Leukoaraiosis May Confound the Interpretation of CT Perfusion in Patients Treated with Mechanical Thrombectomy for Acute Ischemic Stroke

Rudilosso, Salvatore; Laredo, Carlos; Sánchez, Catalina Vivancos; Urra, Xabier; Llull, Laura; Renú, Arturo; Obach, Vı́ctor; Zhao, Yanxin; Moreno, Javier; López-Rueda, Antonio; Amaro, Sergio; Chamorro, Ángel

doi:10.3174/ajnr.a6139

Cited by 11 publications

(10 citation statements)

References 33 publications

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“…Our study applied Fazekas scale to evaluate leukoaraiosis severity, as it is one of the well-established visual rating scales and also has good agreement with other visual scoring systems ( Pantoni et al, 2002 ). Visual rating scales can be easily and reliably administered in clinical practice, and they have been proved to provide valuable prognostic information ( Verdelho et al, 2012 ; Rudilosso et al, 2019 ). However, visual rating scales typically allow for a small number of ordinal ratings, and they may have limited sensitivity to subtle changes as compared to voxel-based volumetric quantification ( Lambert et al, 2016 ; Garnier-Crussard et al, 2022 ).…”

Section: Discussionmentioning

confidence: 99%

Mediating roles of leukoaraiosis and infarcts in the effects of unilateral carotid artery stenosis on cognition

Huang

Chang²,

Wu³

et al. 2022

Front. Aging Neurosci.

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Background and objectivesLeukoaraiosis and infarcts are common in patients with carotid artery stenosis (CAS), and CAS severity, leukoaraiosis and infarcts all have been implicated in cognitive impairments. CAS severity was not only hypothesized to directly impede specific cognitive domains, but also transmit its effects indirectly to cognitive function through ipsilateral infarcts as well as periventricular leukoaraiosis (PVL) and deep white matter leukoaraiosis (DWML). We aimed to delineate the contributions of leukoaraiosis, infarcts and CAS to different specific cognitive domains.Materials and methodsOne hundred and sixty one participants with unilateral CAS (>50%) on the left (n = 85) or right (n = 76) side and 65 volunteers without significant CAS (<50%) were recruited. The PVL, DWML, and infarct severity were visually rated on MRI. A comprehensive cognitive battery was administered and standardized based on age norms. Correlation and mediation analyses were adopted to examine the direct and indirect influence of CAS, leukoaraiosis, and infarct on specific cognitive domains with adjustment for education, hypertension, diabetes mellitus, and hyperlipidemia.ResultsCarotid artery stenosis severity was associated with ipsilateral leukoaraiosis and infarct. Left CAS had direct effects on most cognitive domains, except for visual memory and constructional ability, and transmitted its indirect effects on all cognitive domains through ipsilateral PVL, and on constructional ability and psychomotor through infarcts. Right CAS only had negative direct effects on visual memory, psychomotor, design fluency and color processing speed, and transmitted its indirect effects on visual memory, word and color processing speed through ipsilateral infarcts. The trends of direct and indirect cognitive effects remained similar after covariate adjustment.ConclusionLeft and right CAS would predominantly lead to verbal and non-verbal cognitive impairment respectively, and such effects could be mediated through CAS-related leukoaraiosis and infarct. Given that cognition is subject to heterogeneous pathologies, the exact relationships between markers of large and small vessel diseases and their composite prognostic effects on cognition requires further investigation.

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Section: Discussionmentioning

confidence: 99%

Mediating roles of leukoaraiosis and infarcts in the effects of unilateral carotid artery stenosis on cognition

Huang

Chang²,

Wu³

et al. 2022

Front. Aging Neurosci.

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“…Additionally, compared to previous studies, MRI was the main imaging modality utilized in this study as CT is both less sensitive and less specific to chronic WMH compared to MRI T2-FLAIR, particularly in patients with mild leukoaraiosis [ 21 ]. It should also be acknowledged that recent studies have suggested that leukoaraiosis may confound the interpretation of CT perfusion and thus bias patient eligibility for extended window EVT due to an overestimation of the hypoperfused area [ 22 ]. Thus, further investigation of CSVD burden in patients excluded from treatment with EVT in the extended time window is warranted.…”

Section: Discussionmentioning

confidence: 99%

Severe Cerebral Small Vessel Disease Burden Is Associated With Poor Outcomes After Endovascular Thrombectomy in Acute Ischemic Stroke With Large Vessel Occlusion

Hooper¹,

Nisar²,

McCane³

et al. 2021

Cureus

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Background Despite recent advancements in the treatment of acute ischemic stroke (AIS) with large vessel occlusion (LVO), infarct progression over time and functional outcomes remain variable. This variation in outcomes may be partially attributed to an underlying state of chronic cerebral hypoperfusion and ischemia affecting small cerebral perforating arterioles, venules, and capillaries of the brain; broadly termed cerebral small vessel disease (CSVD). We investigated the association between CSVD burden and the degree of disability following successful recanalization with endovascular thrombectomy (EVT) in patients with AIS presenting with LVO. Methodology We conducted a single center retrospective analysis of all patients presenting with AIS LVO between May 2016 and May 2019. Patients who were premorbidly independent and presented within six hours from the last known well (LKW) with a proximal anterior circulation occlusion confirmed on computed tomography (CT) angiography of the head or neck were treated with EVT. Patients presenting after six hours and up to 24 hours from LKW with a target ischemic core to perfusion mismatch profile on CT or magnetic resonance (MR) perfusion, or a clinical imaging mismatch on MR diffusion-weighted imaging, were also treated. Patients with successful revascularization, defined as a thrombolysis in cerebral infarction score 2b or 3, were included and evaluated for CSVD burden. The presence of CSVD was quantified using the Fazekas scale (0-3). All patients were further evaluated for disability at 90 days using the modified Rankin Scale (mRS, range 0-6). An mRS score of ≤2 was defined as a good functional outcome. Results Of the 190 patients evaluated, absent (Fazekas grade 0), mild (Fazekas grade 1), moderate (Fazekas grade 2), and severe (Fazekas grade 3) CSVD was present in 33 (17.4%), 84 (44.2%), 35 (18.4%), and 38 (20.0%) patients, respectively. Patients with severe CSVD (Fazekas grade 3) were found to be older, had a higher presenting National Institute of Health Stroke Scale (NIHSS), and had greater proportions of preexisting atrial fibrillation and dementia compared to patients with no CSVD (Fazekas grade 0). Using a multivariate ordinal logistic regression model to adjust for age, presenting NIHSS, thrombus location, LKW to groin puncture time, use of tissue plasminogen activator, ischemic infarct volume, development of a symptomatic intracerebral hemorrhage, and treatment with hemicraniectomy, patients with Fazekas grade 3 were significantly more likely to have poor 90-day functional outcomes compared to patients with Fazekas grade 0 (odds ratio 10.25, 95% confidence interval [3.3-31.84]). Conclusions Based on our analytical cohort of AIS LVO patients treated with EVT, we found that patients with severe CSVD burden had worse functional outcomes at 90 days and increased mortality. These results provide evidence that the burden of CSVD may be considered an independent risk factor of poor c...

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“…Rudilosso et al [ 104 ] provided interesting information about the pathophysiology of perfusion abnormalities in RSSI by using CTP. In a visual evaluation, CBF and CBV were classified as reduced, normal or increased, whereas time to drain (TTD) was classified as normal or delayed in comparison with the corresponding contralateral area.…”

Section: Pathophysiology Of Perfusion Issues In Lacunar Strokementioning

confidence: 99%

“…The first documentation of anterograde and retrograde collaterals in acute lacunar infarction was described by Forster et al using DSC-MRI [ 93 ]. CTP was useful for demonstrating a delayed compensatory collateral supply in RSSI [ 104 ]. A further issue in supporting the penumbra hypothesis in lacunar stroke is the documentation that stroke patients with lacunar infarcts may also benefit from pharmacological reperfusion [ 119 ].…”

Section: Practical Implications and Perspectivesmentioning

confidence: 99%

Perfusion Status in Lacunar Stroke: A Pathophysiological Issue

et al. 2023

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The pathophysiology of lacunar infarction is an evolving and debated field, where relevant information comes from histopathology, old anatomical studies and animal models. Only in the last years, have neuroimaging techniques allowed a sufficient resolution to directly or indirectly assess the dynamic evolution of small vessel occlusion and to formulate hypotheses about the tissue status and the mechanisms of damage. The core–penumbra concept was extensively explored in large vessel occlusions (LVOs) both from the experimental and clinical point of view. Then, the perfusion thresholds on one side and the neuroimaging techniques studying the perfusion of brain tissue were focused and optimized for LVOs. The presence of a perfusion deficit in the territory of a single small perforating artery was negated for years until the recent proposal of the existence of a perfusion defect in a subgroup of lacunar infarcts by using magnetic resonance imaging (MRI). This last finding opens pathophysiological hypotheses and triggers a neurovascular multidisciplinary reasoning about how to image this perfusion deficit in the acute phase in particular. The aim of this review is to summarize the pathophysiological issues and the application of the core–penumbra hypothesis to lacunar stroke.

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Leukoaraiosis May Confound the Interpretation of CT Perfusion in Patients Treated with Mechanical Thrombectomy for Acute Ischemic Stroke

Cited by 11 publications

References 33 publications

Mediating roles of leukoaraiosis and infarcts in the effects of unilateral carotid artery stenosis on cognition

Mediating roles of leukoaraiosis and infarcts in the effects of unilateral carotid artery stenosis on cognition

Severe Cerebral Small Vessel Disease Burden Is Associated With Poor Outcomes After Endovascular Thrombectomy in Acute Ischemic Stroke With Large Vessel Occlusion

Perfusion Status in Lacunar Stroke: A Pathophysiological Issue

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