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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] [What about the content of this article? (0)] [Affiliation(s)] [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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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Heitkamp C, Winkelmeier L, Heit JJ, Albers GW, Lansberg MG, Kniep H, Broocks G, Stracke CP, Schell M, Guenego A, Paech D, Wintermark M, Fiehler J, Faizy TD. Early neurological deterioration in patients with acute ischemic stroke is linked to unfavorable cerebral venous outflow. Eur Stroke J 2024; 9:162-171. [PMID: 38069665 PMCID: PMC10916832 DOI: 10.1177/23969873231208277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 09/29/2023] [Indexed: 03/06/2024] Open
Abstract
INTRODUCTION Early neurological deterioration (END) is associated with poor outcomes in patients with acute ischemic stroke due to large vessel occlusion (AIS-LVO). Causes of END after mechanical thrombectomy (MT) include unsuccessful recanalization and reperfusion hemorrhages. However, little is known about END excluding the aforementioned causes. We aimed to investigate factors associated with unexplained END (ENDunexplained) with regard to the cerebral collateral status. PATIENTS AND METHODS Multicenter retrospective study of AIS-LVO patients with successful MT (mTICI 2b-3). On admission CT angiography (CTA), pial arterial collaterals and venous outflow (VO) were assessed using the modified Tan-Scale and the Cortical Vein Opacification Score (COVES), respectively. ENDunexplained was defined as an increase in NIHSS score of ⩾ 4 within the first 24 hours after MT without parenchymal hemorrhage on follow-up imaging. Multivariable regression analyses were performed to examine factors of ENDunexplained and unfavorable functional outcome (modified Rankin Scale score 3-6). RESULTS A total of 620 patients met the inclusion criteria. ENDunexplained occurred in 10% of patients. While there was no significant difference in pial arterial collaterals, patients with ENDunexplained exhibited more often unfavorable VO (81% vs. 53%; P < 0.001). Unfavorable VO (aOR [95% CI]; 2.56 [1.02-6.40]; P = 0.045) was an independent predictor of ENDunexplained. ENDunexplained was independently associated with unfavorable functional outcomes at 90 days (aOR [95% CI]; 6.25 [2.06-18.94]; P = 0.001). DISCUSSION AND CONCLUSION Unfavorable VO on admission CTA was associated with ENDunexplained. ENDunexplained was independently linked to unfavorable functional outcomes at 90 days. Identifying AIS-LVO patients at risk of ENDunexplained may help to select patients for intensified monitoring and guide to optimal treatment regimes.
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Affiliation(s)
- Christian Heitkamp
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany
| | - Laurens Winkelmeier
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany
| | - Jeremy J Heit
- Department of Radiology, Stanford University School of Medicine, Stanford, CA, USA
| | - Gregory W Albers
- Department of Neurology, Stanford University School of Medicine, Stanford, CA, USA
| | - Maarten G Lansberg
- Department of Neurology, Stanford University School of Medicine, Stanford, CA, USA
| | - Helge Kniep
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany
| | - Gabriel Broocks
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany
| | - Christian Paul Stracke
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany
- Department of Neuroradiology, University Hospital Muenster, Muenster, Germany
| | - Maximilian Schell
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Germany
| | - Adrien Guenego
- Department of Neuroradiology, Erasme Medical Center, Brussels, Belgium
| | - Daniel Paech
- Clinic for Neuroradiology, University Hospital Bonn, Germany
| | - Max Wintermark
- Department of Neuroradiology, MD Anderson, Houston, TX, USA
| | - Jens Fiehler
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany
| | - Tobias D Faizy
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany
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Cao R, Ye G, Lu Y, Wang Y, Jiang Y, Sun C, Chen M, Chen J. The Predictive Value of Cerebral Veins on Hemorrhagic Transformation After Endovascular Treatment in Acute Ischemic Stroke Patients: Enhanced Insights From Venous Collateral Circulation Analysis Using Four-Dimensional CTA. Acad Radiol 2024; 31:1024-1035. [PMID: 37517921 DOI: 10.1016/j.acra.2023.06.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2023] [Revised: 06/25/2023] [Accepted: 06/30/2023] [Indexed: 08/01/2023]
Abstract
RATIONALE AND OBJECTIVES A significant complication of endovascular treatment (EVT) is hemorrhagic transformation (HT), which can worsen the outcomes of patients with acute ischemic stroke (AIS). This study aimed to evaluate the predictive value of venous collateral circulation on HT in patients with AIS undergoing EVT. MATERIALS AND METHODS We retrospectively analyzed 126 patients with AIS who received EVT. The four-dimensional computed tomography angiography-based venous collateral score (4D-VCS) and arterial collateral circulation score (4D-ACS) were used to assess venous and arterial collaterals, respectively. Significant variables were identified using the least absolute shrinkage and selection operator algorithm. Logistic regression analysis, receiver operating characteristic (ROC) analysis, and DeLong's test were conducted. RESULTS HT occurred in 41.3% (52/126) of patients. Higher clot burden score (CBS; odds ratio [OR]: 0.82, 95% confidence interval [CI]: 0.71-0.95, p = 0.009), better arterial collateral circulation (OR: 0.59, 95% CI: 0.42-0.83, p = 0.003), and better venous collateral circulation (OR: 0.85, 95% CI: 0.73-0.97, p = 0.020) were significantly associated with reduced HT risk. The area under the curve (AUC) values for CBS, 4D-ACS, and 4D-VCS were 0.730, 0.772, and 0.795, respectively. Model 1 (4D-VCS+CBS) achieved AUC of 0.820, significantly improving over CBS alone (p = 0.0133). Model 2 (4D-VCS+4D-ACS) had an AUC of 0.829, significantly higher than 4D-ACS alone (p = 0.0271). Model 3 (4D-ACS+CBS) had an AUC of 0.790. Model 4 (4D-VCS+4D-ACS+CBS) showed highest AUC of 0.851. Significant correlations were found between 4D-VCS and ischemic core volume (r = -0.684, p < 0.001) and between 4D-VCS and mismatch ratio (r = 0.558, p < 0.001). CONCLUSION Evaluating venous collateral circulation using 4D-VCS could improve HT risk prediction in patients with AIS after EVT. When combined with other predictors, 4D-VCS may potentially enhance diagnostic performance, which suggests the potential role of venous collateral circulation in predicting HT risk.
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Affiliation(s)
- Ruoyao Cao
- Department of Radiology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, PR China (R.C., Y.L., Y.W., C.S., M.C., J.C.); Graduate School of Peking Union Medical College, Beijing, PR China (R.C., M.C.)
| | - Gengfan Ye
- Department of Neurosurgery, Ningbo Medical Center Lihuili Hospital, Ningbo, Zhejiang, PR China (G.Y.)
| | - Yao Lu
- Department of Radiology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, PR China (R.C., Y.L., Y.W., C.S., M.C., J.C.)
| | - Yanyan Wang
- Department of Radiology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, PR China (R.C., Y.L., Y.W., C.S., M.C., J.C.)
| | - Yun Jiang
- Department of Neurology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, PR China (Y.J.)
| | - Chengkan Sun
- Department of Radiology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, PR China (R.C., Y.L., Y.W., C.S., M.C., J.C.)
| | - Min Chen
- Department of Radiology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, PR China (R.C., Y.L., Y.W., C.S., M.C., J.C.); Graduate School of Peking Union Medical College, Beijing, PR China (R.C., M.C.)
| | - Juan Chen
- Department of Radiology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, PR China (R.C., Y.L., Y.W., C.S., M.C., J.C.).
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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: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [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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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Adusumilli G, Christensen S, Yuen N, Mlynash M, Faizy TD, Albers GW, Lansberg MG, Fiehler J, Heit JJ. CT perfusion to measure venous outflow in acute ischemic stroke in patients with a large vessel occlusion. J Neurointerv Surg 2023:jnis-2023-020727. [PMID: 37643804 DOI: 10.1136/jnis-2023-020727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 08/18/2023] [Indexed: 08/31/2023]
Abstract
BACKGROUND Robust venous outflow (VO) profiles, measured by degree of venous opacification on pre-thrombectomy CT angiography (CTA) studies, are strongly correlated with favorable outcomes in patients with large vessel occlusion acute ischemic stroke treated by thrombectomy. However, VO measurements are laborious and require neuroimaging expertise. OBJECTIVE To develop a semi-automated method to measure VO using CTA and CT perfusion imaging studies. METHODS We developed a graphical interface using The Visualization Toolkit, allowing for voxel selection at the confluence and bilateral internal cerebral veins on CTA along with arterial input functions (AIFs) from both internal carotid arteries. We extracted concentration-time curves from the CT perfusion study at the corresponding locations associated with AIF and venous output function (VOF). Outcome analyses were primarily conducted by the Mann-Whitney U and Jonckheere-Terpstra tests. RESULTS Segmentation at the pre-selected AIF and VOF locations was performed on a sample of 97 patients. 65 patients had favorable VO (VO+) and 32 patients had unfavorable VO (VO-). VO+ patients were found to have a significantly shorter VOF time to peak (8.26; 95% CI 7.07 to 10.34) than VO- patients (9.44; 95% CI 8.61 to 10.91), P=0.007. No significant difference was found in VOF curve width and the difference in time between AIF and VOF peaks. CONCLUSIONS Time to peak of VOF at the confluence of sinuses was significantly associated with manually scored venous outflow. Further studies should aim to understand better the association between arterial inflow and venous outflow, and capture quantitative metrics of venous outflow at other locations.
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Affiliation(s)
- Gautam Adusumilli
- Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | | | - Nicole Yuen
- Stanford Stroke Center, Stanford University, Stanford, California, USA
| | - Michael Mlynash
- Stanford Stroke Center, Stanford University, Stanford, California, USA
| | - Tobias D Faizy
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Gregory W Albers
- Stanford Stroke Center, Stanford University, Stanford, California, USA
| | | | - Jens Fiehler
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jeremy J Heit
- Radiology, Neuroadiology and Neurointervention Division, Stanford University, Stanford, California, USA
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Busto G, Morotti A, Carlesi E, Fiorenza A, Di Pasquale F, Mancini S, Lombardo I, Scola E, Gadda D, Moretti M, Miele V, Fainardi E. Pivotal role of multiphase computed tomography angiography for collateral assessment in patients with acute ischemic stroke. Radiol Med 2023:10.1007/s11547-023-01668-9. [PMID: 37351771 DOI: 10.1007/s11547-023-01668-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 06/13/2023] [Indexed: 06/24/2023]
Abstract
The cerebral collateral circulation is the main compensatory mechanism that maintains the ischemic penumbra viable, the tissue at risk for infarction that can be saved if blood flow is restored by reperfusion therapies. In clinical practice, the extent of collateral vessels recruited after vessel occlusion can be easily assessed with computed tomography angiography (CTA) using two different techniques: single-phase CTA (sCTA) and multi-phase CTA (mCTA). Both these methodologies have demonstrated a high prognostic predictive value for prognosis due to the strong association between the presence of good collaterals and favorable radiological and clinical outcomes in patients with acute ischemic stroke (AIS). However, mCTA seems to be superior to sCTA in the evaluation of collaterals and a promising tool for identifying AIS patients who can benefit from reperfusion therapies. In particular, it has recently been proposed the use of mCTA eligibility criteria has been recently proposed for the selection of AIS patients suitable for endovascular treatment instead of the current accepted criteria based on CT perfusion. In this review, we analyzed the characteristics, advantages and disadvantages of sCTA and mCTA to better understand their fields of application and the potential of mCTA in becoming the method of choice to assess collateral extent in AIS patients.
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Affiliation(s)
- Giorgio Busto
- Neuroradiology Unit, Department of Radiology, Careggi University Hospital, Florence, Italy.
- Struttura Organizzativa Dipartimentale di Neuroradiologia, Dipartimento di Scienze Biomediche, Sperimentali e Cliniche "Mario Serio", Università Degli Studi di Firenze, Ospedale Universitario Careggi, Largo Brambilla 3, 50134, Florence, Italy.
| | - Andrea Morotti
- Neurology Unit, Department of Neurological Sciences and Vision, ASST Spedali Civili, Brescia, Italy
| | - Edoardo Carlesi
- Neuroradiology Unit, Department of Radiology, Careggi University Hospital, Florence, Italy
| | - Alessandro Fiorenza
- Neurology Unit, Department of Neurological Sciences and Vision, ASST Spedali Civili, Brescia, Italy
| | - Francesca Di Pasquale
- Diagnostic Imaging Unit, Department of Experimental and Clinical Biomedical Sciences, University of Florence, Florence, Italy
| | - Sara Mancini
- Neuroradiology Unit, Department of Radiology, Careggi University Hospital, Florence, Italy
| | - Ivano Lombardo
- Neuroradiology Unit, Department of Radiology, Careggi University Hospital, Florence, Italy
| | - Elisa Scola
- Neuroradiology Unit, Department of Radiology, Careggi University Hospital, Florence, Italy
| | - Davide Gadda
- Neuroradiology Unit, Department of Radiology, Careggi University Hospital, Florence, Italy
| | - Marco Moretti
- Neuroradiology Unit, Department of Radiology, Careggi University Hospital, Florence, Italy
| | - Vittorio Miele
- Department of Radiology, Careggi University Hospital, Florence, Italy
| | - Enrico Fainardi
- Neuroradiology Unit, Department of Experimental and Clinical Biomedical Sciences, University of Florence, Florence, Italy
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Adusumilli G, Faizy TD, Christensen S, Mlynash M, Loh Y, Albers GW, Lansberg MG, Fiehler J, Heit JJ. Comprehensive Venous Outflow Predicts Functional Outcomes in Patients with Acute Ischemic Stroke Treated by Thrombectomy. AJNR Am J Neuroradiol 2023; 44:675-680. [PMID: 37202117 PMCID: PMC10249690 DOI: 10.3174/ajnr.a7879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Accepted: 04/22/2023] [Indexed: 05/20/2023]
Abstract
BACKGROUND AND PURPOSE Cortical venous outflow has emerged as a robust measure of collateral blood flow in acute ischemic stroke. The addition of deep venous drainage to this assessment may provide valuable information to further guide the treatment of these patients. MATERIALS AND METHODS We performed a multicenter retrospective cohort study of patients with acute ischemic stroke treated by thrombectomy between January 2013 and January 2021. The internal cerebral veins were scored on a scale of 0-2. This metric was combined with existing cortical vein opacification scores to create a comprehensive venous outflow score from 0 to 8 and stratify patients as having favorable-versus-unfavorable comprehensive venous outflow. Outcome analyses were primarily conducted using the Mann-Whitney U and χ2 tests. RESULTS Six hundred seventy-eight patients met the inclusion criteria. Three hundred fifteen were stratified as having favorable comprehensive venous outflow (mean age, 73 years; range, 62-81 years; 170 men), and 363, as having unfavorable comprehensive venous outflow (mean age, 77 years; range, 67-85 years; 154 men). There were significantly higher rates of functional independence (mRS 0-2; 194/296 versus 37/352, 66% versus 11%, P < .001) and excellent reperfusion (TICI 2c/3; 166/313 versus 142/358, 53% versus 40%, P < .001) in patients with favorable comprehensive venous outflow. There was a significant increase in the association of mRS with the comprehensive venous outflow score compared with the cortical vein opacification score (-0.74 versus -0.67, P = .006). CONCLUSIONS A favorable comprehensive venous profile is strongly associated with functional independence and excellent postthrombectomy reperfusion. Future studies should focus on patients with venous outflow status that is discrepant with the eventual outcome.
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Affiliation(s)
- G Adusumilli
- From the Department of Radiology (G.A.), Massachusetts General Hospital, Boston, Massachusetts
| | - T D Faizy
- Department of Neuroradiology (T.D.F., J.F.), University of Hamburg-Eppendorf, Hamburg, Germany
| | | | - M Mlynash
- Stanford Stroke Center (S.C., M.M., G.W.A., M.G.L.)
| | - Y Loh
- Comprehensive Stroke Center (Y.L.), Swedish Neuroscience Institute, Seattle, Washington
| | - G W Albers
- Stanford Stroke Center (S.C., M.M., G.W.A., M.G.L.)
| | - M G Lansberg
- Stanford Stroke Center (S.C., M.M., G.W.A., M.G.L.)
| | - J Fiehler
- Department of Neuroradiology (T.D.F., J.F.), University of Hamburg-Eppendorf, Hamburg, Germany
| | - J J Heit
- Department of Radiology (J.J.H.), Stanford University, Stanford, California
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10
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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11
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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