Cerebral venous outflow profiles are associated with the first pass effect in endovascular thrombectomy

Horn, Noel van; Heit, Jeremy J; Kabiri, Reza; Mader, Marius Marc-Daniel; Christensen, Søren; Mlynash, Michael; Broocks, Gabriel; Meyer, Lukas; Nawabi, Jawed; Lansberg, Maarten G; Albers, Gregory W.; Wintermark, Max; Fiehler, Jens; Faizy, Tobias D.

doi:10.1136/neurintsurg-2021-018078

Cited by 19 publications

(17 citation statements)

References 26 publications

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“…The score is obtained by grading the opacification of three major cortical veins, namely the superficial middle cerebral vein, vein of Labbé, and sphenoparietal sinus, on a scale from 0 to 2 points (0, not visible; 1, moderate opacification; 2, full opacification). A favorable VO was defined as COVES ≥3 based on previous studies [ 17 , 20 ]. VO grading was independently performed by two neuroradiologists (T.D.F.…”

Section: Methodsmentioning

confidence: 99%

“…A favorable VO was defined as COVES ≥3 based on previous studies. 17,20 VO grading was independently performed by two neuroradiologists (T.D.F. and J.J.H., with 10 and 15 years of working experience) with substantial inter-reader agreement.…”

Section: Image Analysismentioning

confidence: 99%

“…18 Recent studies highlighted a potential major role of cortical VO profiles in cerebral microvascular perfusion assessment, EVT success, and ischemic edema formation. 16,17,19,20 To date, it has not been investigated whether VO profiles also constitute an independent prognostic marker in low AS-PECTS patients. We hypothesized that more robust VO profiles are associated with better clinical outcomes and may serve as an additional selection criterion for EVT treatment in AIS-LVO patients presenting with extensive baseline infarct (ASPECTS of ≤5).…”

Section: Introductionmentioning

confidence: 99%

“…Cerebral VO profiles can be assessed using the Cortical Vein Opacification Score (COVES) on computed tomography angiography (CTA) without the need for additional imaging [ 18 ]. Recent studies highlighted a potential major role of cortical VO profiles in cerebral microvascular perfusion assessment, EVT success, and ischemic edema formation [ 16 , 17 , 19 , 20 ].…”

Section: Introductionmentioning

confidence: 99%

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Venous Outflow Profiles Are Linked to Clinical Outcomes in Ischemic Stroke Patients with Extensive Baseline Infarct

et al. 2022

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Background and Purpose The benefit of endovascular thrombectomy (EVT) treatment is still unclear in stroke patients presenting with extensive baseline infarct. The use of additional imaging biomarkers could improve clinical outcome prediction and individualized EVT selection in this vulnerable cohort. We hypothesized that cerebral venous outflow (VO) may be associated with functional outcomes in patients with low Alberta Stroke Program Early CT Score (ASPECTS).Methods We conducted a retrospective multicenter cohort study of patients with acute ischemic stroke due to large vessel occlusion (AIS-LVO). Extensive baseline infarct was defined by an ASPECTS of ≤5 on admission computed tomography (CT). VO profiles were assessed on admission CT angiography using the Cortical Vein Opacification Score (COVES). Favorable VO was defined as COVES ≥3. Multivariable logistic regression was used to determine the association between cerebral VO and good clinical outcomes (90-day modified Rankin Scale score of ≤3).Results A total of 98 patients met the inclusion criteria. Patients with extensive baseline infarct and favorable VO achieved significantly more often good clinical outcomes compared to patients with unfavorable VO (45.5% vs. 10.5%, P<0.001). Higher COVES were strongly associated with good clinical outcomes (odds ratio, 2.17; 95% confidence interval, 1.15 to 4.57; P=0.024), independent of ASPECTS, National Institutes of Health Stroke Scale, and success of EVT.Conclusions Cerebral VO profiles are associated with good clinical outcomes in AIS-LVO patients with extensive baseline infarct. VO profiles could serve as a useful additional imaging biomarker for treatment selection and outcome prediction in low ASPECTS patients.

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Section: Methodsmentioning

confidence: 99%

Section: Image Analysismentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Venous Outflow Profiles Are Linked to Clinical Outcomes in Ischemic Stroke Patients with Extensive Baseline Infarct

et al. 2022

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“…1,19 Multiple studies reported of a strong association of favorable VO profiles with good procedural and long-term clinical outcomes, which warrants further investigation of venous microvascular changes in patients treated with tPA before EVT. 1,4,8,17–20,38…”

Section: Discussionmentioning

confidence: 99%

Intravenous tPA (Tissue-Type Plasminogen Activator) Correlates With Favorable Venous Outflow Profiles in Acute Ischemic Stroke

Faizy

Mlynash

Marks

et al. 2022

Stroke

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BACKGROUND: Intravenous tPA (tissue-type plasminogen activator) is often administered before endovascular thrombectomy (EVT). Recent studies have questioned whether tPA is necessary given the high rates of arterial recanalization achieved by EVT, but whether tPA impacts venous outflow (VO) is unknown. We investigated whether tPA improves VO profiles on baseline computed tomography (CT) angiography (CTA) images before EVT. METHODS: Retrospective multicenter cohort study of patients with acute ischemic stroke due to large vessel occlusion undergoing EVT triage. Included patients underwent CT, CTA, and CT perfusion before EVT. VO profiles were determined by opacification of the vein of Labbé, sphenoparietal sinus, and superficial middle cerebral vein on CTA as 0, not visible; 1, moderate opacification; and 2, full. Pial arterial collaterals were graded on CTA, and tissue-level collaterals were assessed on CT perfusion using the hypoperfusion intensity ratio. Clinical and demographic data were determined from the electronic medical record. Using multivariable regression analysis, we determined the correlation between tPA administration and favorable VO profiles. RESULTS: Seven hundred seventeen patients met inclusion criteria. Three hundred sixty-five patients received tPA (tPA+), while 352 patients were not treated with tPA (tPA−). Fewer tPA+ patients had atrial fibrillation (n=128 [35%] versus n=156 [44%]; P =0.012) and anticoagulants/antiplatelet treatment before acute ischemic stroke due to large vessel occlusion onset (n=130 [36%] versus n=178 [52%]; P <0.001) compared with tPA− patients. One hundred eighty-five patients (51%) in the tPA+ and 100 patients (28%) in the tPA− group exhibited favorable VO ( P <0.001). Multivariable regression analysis showed that tPA administration was a strong independent predictor of favorable VO profiles (OR, 2.6 [95% CI, 1.7–4.0]; P <0.001) after control for favorable pial arterial CTA collaterals, favorable tissue-level collaterals on CT perfusion, age, presentation National Institutes of Health Stroke Scale, antiplatelet/anticoagulant treatment, history of atrial fibrillation and time from symptom onset to imaging. CONCLUSIONS: In patients with acute ischemic stroke due to large vessel occlusion undergoing thrombectomy triage, tPA administration was strongly associated with the presence of favorable VO profiles.

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Prolonged venous transit is associated with worse neurological recovery in successfully reperfused large vessel strokes

Mei,

Salim,

Lakhani

et al. 2024

Ann Clin Transl Neurol

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ObjectiveVenous outflow (VO) impairment predicts unfavorable outcomes in patients with acute ischemic stroke caused by large vessel occlusion (AIS‐LVO). Prolonged venous transit (PVT), a visual qualitative VO marker on CT perfusion (CTP) time to maximum (Tmax) maps, has been associated with unfavorable 90‐day functional outcomes despite successful reperfusion. This study investigates the association between PVT and percent change on the National Institutes of Health Stroke Scale (NIHSS) among AIS‐LVO patients who have undergone successful reperfusion.MethodsWe performed a retrospective analysis of prospectively collected data from consecutive adult AIS‐LVO patients with successful reperfusion (modified Thrombolysis in Cerebral Infarction 2b/2c/3). PVT+ was defined as Tmax ≥10 s in the superior sagittal sinus, torcula, or both. The primary outcome was continuous NIHSS percent change and dichotomous NIHSS percent change ≥70%. Regression analyses were performed to assess the effect of PVT on NIHSS percent change.ResultsIn 119 patients of median (IQR) age 71 (63–81) years, the admission and discharge NIHSS scores were significantly higher in PVT+ patients compared to PVT− patients (17 [14–23.5] vs. 13 [9.5–19], p = 0.011, and 7.5 [4–12] vs. 3 [1–7], p < 0.001, respectively). After adjusting for age, sex, hypertension, diabetes, atrial fibrillation, administration of intravenous thrombolysis (IVT), Alberta Stroke Program Early CT Scores (ASPECTS), mTICI 2c and/or 3, Tmax >6 s volume, and hemorrhagic transformation, PVT+ was significantly associated with lower NIHSS percent change (B = −0.163, 95%CI −0.326 to −0.001, p = 0.049) and was less likely to achieve higher than 70% NIHSS improvement (OR = 0.331, 95% CI 0.127–0.863, p = 0.024).InterpretationPVT+ was significantly associated with reduced neurological improvement despite successful reperfusion in AIS‐LVO patients, highlighting the critical role of VO impairment in short‐term functional outcomes. These findings further validate PVT as a valuable adjunct imaging biomarker derived from CTP for assessing VO profiles in AIS‐LVO.

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Cerebral venous outflow profiles are associated with the first pass effect in endovascular thrombectomy

Cited by 19 publications

References 26 publications

Venous Outflow Profiles Are Linked to Clinical Outcomes in Ischemic Stroke Patients with Extensive Baseline Infarct

Venous Outflow Profiles Are Linked to Clinical Outcomes in Ischemic Stroke Patients with Extensive Baseline Infarct

Intravenous tPA (Tissue-Type Plasminogen Activator) Correlates With Favorable Venous Outflow Profiles in Acute Ischemic Stroke

Prolonged venous transit is associated with worse neurological recovery in successfully reperfused large vessel strokes

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