients with symptomatic intracranial atherosclerotic large vessel severe stenosis or occlusion. Front Neurol 2023; 14:1156315. [PMID: 37228413 PMCID: PMC10203233 DOI: 10.3389/fneur.2023.1156315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 04/20/2023] [Indexed: 05/27/2023] Open
Abstract
Objective The purpose of this study was to investigate the predictive value of intracranial venous outflow for recurrent cerebral ischemic events (RCIE) in patients with symptomatic intracranial atherosclerotic large-vessel severe stenosis or occlusion (sICAS-S/O). Methods This retrospective study included sICAS-S/O patients with anterior circulation who underwent dynamic computed tomography angiography (dCTA) and computed tomography perfusion (CTP). Arterial collaterals were evaluated using the pial arterial filling score for dCTA data, tissue-level collaterals (TLC) were assessed using the high-perfusion intensity ratio (HIR, Tmax >10 s/Tmax >6 s), and cortical veins were evaluated using the multi-phase venous score (MVS) for the vein of Labbé (VOL), sphenoparietal sinus (SPS), and superficial cerebral middle vein (SCMV). The relationships between multi-phase venous outflow (mVO), TLC, and 1-year RCIE were analyzed. Results Ninety-nine patients were included, 37 of whom had unfavorable mVO (mVO-) and 62 of whom had favorable mVO (mVO+). Compared with the mVO+ patients, mVO- patients had a higher admission National Institutes of Health Stroke Scale (NIHSS) score (median, 4 [interquartile range (IQR), 0-9] vs. 1 [IQR, 0-4]; p = 0.048), larger ischemic volume (median, 74.3 [IQR, 10.1-177.9] vs. 20.9 [IQR, 5-86.4] mL; p = 0.042), and worse tissue perfusion (median, 0.04 [IQR, 0-0.17] vs. 0 [IQR, 0-0.03]; p = 0.007). Multivariate regression analysis showed that mVO- was an independent predictor of 1-year RCIE. Conclusion For patients with sICAS-S/O of the anterior circulation, unfavorable intracranial venous outflow is a potential imaging indicator for predicting higher 1-year RCIE risk.
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Affiliation(s)
- Jiali Gao
- Department of Neurology, Clinical Neuroscience Institute, First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Liang Zhang
- Department of Neurology, Clinical Neuroscience Institute, First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Jiaxin Lin
- Department of Neurology, Clinical Neuroscience Institute, First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Jiajie Yang
- Department of Neurology, Clinical Neuroscience Institute, First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Mingzheng Yao
- Department of Neurology, Clinical Neuroscience Institute, First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Zhongyuan Cheng
- Medical Imaging Center, First Affiliated Hospital, Jinan University, Guangzhou, China
| | - Xiangran Cai
- Medical Imaging Center, First Affiliated Hospital, Jinan University, Guangzhou, China
| | - Li’an Huang
- Department of Neurology, Clinical Neuroscience Institute, First Affiliated Hospital of Jinan University, Guangzhou, China
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16
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Shang W, Zhong K, Shu L, Li Z, Hong H. Evaluation of extent vs velocity of cortical venous filing in stroke outcome after endovascular thrombectomy. Neuroradiology 2023:10.1007/s00234-023-03146-5. [PMID: 37022485 DOI: 10.1007/s00234-023-03146-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Accepted: 03/29/2023] [Indexed: 04/07/2023]
Abstract
PURPOSE Abnormal venous drainage may affect the prognosis of patients undergoing endovascular reperfusion therapy (ERT). Herein, time-resolved dynamic computed tomography arteriography (dCTA) was applied to evaluate the relationship between the velocity and extent of cortical venous filling (CVF), collateral status and outcomes. METHODS Thirty-five consecutive patients with acute anterior circulation occlusion who underwent ERT within 24 h of onset and successfully recanalized were enrolled. All patients underwent dCTA before ERT. Slow first or end of CVF was considered to occur when the time point of CVF appearance or disappearance on the affected side occurred after than that on the healthy side, whereas an equal CVF, a CVF reduced by ≤ 50%, or by > 50% on the affected side, were considered good, intermediate, and poor CVF extent, respectively. RESULTS Slow first CVF (29 patients, 82.8%), slow end of CVF (29, 85.7%), and intermediate extent of CVF (7, 20.0%) were not associated with collateral status or outcomes. Poor extent of CVF (6, 17.1%) was associated with poor collateral status, higher proportion of midline shift, larger final infarct volume, higher modified Rankin Scale (mRS) score at discharge, and higher proportion of in-hospital mortality. All patients with transtentorial herniation had poor extent of CVF, and those with poor CVF extent had an mRS score ≥ 3 at discharge. CONCLUSION Poor CVF extent, as assessed by dCTA, is a more accurate and specific marker than slow CVF to identify patients at high risk for poor outcomes after ERT.
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Affiliation(s)
- Wenjin Shang
- Department of Neurology, The First Affiliated Hospital, SunYat-sen University, Guangzhou, Guangdong Province, China
- Guangdong Provincial Key Laboratory of Diagnosis and Treatment of Major Neurological Diseases, Guangzhou, Guangdong Province, China
- National Key Clinical Department and Key Discipline of Neurology, Guangzhou, Guangdong Province, China
| | - Kaiyi Zhong
- Department of Neurology, The First Affiliated Hospital, SunYat-sen University, Guangzhou, Guangdong Province, China
- Guangdong Provincial Key Laboratory of Diagnosis and Treatment of Major Neurological Diseases, Guangzhou, Guangdong Province, China
- National Key Clinical Department and Key Discipline of Neurology, Guangzhou, Guangdong Province, China
| | - Liming Shu
- Department of Neurology, The Second Affiliated Hospital, Guangzhou Medical University, Guangzhou, Guangdong Province, China
| | - Zhuhao Li
- Department of Radiology, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, Guangdong Province, China
| | - Hua Hong
- Department of Neurology, The First Affiliated Hospital, SunYat-sen University, Guangzhou, Guangdong Province, China.
- Guangdong Provincial Key Laboratory of Diagnosis and Treatment of Major Neurological Diseases, Guangzhou, Guangdong Province, China.
- National Key Clinical Department and Key Discipline of Neurology, Guangzhou, Guangdong Province, China.
- Department of Geriatrics, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, Guangdong Province, China.
- Health Management Center, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, Guangdong Province, China.
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17
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Zhang R, Yan S, Zhong W, Chen L, Luo Z, Xu C, Li Q, Xu J, Zhang W, Liu C, Lou M. Impaired intracranial venous outflow profiles are associated with poor outcome in stroke after reperfusion therapy: A hypoperfusion-matched intracranial venous scale. Eur J Radiol 2023; 161:110745. [PMID: 36804310 DOI: 10.1016/j.ejrad.2023.110745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 02/12/2023] [Indexed: 02/17/2023]
Abstract
PURPOSE Arterial blood flow provided prognostic information in acute ischemic stroke (AIS). However, part of the patients with favorable arterial blood flow still suffered from poor outcomes after reperfusion therapy. We aimed to verify the hypothesis that intracranial venous outflow profiles (both cortical and deep) within the hypoperfusion area were associated with clinical outcome in AIS patients who received reperfusion therapy. METHOD We performed a retrospective analysis of prospectively collected data from anterior circulation AIS patients. All patients underwent pretreatment CTP and received reperfusion therapy. We constructed a 5-point hypoperfusion-matched Intracranial Venous Scale (hypo-IVS) from the sum of the contrast enhancement degree (1, attenuated contrast enhancement; 0, complete contrast enhancement) of 4 typical veins (superficial middle cerebral vein, vein of Labbé, vein of Trolard, and internal cerebral vein) whose outflow territories had matched hypoperfusion. Logistic and ordinal regression were used to analyze the association between hypo-IVS and clinical outcome. RESULTS A total of 751 patients were included. Higher Hypo-IVS was significantly associated with poor outcome (3-month mRS of >2; OR = 1.194; 95 % CI: 1.014-1.407; p = 0.033). The adjusted ORs for poor outcome and high 24-hour NIHSS were 1.172 (95 %CI: 1.035-1.328; p = 0.012) and 1.176 (95 %CI: 1.030-1.330; p = 0.010) in ordinal regression, respectively. Hypo-IVS > 2 was an independent risk factor of poor outcome (75.2 % vs 40.8 %; OR = 1.932; 95 %CI: 1.158-3.224; p = 0.012). CONCLUSIONS Intracranial venous outflow profiles deliver prognostic information in AIS and the hypo-IVS is a helpful tool to predict clinical outcomes after reperfusion therapy.
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Affiliation(s)
- Ruoxia Zhang
- Department of Neurology, The 2nd Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - Shenqiang Yan
- Department of Neurology, The 2nd Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - Wansi Zhong
- Department of Neurology, The 2nd Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - Lin Chen
- Department of Neurology, The 2nd Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - Zhongyu Luo
- Department of Neurology, The 2nd Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - Chao Xu
- Department of Neurology, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou, China
| | - Qingqing Li
- Department of Neurology, The 2nd Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - Jinjin Xu
- Intensive Care Unit, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Wenhua Zhang
- Department of Neurology, Hang Zhou Traditional Chinese Medicine Hospital Affiliated to Zhejiang Chinese Medical University, Hangzhou, China
| | - Chang Liu
- Department of Neurology, The 2nd Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Min Lou
- Department of Neurology, The 2nd Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China.
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Han W, Song Y, Rocha M, Shi Y. Ischemic brain edema: Emerging cellular mechanisms and therapeutic approaches. Neurobiol Dis 2023; 178:106029. [PMID: 36736599 DOI: 10.1016/j.nbd.2023.106029] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 01/14/2023] [Accepted: 01/30/2023] [Indexed: 02/05/2023] Open
Abstract
Brain edema is one of the most devastating consequences of ischemic stroke. Malignant cerebral edema is the main reason accounting for the high mortality rate of large hemispheric strokes. Despite decades of tremendous efforts to elucidate mechanisms underlying the formation of ischemic brain edema and search for therapeutic targets, current treatments for ischemic brain edema remain largely symptom-relieving rather than aiming to stop the formation and progression of edema. Recent preclinical research reveals novel cellular mechanisms underlying edema formation after brain ischemia and reperfusion. Advancement in neuroimaging techniques also offers opportunities for early diagnosis and prediction of malignant brain edema in stroke patients to rapidly adopt life-saving surgical interventions. As reperfusion therapies become increasingly used in clinical practice, understanding how therapeutic reperfusion influences the formation of cerebral edema after ischemic stroke is critical for decision-making and post-reperfusion management. In this review, we summarize these research advances in the past decade on the cellular mechanisms, and evaluation, prediction, and intervention of ischemic brain edema in clinical settings, aiming to provide insight into future preclinical and clinical research on the diagnosis and treatment of brain edema after stroke.
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Affiliation(s)
- Wenxuan Han
- Department of Neurology, University of Pittsburgh, Pittsburgh, PA 15213, United States of America
| | - Yang Song
- Department of Neurology, University of Pittsburgh, Pittsburgh, PA 15213, United States of America
| | - Marcelo Rocha
- Department of Neurology, University of Pittsburgh, Pittsburgh, PA 15213, United States of America
| | - Yejie Shi
- Department of Neurology, University of Pittsburgh, Pittsburgh, PA 15213, United States of America.
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19
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Seifert K, Heit JJ. Collateral Blood Flow and Ischemic Core Growth. Transl Stroke Res 2023; 14:13-21. [PMID: 35699917 DOI: 10.1007/s12975-022-01051-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 06/02/2022] [Accepted: 06/06/2022] [Indexed: 01/31/2023]
Abstract
Treatment of a large vessel occlusion in the acute ischemic stroke setting focuses on vessel recanalization, and endovascular thrombectomy results in favorable outcomes in appropriate candidates. Expeditious treatment is imperative, but patients often present to institutions that do not have neurointerventional surgeons and need to be transferred to a comprehensive stroke center. These treatment delays are common, and it is important to identify factors that mitigate the progression of the ischemic core in order to maximize the preservation of salvageable brain tissue. Collateral blood flow is the strongest factor known to influence ischemic core growth, which includes the input arterial vessels, tissue-level vessels, and venous outflow. Collateral blood flow at these different levels may be imaged by specific imaging techniques that may also predict ischemic core growth during treatment delays and help identify patients who would benefit from transfer and endovascular therapy, as well as identify those patients in whom transfer may be futile. Here we review collateral blood flow and its relationship to ischemic core growth in stroke patients.
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Affiliation(s)
- Kimberly Seifert
- Department of Radiology, Stanford University School of Medicine, Stanford, CA, USA
| | - Jeremy J Heit
- Department of Radiology, Stanford University School of Medicine, Stanford, CA, USA. .,Radiology and Neurosurgery, Stanford University School of Medicine, 453 Quarry Road, Palo Alto, CA, 94304, USA.
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20
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Shang W, Zhong K, Shu L, Li Z, Hong H. Poor Internal Jugular Venous Outflow Is Associated with Poor Cortical Venous Outflow and Outcomes after Successful Endovascular Reperfusion Therapy. Brain Sci 2022; 13:brainsci13010032. [PMID: 36672011 PMCID: PMC9856844 DOI: 10.3390/brainsci13010032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 12/16/2022] [Accepted: 12/19/2022] [Indexed: 12/25/2022] Open
Abstract
Many patients show poor outcomes following endovascular reperfusion therapy (ERT), and poor cortical venous outflow is a risk factor for these poor outcomes. We investigated the association between the outflow of the internal jugular vein (IJV) and baseline cortical venous outflow and the outcomes after ERT. We retrospectively enrolled 78 patients diagnosed with an acute anterior circulation stroke and successful ERT. Poor IJV outflow on the affected side was defined as stenosis ≥50% or occlusion of ipsilateral IJV, and poor outflow of bilateral IJVs was defined as stenosis ≥50% or occlusion of both IJVs. Poor cortical venous outflow was defined as a cortical vein opacification score (COVES) of 0 on admission. Multivariate analysis showed that poor outflow of IJV on the affected side was an independent predictor for hemorrhagic transformation. The poor outflow of bilateral IJVs was an independent risk factor for poor clinical outcomes. These patients also had numerical trends of a higher incidence of symptomatic intracranial hemorrhage, midline shift >10 mm, and in-hospital mortality; however, statistical significance was not observed. Additionally, poor IJV outflow was an independent determinant of poor cortical venous outflow. For acute large vessel occlusion patients, poor IJV outflow is associated with poor baseline cortical venous outflow and outcomes after successful ERT.
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Affiliation(s)
- Wenjin Shang
- Department of Neurology, The First Affiliated Hospital, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Diagnosis and Treatment of Major Neurological Diseases, National Key Clinical Department and Key Discipline of Neurology, Guangzhou 510080, China
| | - Kaiyi Zhong
- Department of Neurology, The First Affiliated Hospital, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Diagnosis and Treatment of Major Neurological Diseases, National Key Clinical Department and Key Discipline of Neurology, Guangzhou 510080, China
| | - Liming Shu
- Department of Neurology, The Second Affiliated Hospital, Guangzhou Medical University, Guangzhou 510260, China
| | - Zhuhao Li
- Department of Radiology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou 510080, China
| | - Hua Hong
- Department of Neurology, The First Affiliated Hospital, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Diagnosis and Treatment of Major Neurological Diseases, National Key Clinical Department and Key Discipline of Neurology, Guangzhou 510080, China
- Department of Geriatrics, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou 510080, China
- Health Management Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou 510080, China
- Correspondence: ; Tel.: +86-13380007226
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21
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Drozdov AA, Arora M, Leon Guerrero CR, Sparks AD, Reza Taheri M. Appearance of medullary and cortical veins on multiphase CT-angiography in patients with acute ischemic stroke. Clin Neurol Neurosurg 2022; 224:107523. [PMID: 36462378 DOI: 10.1016/j.clineuro.2022.107523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 10/07/2022] [Accepted: 11/11/2022] [Indexed: 11/16/2022]
Abstract
OBJECTIVE We sought to determine if interhemispheric asymmetry of cortical and medullary veins evaluated on CT angiography can provide a more accurate prediction of outcome in patients with acute ischemic stroke when compared to hemispheric asymmetry of cortical or medullary vein drainage alone. METHODS We retrospectively reviewed a database of patients with anterior circulation distribution acute ischemic stroke, who were evaluated by multiphase CTA. Cortical veins were evaluated using the adopted Prognostic Evaluation based on Cortical vein score difference In Stroke (PRECISE) system. Medullary veins were evaluated by the presence of asymmetry determined by 5 or more medullary veins visualized in one hemisphere as compared to the contralateral. Good clinical outcome was defined as a Modified Rankin Scale of 0-2 at 90 days. RESULTS 64 patients were included. The adopted PRECISE score was associated with a good clinical outcome in patients with AIS (OR=3.29; 95 % CI: 1.16 - 9.30; p = 0.023) and had a stronger association with clinical outcome (AUC=0.644) as compared to the asymmetry of MV (AUC=0.609). In a multivariable logistic regression model, combined medullary and cortical vein asymmetry were independently associated with clinical outcomes (AUC=0.721). CONCLUSION Combined cortical and medullary vein interhemispheric asymmetry is a stronger predictor of clinical outcome in acute ischemic stroke compared to cortical or medullary vein asymmetry alone.
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Affiliation(s)
- Aleksandr A Drozdov
- George Washington University Hospital, Department of Radiology, The United States.
| | - Mudit Arora
- George Washington University Hospital, Department of Radiology, The United States.
| | | | - Andrew D Sparks
- George Washington University Medical Faculty Associates, Department of Surgery, The United States.
| | - M Reza Taheri
- George Washington University Hospital, Department of Radiology, The United States.
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22
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Peretz S, Pardo K, Naftali J, Findler M, Raphaeli G, Barnea R, Khasminsky V, Auriel E. Delayed CTP-Derived Deep Venous Outflow: A Novel Predictor of Striatocapsular Infarction after M1 Thrombectomy. AJNR Am J Neuroradiol 2022; 43:1608-1614. [PMID: 36265892 PMCID: PMC9731248 DOI: 10.3174/ajnr.a7670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 09/08/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND AND PURPOSE Isolated striatocapsular infarction occurs commonly in patients with ischemic stroke following M1 thrombectomy. We aimed to explore the correlation between CTP-derived parameters of deep venous outflow at presentation and subsequent striatocapsular infarction in a retrospective cohort of such patients. MATERIALS AND METHODS TTP and peak enhancement were measured on CTP-derived time-attenuation curves of the internal cerebral and thalamostriate veins bilaterally. The difference in TTP (ΔTTP) and the relative decrease in venous enhancement between the ischemic and normal sides were calculated. NCCT performed 24 (SD, 12) hours postthrombectomy was used to determine tissue fate in the caudate head, caudate body, lentiform nucleus, and internal capsule. Striatocapsular ischemia (striatocapsular infarction-positive) was defined as infarction and striatocapsular injury as either infarction, contrast enhancement, or hemorrhagic transformation in ≥1 of these regions. A striatocapsular ischemia score was calculated (0 = no ischemic region, 1 = 1 ischemic region, 2 = ≥2 ischemic regions). RESULTS One hundred sixteen patients were included in the analysis. Sixty-one patients had striatocapsular infarction (striatocapsular infarction-positive). The mean thalamostriate ΔTTP was 1.95 (SD, 1.9) seconds for patients positive for striatocapsular infarction and 0.79 (SD, 2.1) for patients negative for it (P = .010). Results were similar for striatocapsular injury. The mean thalamostriate ΔTTP was 0.79 (SD, 2.1), 1.68 (SD, 1.4), and 2.05 (SD, 2) for striatocapsular infarction scores of 0, 1, and 2, respectively (P = .030). CONCLUSIONS CTP-derived thalamostriate ΔTTP is an excellent surrogate marker for striatocapsular infarction in patients post-M1 thrombectomy. The novel approach of extracting venous outflow parameters from CTP has numerous potential applications and should be further explored.
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Affiliation(s)
- S Peretz
- From the Departments of Neurology (S.P., K.P., J.N., M.F., G.R., R.B., E.A.)
- Sackler School of Medicine (S.P., K.P., J.N., M.F., G.R., R.B., V.K., E.A.), Tel-Aviv University, Tel-Aviv, Israel
| | - K Pardo
- From the Departments of Neurology (S.P., K.P., J.N., M.F., G.R., R.B., E.A.)
- Sackler School of Medicine (S.P., K.P., J.N., M.F., G.R., R.B., V.K., E.A.), Tel-Aviv University, Tel-Aviv, Israel
| | - J Naftali
- From the Departments of Neurology (S.P., K.P., J.N., M.F., G.R., R.B., E.A.)
- Sackler School of Medicine (S.P., K.P., J.N., M.F., G.R., R.B., V.K., E.A.), Tel-Aviv University, Tel-Aviv, Israel
| | - M Findler
- From the Departments of Neurology (S.P., K.P., J.N., M.F., G.R., R.B., E.A.)
- Sackler School of Medicine (S.P., K.P., J.N., M.F., G.R., R.B., V.K., E.A.), Tel-Aviv University, Tel-Aviv, Israel
| | - G Raphaeli
- From the Departments of Neurology (S.P., K.P., J.N., M.F., G.R., R.B., E.A.)
- Sackler School of Medicine (S.P., K.P., J.N., M.F., G.R., R.B., V.K., E.A.), Tel-Aviv University, Tel-Aviv, Israel
| | - R Barnea
- From the Departments of Neurology (S.P., K.P., J.N., M.F., G.R., R.B., E.A.)
- Sackler School of Medicine (S.P., K.P., J.N., M.F., G.R., R.B., V.K., E.A.), Tel-Aviv University, Tel-Aviv, Israel
| | - V Khasminsky
- Radiology (V.K.), Rabin Medical Center, Beilinson Hospital, Petach Tikva, Israel
- Sackler School of Medicine (S.P., K.P., J.N., M.F., G.R., R.B., V.K., E.A.), Tel-Aviv University, Tel-Aviv, Israel
| | - E Auriel
- From the Departments of Neurology (S.P., K.P., J.N., M.F., G.R., R.B., E.A.)
- Sackler School of Medicine (S.P., K.P., J.N., M.F., G.R., R.B., V.K., E.A.), Tel-Aviv University, Tel-Aviv, Israel
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van Horn N, Heit JJ, Kabiri R, Mader MM, Christensen S, Mlynash M, Broocks G, Meyer L, Nawabi J, Lansberg MG, Albers GW, Wintermark M, Fiehler J, Faizy TD. Cerebral venous outflow profiles are associated with the first pass effect in endovascular thrombectomy. J Neurointerv Surg 2022; 14:1056-1061. [PMID: 34750110 PMCID: PMC9606492 DOI: 10.1136/neurintsurg-2021-018078] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 10/24/2021] [Indexed: 12/26/2022]
Abstract
BACKGROUND Recent studies found that favorable venous outflow (VO) profiles are associated with higher reperfusion rates after mechanical thrombectomy (MT) in patients with acute ischemic stroke due to large vessel occlusion (AIS-LVO). Fewer retrieval attempts and first-pass revascularization during MT lead to better functional outcomes. OBJECTIVE To examine the hypothesis that favorable VO profiles assessed on baseline CT angiography (CTA) images correlate with successful vessel reperfusion after the first retrieval attempt and fewer retrieval attempts. METHODS A multicenter retrospective cohort study of patients with AIS-LVO treated by MT. Baseline CTA was used to determine the cortical vein opacification score (COVES). Favorable VO was defined as COVES ≥3. Primary outcomes were successful with excellent vessel reperfusion status, defined as Thrombolysis in Cerebral Infarction (TICI) 2b/3 and 2c/3 after first retrieval attempt. RESULTS 617 patients were included in this study, of whom 205 (33.2%) had first pass reperfusion. In univariate analysis, ordinal COVES (p=0.011) values were significantly higher in patients with first pass than in those with non-first pass reperfusion, while the number of patients exhibiting favorable pial arterial collaterals using the Maas scale on CTA did not differ (p=0.243). In multivariable logistic regression analysis, higher COVES were independently associated with TICI 2b/3 (OR=1.25, 95% CI 1.1 to 1.42; p=0.001) and TICI 2c/3 (OR=1.2, 95% CI 1.04 to 1.36; p=0.011) reperfusion after one retrieval attempt, controlling for penumbra volume and time from symptom onset to vessel reperfusion. CONCLUSIONS Favorable VO, classified as higher COVES, is independently associated with successful and excellent first pass reperfusion in patients with AIS-LVO treated by endovascular thrombectomy.
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Affiliation(s)
- Noel van Horn
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jeremy J Heit
- Department of Radiology, Stanford University School of Medicine, Stanford, California, USA
| | - Reza Kabiri
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Marius M Mader
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Hamburg, Germany
| | - Soren Christensen
- Department of Neurology and Neurological Sciences, Stanford, Stanford, California, USA
| | - Michael Mlynash
- Department of Neurology and Neurological Sciences, Stanford, Stanford, California, USA
| | - Gabriel Broocks
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Lukas Meyer
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jawed Nawabi
- Department of Radiology, Charité School of Medicine and University Hospital Berlin, Berlin, Germany
| | - Maarten G Lansberg
- Department of Neurology and Neurological Sciences, Stanford, Stanford, California, USA
| | - Gregory W Albers
- Department of Neurology and Neurological Sciences, Stanford, Stanford, California, USA
| | - Max Wintermark
- Department of Radiology, Stanford University School of Medicine, Stanford, California, USA
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Tobias D Faizy
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Department of Radiology, Stanford University School of Medicine, Stanford, California, USA
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Xu J, Zhang Z, Jin B, Geng Y, Lin L, Zhang S. Delayed filling of the superficial middle cerebral vein in acute large artery occlusion. Front Neurol 2022; 13:955804. [PMID: 36303557 PMCID: PMC9592715 DOI: 10.3389/fneur.2022.955804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Accepted: 08/02/2022] [Indexed: 11/25/2022] Open
Abstract
Objective This study aimed to determine whether baseline delayed filling of the superficial middle cerebral vein (SMCV) was an independent cause of stroke prognosis in patients with acute anterior large vessel occlusion (LVO). Methods Consecutive patients with acute LVO [middle cerebral artery M1 ± intracranial internal carotid artery (ICA)] between March 2019 and May 2020 were included. Delayed SMCV was defined as delayed filling of SMCV in the affected side compared with the normal side throughout the venous phase on four-dimensional computed tomographic angiography (4D-CTA) reconstructed from CT perfusion imaging. The modified Rankin scale (mRS) was used to evaluate the prognosis of these patients 3 months after stroke. Results Of 54 patients in total, 47 (87.0%) patients presented with baseline delayed SMCV, and 36 (76.6%) patients achieved SMCV reversal (ipsilateral delayed SMCV reversed to bilateral symmetrical SMCV) after reperfusion therapy. Successful reperfusion was independently associated with SMCV reversal [odds ratio (OR) = 69.328, 95% confidence interval (CI) = 2.818–175.342]. A significant association between baseline SMCV delay and a 3-month poor outcome (OR = 19.623, 95% CI = 1.567–245.727, p = 0.021) was observed using a multivariable regression analysis. Compared with patients with persistent delayed SMCV, patients with reversed SMCV did not show a significant difference in the risk of a 3-month poor outcome (OR = 1.177, 95% CI = 0.147–9.448). Conclusions In patients with acute LVO, baseline delayed SMCV was an independent cause of poor stroke prognosis, and SMCV reversal cannot reverse the 3-month stroke prognosis. Therefore, the evaluation of baseline SMCV filling status should be strengthened in clinical practice.
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Affiliation(s)
- Jingsi Xu
- The Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, China
| | - Zheyu Zhang
- The Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, China
- Department of Neurology, People's Hospital of Hangzhou Medical College, Zhejiang Provincial People's Hospital, Hangzhou, China
| | - Bo Jin
- Department of Neurology, People's Hospital of Hangzhou Medical College, Zhejiang Provincial People's Hospital, Hangzhou, China
| | - Yu Geng
- Department of Neurology, People's Hospital of Hangzhou Medical College, Zhejiang Provincial People's Hospital, Hangzhou, China
| | - Longting Lin
- Department of Neurology, John Hunter Hospital, Hunter Medical Research Institute, University of Newcastle, Newcastle, NSW, Australia
| | - Sheng Zhang
- Department of Neurology, People's Hospital of Hangzhou Medical College, Zhejiang Provincial People's Hospital, Hangzhou, China
- *Correspondence: Sheng Zhang
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Faizy TD, Mlynash M, Kabiri R, Christensen S, Kuraitis G, Meyer L, Bechstein M, Van Horn N, Lansberg MG, Albers G, Fiehler J, Wintermark M, Heit JJ. Favourable arterial, tissue-level and venous collaterals correlate with early neurological improvement after successful thrombectomy treatment of acute ischaemic stroke. J Neurol Neurosurg Psychiatry 2022; 93:jnnp-2021-328041. [PMID: 35577509 DOI: 10.1136/jnnp-2021-328041] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Accepted: 01/09/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUND AND PURPOSE Early neurological improvement (ENI) after thrombectomy is associated with better long-term outcomes in patients with acute ischaemic stroke due to large vessel occlusion (AIS-LVO). Whether cerebral collaterals influence the likelihood of ENI is poorly described. We hypothesised that favourable collateral perfusion at the arterial, tissue-level and venous outflow (VO) levels is associated with ENI after thrombectomy. MATERIALS AND METHODS Multicentre retrospective study of patients with AIS-LVO treated by thrombectomy. Tissue-level collaterals (TLC) were measured on cerebral perfusion studies by the hypoperfusion intensity ratio. VO and pial arterial collaterals (PAC) were determined by the Cortical Vein Opacification Score and the modified Tan scale on CT angiography, respectively. ENI was defined as improvement of ≥8 points or a National Institutes of Health Stroke Scale score of 0 hour or 1 24 hours after treatment. Multivariable regression analyses were used to determine the association of collateral biomarkers with ENI and good functional outcomes (modified Rankin Scale 0-2). RESULTS 646 patients met inclusion criteria. Favourable PAC (OR: 1.9, CI 1.2 to 3.1; p=0.01), favourable VO (OR: 3.3, CI 2.1 to 5.1; p<0.001) and successful reperfusion (OR: 3.1, CI 1.7 to 5.8; p<0.001) were associated with ENI, but favourable TLC were not (p=0.431). Good functional outcomes at 90-days were associated with favourable TLC (OR: 2.2, CI 1.4 to 3.6; p=0.001), VO (OR: 5.7, CI 3.5 to 9.3; p<0.001) and ENI (OR: 5.7, CI 3.3 to 9.8; p<0.001), but not PAC status (p=0.647). CONCLUSION Favourable PAC and VO were associated with ENI after thrombectomy. Favourable TLC predicted longer term functional recovery after thrombectomy, but the impact of TLC on ENI is strongly dependent on vessel reperfusion.
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Affiliation(s)
- Tobias Djamsched Faizy
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Michael Mlynash
- Department of Neurology and Neurological Sciences, Stanford University, Stanford, California, USA
| | - Reza Kabiri
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Department of Radiology, Stanford University, Stanford, California, USA
| | - Soren Christensen
- Department of Neurology and Neurological Sciences, Stanford University, Stanford, California, USA
| | | | - Lukas Meyer
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Matthias Bechstein
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Noel Van Horn
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Maarten G Lansberg
- Department of Neurology and Neurological Sciences, Stanford University, Stanford, California, USA
| | - Greg Albers
- Department of Neurology and Neurological Sciences, Stanford University, Stanford, California, USA
| | - Jens Fiehler
- Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Hamburg, Germany
| | - Max Wintermark
- Department of Radiology, Stanford University, Stanford, California, USA
| | - Jeremy J Heit
- Department of Radiology, Stanford University School of Medicine, Stanford, California, USA
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Su M, Chen Z, Chen X, Huang J, Li Z, Zhou Y, Xu G. Venous Flow Profiles on Perfusion CT are Associated with Futile Recanalization After Thrombectomy. Neuropsychiatr Dis Treat 2022; 18:933-942. [PMID: 35515078 PMCID: PMC9064056 DOI: 10.2147/ndt.s360626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 04/09/2022] [Indexed: 11/23/2022] Open
Abstract
Background and Purpose Robust venous outflow (VO) reflects favourable tissue reperfusion in acute ischaemic stroke (AIS) patients with large vessel occlusion (LVO). We aimed to investigate the association of the venous outflow profile on computed tomographic perfusion (CTP) and futile recanalization in anterior circulation AIS patients with LVO after thrombectomy. Methods This was a retrospective study of consecutive AIS patients due to anterior circulation LVO who underwent CTP before thrombectomy. Patients who achieved successful recanalization defined as a modified Thrombolysis in Cerebral Infarction (mTICI) score of 2b or 3 after thrombectomy were included. Based on the venous time-intensity curve of CTP, the peak time of venous outflow (PTV), total venous outflow time (TVT), and difference value of arteriovenous peak time (D-value) were recorded. A modified mRS score of 3-6 at 3 months was regarded as futile recanalization (FR). Logistic regression analysis was applied to assess risk factors for FR. We used receiver operating characteristic curves (ROCs) to evaluate the predictive value of venous outflow time parameters based on VO for FR. Results Eighty patients were included; 35 (43.8%) achieved good functional outcomes, and 45 (56.3%) had unfavourable functional outcomes, that is, FR. Adjusting confounding factors, binary stepwise logistic regression analysis showed that delayed PTV was independently associated with FR (odds ratio, 1.374 [95% CI, 1.093-1.726], P = 0.007). ROCs indicated that PTV effectively predicted unfavourable outcomes at 3 months (area under the curve (AUC) = 0.729, p< 0.001). The combined model was a powerful predictor of FR with an AUC of 0.824 and a cut-off value of 0.631 (p< 0.001). Conclusion Delayed PTV is independently related to FR in anterior circulation AIS patients with LVO achieving successful recanalization after thrombectomy. Our results highlight that the time of VO may be a potential marker for FR.
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Affiliation(s)
- Mouxiao Su
- The First School of Clinical Medicine, Southern Medical University, Guangzhou, 510000, People’s Republic of China
- Department of Neurology, School of Medicine, Mianyang Central Hospital, University of Electronic Science and Technology of China, Mianyang, 621000, People’s Republic of China
| | - Zhonglun Chen
- Department of Neurology, School of Medicine, Mianyang Central Hospital, University of Electronic Science and Technology of China, Mianyang, 621000, People’s Republic of China
| | - Xinyue Chen
- CT Collaboration, Siemens Healthineers, Chengdu, 610000, People’s Republic of China
| | - Jiaxing Huang
- Department of Radiology, School of Medicine, Mianyang Central Hospital, University of Electronic Science and Technology of China, Mianyang, 621000, People’s Republic of China
| | - Zhaokun Li
- Department of Neurology, School of Medicine, Mianyang Central Hospital, University of Electronic Science and Technology of China, Mianyang, 621000, People’s Republic of China
| | - Ying Zhou
- Department of Radiology, School of Medicine, Mianyang Central Hospital, University of Electronic Science and Technology of China, Mianyang, 621000, People’s Republic of China
| | - Gelin Xu
- The First School of Clinical Medicine, Southern Medical University, Guangzhou, 510000, People’s Republic of China
- Department of Neurology, Jinling Hospital, Medical School of Nanjing University, Nanjing, 210002, People's Republic of China
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Review of net water uptake in the management of acute ischemic stroke. Eur Radiol 2022; 32:5517-5524. [DOI: 10.1007/s00330-022-08658-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 01/24/2022] [Accepted: 02/12/2022] [Indexed: 12/15/2022]
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van Horn N, Heit JJ, Kabiri R, Broocks G, Christensen S, Mlynash M, Meyer L, Schoenfeld MH, Lansberg MG, Albers GW, Fiehler J, Wintermark M, Faizy TD. Venous outflow profiles are associated with early edema progression in ischemic stroke. Int J Stroke 2022; 17:1078-1084. [PMID: 34983276 DOI: 10.1177/17474930211065635] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND In patients with acute ischemic stroke due to large vessel occlusion (AIS-LVO), development of extensive early ischemic brain edema is associated with poor functional outcomes, despite timely treatment. Robust cortical venous outflow (VO) profiles correlate with favorable tissue perfusion. We hypothesized that favorable VO profiles (VO+) correlate with a reduced early edema progression rate (EPR) and good functional outcomes. METHODS Multicenter, retrospective analysis to investigate AIS-LVO patients treated by mechanical thrombectomy between May 2013 and December 2020. Baseline computed tomography angiography (CTA) was used to determine VO using the cortical vein opacification score (COVES); VO+ was defined as COVES ⩾ 3 and unfavorable as COVES ⩽ 2. EPR was determined as the ratio of net water uptake (NWU) on baseline non-contrast CT and time from symptom onset to admission imaging. Multivariable regression analysis was performed to assess primary (EPR) and secondary outcome (good functional outcomes defined as 0-2 points on the modified Rankin scale). RESULTS A total of 728 patients were included. Primary outcome analysis showed VO+ (β: -0.03, SE: 0.009, p = 0.002), lower presentation National Institutes of Health Stroke Scale (NIHSS; β: 0.002, SE: 0.001, p = 0.002), and decreased time from onset to admission imaging (β: -0.00002, SE: 0.00004, p < 0.001) were independently associated with reduced EPR. VO+ also predicted good functional outcomes (odds ratio (OR): 5.07, 95% CI: 2.839-9.039, p < 0.001), while controlling for presentation NIHSS, time from onset to imaging, general vessel reperfusion, baseline Alberta Stroke Program Early CT Score, infarct core volume, EPR, and favorable arterial collaterals. CONCLUSIONS Favorable VO profiles were associated with slower infarct edema progression and good long-term functional outcomes as well as better neurological status and ischemic brain alterations at admission.
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Affiliation(s)
- Noel van Horn
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jeremy J Heit
- Department of Radiology, Stanford University School of Medicine, Stanford, CA, USA
| | - Reza Kabiri
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Gabriel Broocks
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Soren Christensen
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - Michael Mlynash
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - Lukas Meyer
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | - Maarten G Lansberg
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - Gregory W Albers
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Max Wintermark
- Department of Radiology, Stanford University School of Medicine, Stanford, CA, USA
| | - Tobias D Faizy
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Department of Radiology, Stanford University School of Medicine, Stanford, CA, USA
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Singh N, Bala F, Kim BJ, Najm M, Ahn SH, Fainardi E, Rubiera M, Khaw AV, Zini A, Goyal M, Menon BK, Almekhlafi M. Time-resolved assessment of cortical venous drainage on multiphase CT angiography in patients with acute ischemic stroke. Neuroradiology 2021; 64:897-903. [PMID: 34704112 DOI: 10.1007/s00234-021-02837-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 10/13/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE Cortical vein opacification is not routinely assessed in patients presenting with acute ischemic stroke (AIS), and the value of temporal assessment of venous outflow is not known. We evaluated the utility of assessing cortical venous drainage over time using multiphase CT angiography (mCTA). METHODS Cortical venous drainage was assessed in patients from the Precise and Rapid Assessment of Collaterals Using Multi-Phase CTA in the Triage of Patients With Acute Ischemic Stroke for IA Therapy prospective multicenter cohort study of patients with symptoms of AIS with ICA and/or middle cerebral artery occlusion on baseline mCTA. Opacification of vein of Labbe, sphenoparietal sinus, superficial middle cerebral vein, and vein of Trolard of the affected hemisphere was graded as no (0), partial (1), or full (2) opacification in each mCTA phase. The venous opacification scores for each phase were added to generate a total venous score (TVS) (range 0-24). Primary outcome was 90-day modified Rankin score. Repeated measures analysis was used to assess the effect of phase timing on venous score on outcome. RESULTS Of 432 patients, 284 (65.7%) had proximal arterial occlusions. Median venous opacification score per phase (range 0-8) was 3 (IQR 1-6) in the first phase and increased in the second and third phases [median (IQR): 6 (5-8) and 8 (6-8), respectively] of the mCTA. In a multivariable analysis adjusting for age, baseline National Institutes of Health Stroke Scale, and Alberta stroke program early CT score, a significant association between TVS and 90-day mRS was noted ([adjusted cOR for TVS 6-11: 0.16 (95% CI 0.05-0.51); TVS 12-17: 0.18 (95% CI 0.06-0.57); TVS 18-24: 0.20 (0.06-0.63)]. Repeated measures analysis of venous scores from all three phases showed a significant effect of time/phase on TVS (p < 0.001). CONCLUSION This study concludes that venous opacification over time on multiphase CTA is associated with 90-day clinical outcome. There was however no added benefit of venous scoring vis-a-vis arterial collateral assessment in predicting outcome.
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Affiliation(s)
- Nishita Singh
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary and Foothills Medical Centre, Calgary, AB, Canada.
| | - Fouzi Bala
- Department of Radiology, Cumming School of Medicine, University of Calgary and Foothills Medical Centre, Calgary, AB, Canada
| | - B J Kim
- Department of Neurology and Cerebrovascular Center, Seoul National University Bundang Hospital, Seongnamsi, Gyeonggi-do, Republic of Korea
| | - Mohamed Najm
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary and Foothills Medical Centre, Calgary, AB, Canada
| | - Seong Hwan Ahn
- Department of Neurology, Chosun University Hospital, Gwangju, Republic of Korea
| | - Enrico Fainardi
- Department of Experimental and Clinical Biomedical Sciences, University of Florence, Florence, Italy
| | - Marta Rubiera
- Stroke Unit, Department of Neurology, Vall d'Hebron University Hospital, Vall d'Hebron Research Institute, Barcelona, Spain
| | - Alexander V Khaw
- Department of Clinical Neurosciences, University of Western Ontario, London Health Sciences Centre, London, Canada
| | - Andrea Zini
- Department of Neurology and Stroke Center, IRCCS Istituto Delle Scienze Neurologiche Di Bologna, Maggiore Hospital, Bologna, Italy
| | - Mayank Goyal
- Department of Radiology, Cumming School of Medicine, University of Calgary and Foothills Medical Centre, Calgary, AB, Canada
| | - Bijoy K Menon
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary and Foothills Medical Centre, Calgary, AB, Canada.,Department of Radiology, Cumming School of Medicine, University of Calgary and Foothills Medical Centre, Calgary, AB, Canada
| | - Mohammed Almekhlafi
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary and Foothills Medical Centre, Calgary, AB, Canada.,Department of Radiology, Cumming School of Medicine, University of Calgary and Foothills Medical Centre, Calgary, AB, Canada
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Xia H, Sun H, He S, Zhao M, Huang W, Zhang Z, Xue Y, Fu P, Chen W. Absent Cortical Venous Filling Is Associated with Aggravated Brain Edema in Acute Ischemic Stroke. AJNR Am J Neuroradiol 2021; 42:1023-1029. [PMID: 33737267 DOI: 10.3174/ajnr.a7039] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Accepted: 12/01/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND PURPOSE Predicting malignant cerebral edema can help identify patients who may benefit from appropriate evidence-based interventions. We investigated whether absent cortical venous filling is associated with more pronounced early brain edema, which leads to malignant cerebral edema. MATERIALS AND METHODS Patients with acute ischemic stroke caused by large-vessel occlusion in the MCA territory who presented between July 2017 and September 2019 to our hospital were included. Collateral filling was rated using the modified Tan scale on CTA, and good collaterals were defined as a score of 2-3. The Cortical Vein Opacification Score (COVES) was calculated, and absent cortical venous filling was defined as a score of 0. Early brain edema was determined using net water uptake on baseline CT images. Malignant cerebral edema was defined as a midline shift of ≥5 mm on follow-up imaging or a massive cerebral swelling leading to decompressive hemicraniectomy or death. Multivariate linear and logistic regression models were performed to analyze data. RESULTS A total of 163 patients were included. Net water uptake was significantly higher in patients with absent than in those with favorable cortical venous filling (8.1% versus 4.2%; P < .001). In the multivariable regression analysis, absent cortical venous filling (β = 2.04; 95% CI, 0.75-3.32; P = .002) was significantly and independently associated with higher net water uptake. Absent cortical venous filling (OR, 14.68; 95% CI, 4.03-53.45; P < .001) and higher net water uptake (OR, 1.29; 95% CI, 1.05-1.58; P = .016) were significantly associated with increased likelihood of malignant cerebral edema. CONCLUSIONS Patients with absent cortical venous filling were associated with an increased early brain edema and a higher risk of malignant cerebral edema. These patients may be targeted for optimized adjuvant antiedematous treatment.
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Affiliation(s)
- H Xia
- From the Department of Radiology (H.X.), Shaoxing People's Hospital (Shaoxing Hospital, Zhejiang University School of Medicine), Shaoxing, Zhejiang, China
| | - H Sun
- Department of Radiology (H.S., S.H., M.Z., W.H., Z.Z., Y.X., P.F., W.C.), The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - S He
- Department of Radiology (H.S., S.H., M.Z., W.H., Z.Z., Y.X., P.F., W.C.), The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - M Zhao
- Department of Radiology (H.S., S.H., M.Z., W.H., Z.Z., Y.X., P.F., W.C.), The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - W Huang
- Department of Radiology (H.S., S.H., M.Z., W.H., Z.Z., Y.X., P.F., W.C.), The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Z Zhang
- Department of Radiology (H.S., S.H., M.Z., W.H., Z.Z., Y.X., P.F., W.C.), The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Y Xue
- Department of Radiology (H.S., S.H., M.Z., W.H., Z.Z., Y.X., P.F., W.C.), The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - P Fu
- Department of Radiology (H.S., S.H., M.Z., W.H., Z.Z., Y.X., P.F., W.C.), The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - W Chen
- Department of Radiology (H.S., S.H., M.Z., W.H., Z.Z., Y.X., P.F., W.C.), The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
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Yu KW, Lin CJ, Luo CB, Lin YY, Guo WY, Chang FC, Lee IH, Lin CJ, Chung CP, Chien C. Single-phase computed tomography angiography sufficiently predicts outcomes after mechanical thrombectomy. J Chin Med Assoc 2020; 83:478-483. [PMID: 32217991 DOI: 10.1097/jcma.0000000000000300] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Arterial collateral (AC) assessed by single-phase computed tomography angiography (CTA) or multiphase CTA has been used to predict clinical outcomes in patients undergoing mechanical thrombectomy (MT). Recently, venous opacification (VO) was proposed as another accurate image marker. This study aimed to compare the efficacy using AC and VO as predictors of MT outcome. METHODS Patients with occlusion of the proximal anterior circulation undergoing MT were included retrospectively. We assessed the AC status respectively according to different methods: modified Tan score, Miteff score in single-phase CTA, and pial arterial filling score in multiphase CTA. VO was assessed according to cortical vein opacification score. Favorable clinical outcome was defined as modified Rankin Scale 0-2 90 days after MT. Logistic regression models were established and receiver operating characteristics curve were used to determine the predictability of favorable outcome in patients with adequate AC and VO. RESULTS A total of 75 patients were enrolled. Adequate AC identified by modified Tan score (odds ratio, 7.3; p < 0.001), Miteff score (odds ratio, 4.5; p = 0.009), significantly predicted favorable outcome, but not adequate VO. The area under the curve was largest for adequate AC in model of modified Tan score 0.730 (95% CI, 0.60-0.86), while adequate VO showed the least area under the curve: 0.577 (95% CI, 0.43-0.73). CONCLUSION We considered adequate AC in single-phase CTA could be reliable enough as an imaging marker rather than adequate VO to predict favorable outcome after MT.
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Affiliation(s)
- Kai-Wei Yu
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Chung-Jung Lin
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Chao-Bao Luo
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Yung-Yang Lin
- Department of Critical Care Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Wan-Yuo Guo
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Feng-Chi Chang
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - I-Hui Lee
- Department of Neurology Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Chun-Jen Lin
- Department of Neurology Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Chih-Ping Chung
- Department of Neurology Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Chun Chien
- Department of Neurology Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
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Hoffman H, Ziechmann R, Swarnkar A, Masoud HE, Gould G. Cortical Vein Opacification for Risk Stratification in Anterior Circulation Endovascular Thrombectomy. J Stroke Cerebrovasc Dis 2019; 28:1710-1717. [PMID: 30878371 DOI: 10.1016/j.jstrokecerebrovasdis.2019.02.016] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Revised: 02/01/2019] [Accepted: 02/14/2019] [Indexed: 11/27/2022] Open
Abstract
INTRODUCTION There is continued interest in identifying factors that predict a favorable outcome after endovascular thrombectomy (EVT) for anterior circulation large vessel occlusion (ACLVO). We compared the predictive values of 2 different scoring systems for evaluating venous collateral circulation. METHODS A retrospective review of patients who underwent EVT for ACLVO at a single institution was performed. Those who underwent preprocedural computed tomography angiography (CTA) were selected. The Cortical Vein Opacification Score (COVES) and Prognostic Evaluation based on Cortical vein score difference In Stroke (PRECISE) score were calculated from each patient's CTA. Our primary outcome of interest was the Modified Rankin Scale (mRS) score at 90 days. RESULTS A total of 103 patients were included in the study (average age = 68.3 years, median National Institutes of Health Stroke Scale = 15). The mean time to reperfusion was 6.4 hours and Thrombolysis in Cerebral Infarction 2B or 3 reperfusion was achieved in 77.7% of cases. An unfavorable COVES score was significantly associated with an unfavorable (mRS 3-6) outcome (adjusted odds ratio [aOR]: 3.06; 95% confidence interval [CI] 1.15-8.13, P = .025), while an unfavorable PRECISE score was not (aOR: 1.02; 95% CI .37-2.80, P = .966). Based on the Receiver Operating Characteristic analysis, the COVES score had a sensitivity of 68.1%, specificity of 71.4%, and area under the curve (AUC) of .77. The PRECISE score had a sensitivity of 68.9%, specificity of 70.7%, and the AUC of .73. CONCLUSIONS The COVES score, but not the PRECISE score, is associated with functional outcomes at 90 days after EVT for ACLVO.
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Affiliation(s)
- Haydn Hoffman
- Department of Neurosurgery, State University of New York Upstate, Syracuse, New York.
| | - Robert Ziechmann
- Department of Neurosurgery, State University of New York Upstate, Syracuse, New York
| | - Amar Swarnkar
- Department of Radiology, State University of New York Upstate, Syracuse, New York
| | - Hesham E Masoud
- Department of Neurology, State University of New York Upstate, Syracuse, New York
| | - Grahame Gould
- Department of Neurosurgery, State University of New York Upstate, Syracuse, New York
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