Perfusion imaging-based tissue-level collaterals predict ischemic lesion net water uptake in patients with acute ischemic stroke and large vessel occlusion

Faizy, Tobias D.; Kabiri, Reza; Christensen, Søren; Mlynash, Michael; Kuraitis, Gabriella; Broocks, Gabriel; Hanning, Uta; Nawabi, Jawed; Lansberg, Maarten G; Marks, Michael P.; Albers, Gregory W.; Fiehler, Jens; Wintermark, Max; Heit, Jeremy J

doi:10.1177/0271678x21992200

Cited by 42 publications

(37 citation statements)

References 23 publications

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“…On baseline imaging evaluation (Table 2), there were significant differences between the CCC groups with respect to the degree of cerebral ischemia. CCC+ patients had the highest ASPECTS (9)(10) 2).…”

Section: Resultsmentioning

confidence: 97%

“…A total of 341 of 740 patients from the combined database of the University Medical Center Hamburg-Eppendorf and Stanford University had been previously included into another study. 9 That study investigated the association of the hypoperfusion intensity ratio (HIR) (tissue-level collaterals) with ischemic lesion net water uptake after thrombectomy treatment.…”

Section: Standard Protocol Approvals Registrations and Patient Consentsmentioning

confidence: 99%

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The Cerebral Collateral Cascade

et al. 2022

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Background and Purpose:Robust cerebral collaterals are associated with favorable outcomes in patients with acute ischemic stroke due to large vessel occlusion treated by thrombectomy. However, collateral status assessment mostly relies on single imaging biomarkers and a more comprehensive holistic approach may provide deeper insights into the biology of collateral perfusion on medical imaging. Comprehensive collateralization is defined as blood flow of cerebral arteries through the brain tissue and into draining veins. We hypothesized that a comprehensive analysis of the cerebral collateral cascade (CCC) on an arterial, tissue and venous level would predict clinical and radiological outcomes.Materials and Methods:Multicenter retrospective cohort study of acute stroke patients undergoing thrombectomy triage. CCC was determined by quantifying pial arterial collaterals, tissue-level collaterals, and venous outflow. Pial arterial collaterals were determined by CT angiography, tissue-level collaterals were assessed on CT perfusion. Venous outflow was assessed on CT angiography using the cortical vein opacification score. 3 groups were defined: CCC+ (good pial collaterals, tissue-level collaterals, and venous outflow), CCC- (poor pial collaterals, tissue-level collaterals, and venous outflow) and CCCmixed (remainder of patients). Primary outcome was functional independence (modified Rankin Scale: 0-2) at 90-days. Secondary outcome was final infarct volume.Results:647 patients met inclusion criteria: 176 CCC+, 345 CCC mixed and 126 CCC-. Multivariable ordinal logistic regression showed that CCC+ predicted good functional outcomes (OR=18.9 [95% CI 8-44.5]; p<0.001) compared to CCC- and CCCmixed patients. CCCmixed patients likely had better functional outcomes compared to CCC- patients (OR=2.5 [95% CI 1.2-5.4]; p=0.014). Quantile regression analysis (50th percentile) showed that CCC+ (β: -78.5, 95% CI -96.0- -61.1; p<0.001) and CCCmixed (β: -64.0, 95% CI -82.4- -45.6; p<0.001) profiles were associated with considerably lower final infarct volumes compared to CCC- profiles.Conclusion:Comprehensive assessment of the collateral blood flow cascade in acute stroke patients is a strong predictor of clinical and radiological outcomes in patients treated by thrombectomy.

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Section: Resultsmentioning

confidence: 97%

Section: Standard Protocol Approvals Registrations and Patient Consentsmentioning

confidence: 99%

The Cerebral Collateral Cascade

et al. 2022

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“…12 It is well established that collateral status is key to the infarct progression and clinical outcomes of patients with large vessel occlusions. 26,27 However, recent studies using dynamic 4-dimentional angiography derived from perfusion CT acquisitions have visualized collateral flow in SSIs, with compensatory blood supply to the ischemic area from adjacent perforator arteries. 20,28 Moreover, CSVD has now been recognized to reflect whole-brain endothelial dysfunction, which is strongly correlated with loss of brain reactivity, and is reflected by a more globally compromised CBF.…”

Section: Discussionmentioning

confidence: 99%

Hemispheric cerebral blood flow predicts outcome in acute small subcortical infarcts

Hong

Ling

et al. 2021

J Cereb Blood Flow Metab

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The association between baseline perfusion measures and clinical outcomes in patients with acute small subcortical infarcts (SSIs) has not been studied in detail. Post-processed acute perfusion CT and follow-up diffusion-weighted imaging of 71 patients with SSIs were accurately co-registered. Relative perfusion values were calculated from the perfusion values of the infarct lesion divided by those of the mirrored contralateral area. The association between perfusion measures with clinical outcomes and the interaction with intravenous thrombolysis were studied. Additionally, the perfusion measures for patients having perfusion CT before and after thrombolysis were compared. Higher contralateral hemispheric cerebral blood flow (CBF) was the only independent predictor of an excellent clinical outcome (modified Rankin Scale of 0-1) at 3 months (OR = 1.3, 95% CI 1.1–1.4, P = 0.001) amongst all the perfusion parameters, and had a significant interaction with thrombolysis (P = 0.04). Patients who had perfusion CT after thrombolysis demonstrated a better perfusion profile (relative CBF ≥1) than those who had perfusion CT before thrombolysis (After:45.5%, Before:21.1%, P = 0.03). This study implies that for patients with SSIs, hemispheric CBF is a predictor of clinical outcome and has an influence on the effect of intravenous thrombolysis.

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“…Although NWU may constitute a quantitative imaging parameter that can be determined in a standardized fashion, collateral scores are mostly assessed based on a subjective visual rating approach in CTA. 26,27 Further prospective studies are needed to reliably assess whether NWU might be used to select patients for treatment in the extended time window in daily clinical practice. The purpose of this exploratory study was to evaluate and discuss the potential value of NWU and its diagnostic ability to classify outcome.…”

Section: Clinical and Population Sciencesmentioning

confidence: 99%

Quantitative Lesion Water Uptake as Stroke Imaging Biomarker: A Tool for Treatment Selection in the Extended Time Window?

Broocks

Kemmling

Teßarek

et al. 2022

Stroke

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Background and Purpose: Patients presenting in the extended time window may benefit from mechanical thrombectomy. However, selection for mechanical thrombectomy in this patient group has only been performed using specialized image processing platforms, which are not widely available. We hypothesized that quantitative lesion water uptake calculated in acute stroke computed tomography (CT) may serve as imaging biomarker to estimate ischemic lesion progression and predict clinical outcome in patients undergoing mechanical thrombectomy in the extended time window. Methods: All patients with ischemic anterior circulation stroke presenting within 4.5 to 24 hours after symptom onset who received initial multimodal CT between August 2014 and March 2020 and underwent mechanical thrombectomy were analyzed. Quantitative lesion net water uptake was calculated from the admission CT. Prediction of clinical outcome was assessed using univariable receiver operating characteristic curve analysis and logistic regression analyses. Results: One hundred two patients met the inclusion criteria. In the multivariable logistic regression analysis, net water uptake (odds ratio, 0.78 [95% CI, 0.64–0.95], P =0.01), age (odds ratio, 0.94 [95% CI, 0.88–0.99]; P =0.02), and National Institutes of Health Stroke Scale (odds ratio, 0.88 [95% CI, 0.79–0.99], P =0.03) were significantly and independently associated with favorable outcome (modified Rankin Scale score ≤1), adjusted for degree of recanalization and Alberta Stroke Program Early CT Score. A multivariable predictive model including the above parameters yielded the highest diagnostic ability in the classification of functional outcome, with an area under the curve of 0.88 (sensitivity 92.3%, specificity 82.9%). Conclusions: The implementation of quantitative lesion water uptake as imaging biomarker in the diagnosis of patients with ischemic stroke presenting in the extended time window might improve clinical prognosis. Future studies could test this biomarker as complementary or even alternative tool to CT perfusion.

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Perfusion imaging-based tissue-level collaterals predict ischemic lesion net water uptake in patients with acute ischemic stroke and large vessel occlusion

Cited by 42 publications

References 23 publications

The Cerebral Collateral Cascade

The Cerebral Collateral Cascade

Hemispheric cerebral blood flow predicts outcome in acute small subcortical infarcts

Quantitative Lesion Water Uptake as Stroke Imaging Biomarker: A Tool for Treatment Selection in the Extended Time Window?

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