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

Abstract

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...

Cerebral Small Vessel Disease – A Longitudinal 10 Years Evidenced Study

“…Hooper et al [40] have recorded that preexisting CSVD as risk factor for poor clinical outcome and predictor for mortality in patients with asymptomatic ishemic stroke, despite successful recanalization with endovascular thrombectomy for large vessel occlusion, the probable reason could be pathological changes with chronic cerebral hypo perfusion and ischemia affecting small perforating cerebral arterials ,venules ad capillaries in CVD as recorded by Streifer et al 2017 but this research findings where the subject was conservatively treated him holistic approach of meditation and physiotherapy and lifestyle modification.…”

Impact of leukoaraiosis or blood pressure on clinical outcome, mortality and symptomatic intracerebral hemorrhage after mechanical thrombectomy in acute ischemic stroke

“…The rate of good clinical outcome (45.5%), mortality (23.9%) and sICH (10.4%) was similar to the results of our study. Numerous other studies were able to confirm LA as an independent risk factor for an poor clinical result 19 , 20 and increased mortality 21 , 22 while few studies were not able to demonstrate an independent influence on the clinical result 23 or mortality 24 . Meta-analyses have shown an association between severe or moderate to severe LA and an poor clinical result and higher mortality 25 , 26 .…”

Overall cerebral small vessel disease burden is associated with outcome of acute ischemic stroke after mechanical thrombectomy

“…There were some studies investigating the relationship between CSVD and outcome of MT, but most of them were concentrating on single CSVD imaging features. [14][15][16] For example, a systemic retrospective study revealed that the poor 90-day outcome of MT was associated with severe leukoaraiosis and CMB but independent of the lacuna. 4 Consistently, our study also noted that the severe WMH was correlated to the poor 90-day outcome of MT in Multivariate logistic regression analysis.…”