Automated scoring of collaterals, blood pressure, and clinical outcome after endovascular treatment in patients with acute ischemic stroke and large-vessel occlusion

Automated assessment of collateral circulation and infarct core: predictors of functional outcomes in acute ischemic stroke following endovascular thrombectomy

PURPOSE

This study aimed to evaluate the predictive value of automatically assessed collateral circulation (CC) and infarct core for functional outcome in acute ischemic stroke (AIS) patients treated with endovascular thrombectomy (EVT).

METHODS

We conducted a retrospective cohort study of 208 patients with anterior large vessel occlusion treated with EVT. Two AI-powered software were used to automatically assess CC and infarct core. Comparative analyses included patient demographics, clinical and imaging data, and functional outcome. Univariate and multivariable logistic regression analyses were conducted to predict the 90-day functional outcome. A favorable outcome was defined as a modified Rankin scale (mRS) score ≤ 2.

RESULTS

Among the 208 patients, 114 (54.8%) were women and 94 were men, with a mean age of 71.4 ± 13.3 years. Patients with higher collateral score (CS) exhibited lower infarct core volumes (p < 0.001) and better mRS score at 90 days (p = 0.008). Among patients with a favorable outcome, the mean infarct core volume was lower compared to those with poor outcomes (5 mL vs. 8.6 mL, p = 0.003). In univariate logistic regression, both infarct core (OR 0.94, p = 0.005) and CS (OR 1.84, p = 0.014) were predictors of favorable outcome. However, in multivariable models, only infarct core remained a significant independent predictor [AORs of 0.95 (p = 0.021) and 0.96 (p = 0.039)].

CONCLUSION

Automatically assessed infarct core is a robust predictor of functional outcome in AIS patients post-EVT, while CS's predictive value diminishes when adjusted for infarct core. These findings support the integration of AI-powered evaluations in clinical settings to improve prognosis and treatment strategies for AIS.

Determinants of Leptomeningeal Collateral Status in Acute Ischemic Stroke: A Systematic Review and Meta-Analysis of Observational Studies

BACKGROUND

Leptomeningeal collateral status is a major determinant of outcomes in patients with acute ischemic stroke; however, the factors that determine collateral status are not well understood. We conducted a comprehensive systematic review and meta-analysis to identify determinants associated with collateral status in patients with anterior circulation infarction.

METHODS AND RESULTS

The PubMed, EMBASE, Web of Science, and Cochrane Central Register of Controlled Trials databases were searched for studies that reported the determinants of leptomeningeal collateral status in acute ischemic stroke between January 2000 and June 2023. A random-effects meta-analysis model was used to pool the determinants of leptomeningeal collateral status. Eighty-one studies with 17 366 patients met the inclusion criteria. We analyzed 31 potential risk factors, and the results indicated that worse leptomeningeal collateral status was significantly associated with older age (weighted mean difference, 1.22 [95% CI, 0.69 to 1.76]), male sex (odds ratio [OR], 1.12 [95% CI, 1.02 to 1.23]), hypertension (OR, 1.27 [95% CI, 1.15 to 1.40]), diabetes (OR, 1.21 [95% CI, 1.10 to 1.33]), atrial fibrillation (OR, 1.26 [95% CI, 1.09 to 1.46]), cardioembolic stroke (OR, 1.27 [95% CI, 1.04 to 1.55]), internal carotid artery occlusion (OR, 1.84 [95% CI, 1.50 to 2.25]), and higher admission blood glucose (weighted mean difference, 8.74 [95% CI, 2.52 to 18.51]).

CONCLUSIONS

Hypertension and diabetes could be modifiable risk factors associated with leptomeningeal collateral status. Older age and male sex could be nonmodified risk factors. Further high-quality therapeutic studies focusing on controlling risk factors are needed to support our findings.

Hypoperfusion Intensity Ratio as an Indirect Imaging Surrogate in Patients With Anterior Circulation Large-Vessel Occlusion and Association of Baseline Characteristics With Poor Collateral Status

BACKGROUND

Collateral status (CS) plays a crucial role in infarct growth rate, risk of postthrombectomy hemorrhage, and overall clinical outcomes in patients with acute ischemic stroke (AIS) secondary to anterior circulation large-vessel occlusions (LVOs). Hypoperfusion intensity ratio has been previously validated as an indirect noninvasive pretreatment imaging biomarker of CS. In addition to imaging, derangements in admission laboratory findings can also influence outcomes in patients with AIS-LVO. Therefore, our study aims to assess the relationship between admission laboratory findings, baseline characteristics, and CS, as assessed by hypoperfusion intensity ratio in patients with AIS-LVO.

METHODS AND RESULTS

In this retrospective study, consecutive patients presenting with AIS secondary to anterior circulation LVO who underwent pretreatment computed tomography perfusion were included. The computed tomography perfusion data processed by RAPID (Ischema View, Menlo Park, CA) generated the hypoperfusion intensity ratio. Binary logistic regression models were used to assess the relationship between patients' baseline characteristics, admission laboratory findings, and poor CS. A total of 221 consecutive patients with AIS-LVO between January 2017 and September 2022 were included in our study (mean±SD age, 67.0±15.8 years; 119 men [53.8%]). Multivariable logistic regression showed that patients with AIS caused by cardioembolic and cryptogenic causes (adjusted odds ratio [OR], 2.67; 95% CI, 1.20-5.97; P=0.016), those who presented with admission National Institutes of Health Stroke Scale score ≥12 (adjusted OR, 3.12; 95% CI, 1.61-6.04; P=0.001), and male patients (adjusted OR, 2.06; 95% CI, 1.13-3.77; P=0.018) were associated with poor CS.

CONCLUSIONS

Stroke caused by cardioembolic or cryptogenic causes, admission National Institutes of Health Stroke Scale score of ≥12, and male sex were associated with poor CS, as defined by hypoperfusion intensity ratio in the patients with AIS-LVO.

Automated evaluation of collateral circulation for outcome prediction in acute ischemic stroke

INTRODUCTION

The assessment of collateral circulation in acute ischemic stroke management is essential. Modern tools, such as Brainomix's e-CTA, powered by artificial intelligence, provide detailed insights into collateral assessment. This retrospective study aims to identify factors contributing to favorable collateral status and compare outcomes between patients with good collaterals (grade 3) and fair collaterals (grade 0-2).

METHOD

This retrospective study included 97 patients admitted to the Stroke Unit at the Hospital de Clínicas of the Federal University of Paraná, Brazil, from September 2021 to January 2023. Comparative analyses involved demographic factors, cardiovascular risk factors, and the combined outcome of mortality and moderate to severe disability at discharge, 30-day, and 90-day follow-ups.

RESULTS

Among the 97 cases, 58.8 % showed 'good collaterals' with a grade 3 status. Variables affecting collateral status included age (p = 0.042), neutrophil-lymphocyte ratio (p = 0.005), and initial NIHSS scores (p<0.001). The presence of good collaterals according to e-CTA reduced the odds of death and moderate-severe disability at discharge (p = 0.003; OR 0.27) and at 30 days (p = 0.015; OR 0.33), although this effect diminished at the 90-day mark after multivariate analysis.

DISCUSSION

Automated collateral assessment through e-CTA is a valuable tool in acute ischemic stroke evaluation. Good e-CTA collateral score serve as a promising imaging biomarker, guiding informed clinical decisions during Stroke Unit hospitalizations. This study highlights the relationship between collaterals and stroke outcomes and underscores the potential for AI-driven tools to enhance stroke care management.